Salient Features: SUBJECTIVE
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2 y/o male
Sudden onset of severe headache
Numbness of the right side of the face
Upward rolling of the eye & rigidity of all extremities associated with
loss of consciousness
Twitching of the right side of the face
Dysarthria
Dysphagia
(-) Fever
(-) Trauma
(+) Family history of Neurocysticercosis
(+) Family history of Stroke, HPN, DM
(-) Family history of TB
Usually eats raw fish and meat
Salient Features: OBJECTIVE
 Dysarthic
 Shallow right nasolabial fold
 Tongue deviated to the right
What is the neurologic problem?
• Increased intracranial pressure
• Meningeal irritation
• Focal neurologic deficits
What is the neurologic problem?
• Increased intracranial pressure
– A. headache with or without vomiting
– B. papilledema
– C. lateral rectus palsy
– D. deterioration of level of conciousness
What is the neurologic problem?
• Increased intracranial pressure
– (+) headache with or without vomiting
– (-) papilledema
– (-) lateral rectus palsy
– (-) deterioration of level of conciousness
What is the neurologic problem?
• Meningeal irritation
– A. headache with or without vomiting
– B. nuchal rigidity
– C. brudzinski
– D. kernig
What is the neurologic problem?
• Meningeal irritation
– (+) headache with or without vomiting
– (-) nuchal rigidity
– (-) brudzinski
– (-) kernig
What is the neurologic problem?
• Focal neurologic deficits
slurring of speech
– seizures
memory impairment
emotional and behavioral changes
facial asymmetry
weakness of extremities
incoordination
reflex asymmetry or pathological reflex
sensory impairment
What is the neurologic problem?
• Focal neurologic deficits
• (+) slurring of speech
• (+) seizures
• (+) facial asymmetry
(+) shallow right nasolabial fold
(+) tongue deviated to the R
(+) sensory impairment
(-) memory impairment
(-) emotional and behavioral changes
(-) weakness of extremities
(-) incoordination
(-) reflex asymmetry or pathological reflex
What is the neurologic problem?
FOCAL NEUROLOGIC DEFICITS
Where is the lesion?
Levelization, Lateralization,
Localization
Levelization
 Dysarthic
 Shallow right nasolabial fold
 Tongue deviated to the right
 upper motor neuron
Levelization
 Upper Motor Neuron




cerebrum
cerebellum
brainstem
spinal cord
Levelization
 autonomic dysfunction
 sensory level
 spinal cord
Levelization
 can do APST & FTNT
 can do heel to shin test
 (-) Romberg’s test
 cerebellum
Levelization
 crossed motor paralysis
 brainstem
Levelization
 right-sided facial numbness and twitching,
facial asymmetry and tongue deviation
 complex focal seizures
 cerebrum




Lateralization
numbness of the right side of the face
twitching of the right side of the face
shallow right nasolabial fold
tongue deviated to the right
 left
Levelize: cerebrum
Lateralize: left
Localization: frontal lobe
Salient Features: OBJECTIVE
 MRI findings of a solitary ring enhancing cystic
lesion at left posterior frontal cortical and
subcortical white matter with surrounding
vasogenic edema and focal central calcific
focus within the lesion
Differential Diagnoses
RING ENHANCING LESIONS
Differential Diagnoses for Ringenhancing lesions
• Metastases;
• Abscess, (pyogenic abscess and abscess caused
by bacterial fungal and parasitic pathogens;
• Glioma and other primary CNS neoplasms;
• Infarction;
• Contusion;
• Demyelination (multiple sclerosis, acute
disseminated encephalomyelitis);
• Resolving hematoma/radionecrosis
Irene Cortese, Clinical Neurophysiology, The Johns Hopkins University, Baltimore, Maryland; 2006.
