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: 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. Cerebellar disease. The drift here is usually upwards. It also includes slow pronation of the wrist and elbow. 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) lesions Weakness Very little muscle wasting. Increased tone is present (may be clasp-knife, may have clonus). The reflexes are increased (except absent superficial reflexes). Extensor (Babinski) plantar response (upgoing toe). Signs of lower motor neurone lesions Wasting is a prominent feature. Tone is reduced. Reflexes are reduced Plantar response is normal or absent. 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 Complete blood count 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 Where do they typically occur? 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 (?)