Differential Diagnoses for Ringenhancing lesions
• Cerebrovascular diseases
– acute or sudden
• Demyelinating, inflammatory, or infectious
diseases
– subacute onset
• Brain tumors
– insidious onset and gradual progression of signs
and symptoms
Differential Diagnoses for Ringenhancing lesions
• Cerebrovascular diseases
– acute or sudden
• Demyelinating, inflammatory, or infectious
diseases
– subacute onset
• Brain tumors
– insidious onset and gradual progression of signs
and symptoms
Differential Diagnoses for Ringenhancing lesions
• Metastases;
• Abscess, (pyogenic abscess and abscess caused
by bacterial fungal and parasitic pathogens;
• Glioma and other primary CNS neoplasms;
• Infarction;
• Contusion;
• Demyelination (multiple sclerosis, acute
disseminated encephalomyelitis);
• Resolving hematoma/radionecrosis
Irene Cortese, Clinical Neurophysiology, The Johns Hopkins University, Baltimore, Maryland; 2006.
Differential Diagnoses for Ringenhancing lesions
• Largely depend on the immune status of the patient
• Immunocompetent host:
– tumors (primary and metastatic)
– pyogenic abscesses and abscesses caused by atypical organisms
– demyelinating disease
• Immunocompromised host:
– toxoplasmosis
– primary CNS lymphoma
– also at risk for abscesses
• Tuberculous brain abscess should be considered in endemic
regions in both immunocompetent and
immunocompromised hosts.
Irene Cortese, Clinical Neurophysiology, The Johns Hopkins University, Baltimore, Maryland; 2006.
Differential Diagnoses for Ringenhancing lesions
• Largely depend on the immune status of the patient
• Immunocompetent host:
– tumors (primary and metastatic)
– pyogenic abscesses and abscesses caused by atypical organisms
– demyelinating disease
• Immunocompromised host:
– toxoplasmosis
– primary CNS lymphoma
– also at risk for abscesses
• Tuberculous brain abscess should be considered in endemic
regions in both immunocompetent and
immunocompromised hosts.
Irene Cortese, Clinical Neurophysiology, The Johns Hopkins University, Baltimore, Maryland; 2006.
Differential Diagnoses
• In the tropics, infectious and post infectious
disorders are more common than
demyelinating disorders such as Multiple
Sclerosis which is more common in the west
Differential diagnosis of white matter diseases in the tropics: An overview
Lekha Pandit
Department of Neurology, KS Hegde Medical Academy, Mangalore-575018, Karnataka, India
Differential Diagnoses for Ringenhancing lesions
• Metastases;
• Abscess, (pyogenic abscess and abscess
caused by bacterial fungal and parasitic
pathogens;
• Glioma and other primary CNS neoplasms
Irene Cortese, Clinical Neurophysiology, The Johns Hopkins University, Baltimore, Maryland; 2006.
Impression
• Complex Focal Seizure secondary to an
intracranial mass lesion on the left frontal lobe
probably secondary to:
(1) Metastases
(2) Primary brain tumor
(3) Infections
What specific kinds of infections can
we include in our DDX?
• Differential diagnosis for complete ring
enhancing cystic lesions commonly include
brain abscess, cysticercosis, tuberculoma and
toxoplasmosis in a tropical country set up.
Differential diagnosis of white matter diseases in the tropics: An overview
Lekha Pandit
Department of Neurology, KS Hegde Medical Academy, Mangalore-575018, Karnataka, India
Primary Differentials
• Complex Focal Seizure secondary to an
intracranial mass lesion on the left frontal lobe
probably secondary to:
(1)
(2)
(3)
(4)
(5)
Metastases
Primary brain tumor
Abscess
Neurocysticercosis
Tuberculoma
Salient Features: SUBJECTIVE
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2 y/o male
Sudden onset of severe headache
Numbness of the right side of the face
Upward rolling of the eye & rigidity of all extremities associated with
loss of consciousness
Twitching of the right side of the face
Dysarthria
Dysphagia
(-) Fever
(-) Trauma
(+) Family history of Neurocysticercosis
(+) Family history of Stroke, HPN, DM
(-) Family history of TB
Usually eats raw fish and meat
Impression
• Complex Focal Seizure secondary to an
intracranial mass lesion on the left frontal lobe
probably secondary to Neurocysticercosis