(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

NEURORADIOLOGY:

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 49-year-old right-handed man developed progressive cognitive difficulties over a four month period. Recent memory was impaired. He was unable to do the payroll at his company and would get lost in familiar surroundings. There were word-finding and language difficulties. He had associated fatigue, anorexia, daytime somnolence and weight loss of thirty pounds. Gait imbalance and urinary incontinence developed later.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a man in his mid-70's who had a subungual acral lentiginous melanoma (T3N1M0) with gangrene change of left big toe underwent amputation 15 months ago. Metastatic malignant melanoma of left inguinal lymph node was diagnosed with biopsy 14 months ago. Progressive visual disturbance was noted and a pituitary tumor was found with hypoglycemic episode one month ago. He presented to hospital with falling down with initial loss of consciousness 2 days before admission. His past medical history was significant for chronic obstructive pulmonary disease. Endocrinologic analysis showed modest hyperprolactinemia, hypothyroidism and partial insufficiency of the adrenocorticotropic hormone. CT scans of chest, abdomen and pelvis revealed enlarged lymph nodes in mediastinum, porta hepatis, para-aortic area and bilateral inguinal regions. The largest one was 18 mm in long axis at left inguina. A soft tissue mass, about 3 cm in the largest dimension, was noted at left renal hilum. Melanoma with multifocal metastasis was considered. Cranial CT showed a huge soft tissue mass with hyperdense foci suggesting hemorrhage in intrasellar and suprasellar region. Apoplexy was highly suspected. Cerebral MRI demonstrated a 62x33x49 mm soft tissue tumor occupying the enlarged pituitary fossa, extending upward to suprasellar and bilateral sublental regions, and encasing bilateral internal carotid arteries and left middle cerebral artery (Figure 1). The tumor was mainly T1-isointense and T2-hyperintense to the gray matter, and homogeneously enhanced after contrast administration. Several small foci inside the tumor bulk had T1-hyperintensity, T2-hypointensity and no enhancement, indicating composition of subacute hematoma or melanin. The patient underwent transsphenoidal surgical resection of pituitary tumor.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A man in his mid-sixties complained about an increasing sense of abdominal "constriction" over a two years period. Eighteen months after the onset of this symptom additional tingling of the legs was perceived. Half a year later mild gait ataxia developed although there was no evidence of gross motor or sensory deficits. A painful micturition prompted the patient to undergo a detailed neurological investigation. The clinical finding consisted of a mild muscular weakness at the lower limbs associated with sensory disturbances.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A man in the seventh decade of life lives independently and has end stage liver disease. He presented to the ED with complaints of increasing gait disturbances over the past several weeks and new onset diplopia and blurry vision. He also complains of persistent headaches, body aches, and intermittent confusion. He had nausea and vomiting, which had impaired his ability to take his lactulose as prescribed. Recently, he had been admitted to the hospital multiple times for what was diagnosed as hepatic encephalopathy. The patient was admitted to the hospital and neurology was consulted.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 48-year-old man with a history of hypertension, peripheral vascular disease and a 50-pack-year history of smoking, presented with new onset vertigo, tinnitus, diplopia and ataxia in January of 1978. There was no family history of any brain lesions, neurological symptoms or other contributory diseases. CT scan showed a radiolucent defect in the left cerebellar hemisphere with a possible mural nodule. In ensuing months, worsening symptoms were experienced with a corresponding increase in lesion size on re-imaging. Four months later, a left posterior fossa craniotomy was performed and revealed a single cystic lesion containing copious amounts of straw- colored fluid and a single mural nodule in the inferior portion of the cyst. Following resection, he was followed clinically until 1985 at which time follow-up was discontinued. He did well until January of 1993 when he presented with progressively worsening episodic headaches and retro-orbital pressure. In the following months, additional symptoms including slurred speech, left facial droop; upper and lower extremity weakness were documented. Subsequent MRIs of the brain (02/93, 03/93) showed diffuse nodular leptomeningeal enhancement in the posterior fossa. Multiple low intensity lesions coated the cerebellum, and similar lesions were located anterior to the pons, in the suprasellar cistern, at the tip of the temporal lobe, in the right Meckel's cave, and in the third ventricle (Figures 1, 2 and 3). In addition, an MRI of the spine (03/93) showed multiple extra-axial intradural enhancing nodules throughout the length of the thoracic cord, consistent with drop metastases. He was admitted for radiotherapy, receiving 2600 rads in 10 fractions over a 19- day period in March 1993. During this hospitalization, his hematocrit ranged from 53 to 61%, demonstrating polycythemia. Despite therapy, his condition progressively declined, and he succumbed. The family authorized consent for examination of the brain only at autopsy.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

An african american male in his 50s presented to the Emergency Room with intractable pain of the left lumbar region that radiated down his leg. He had a 14-year history of chronic back pain due to an industrial injury normally kept under control with Ibuprofen, 800 mg tid. Three days prior to admission, however, his back pain became much worse than usual until it reached a 10/10 severity, and was not relieved by Ibuprofen. . Three months prior to this admission, he suffered Streptococcus pneumoniae pneumonia and bacteremia, which were treated successfully with cefuroxime, azithromycin, and levofloxacin.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

An 11 year old boy presents with a 1-year history of sharp sacral pain radiating to the buttock and legs, left greater than right. His past medical history is unremarkable. No focal neurologic deficits are noted on examination. However, he has a pronounced antalgic gait with a crouched, widened stance. MRI of the lumbosacral spine (Figure 1) respectively reveals a sagittal T1 weighted image with a slightly hypointense lesion extending from S1 to S3. The lesion is hyperintense on T2, and in the T1 weighted sagittal image the mass exhibits homogeneous contrast enhancement after Gadolinium injection. The axial imaging post-contrast redemonstrates the lesion within the spinal canal. The inferior aspect is located asymmetric to the left and on lower cuts there is likely extension along an exiting nerve root due to thickening and enhancement of the left S3 nerve root (not shown). No other lesions are identified within the cervical, thoracic, or lumbar spine.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

An eleven year-old male patient was addressed to our institution with headache, vomiting and right VI cranial nerve paralysis. Clinical examination did not reveal any other neurological deficits. During skin examination multiple congenital melanocytic nevi were observed (Fig 1a). MRI scans showed a leptomeningeal lesion extending from T5 to T11 (Fig 1b). This lesion was hypersignal on T1 sequence enhanced with gadolinium injection and hypointense signal on T2 sequence. At the supratentorial level a dilatation of the lateral and the third ventricle with a wide posterior fossa were found, without tumoral lesion (Fig 1c).

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

An 11 years old male patient suffered from a blunt head injury after tumbling in consequence of a short episode of vertigo and visual disturbances. Thereafter, the patient was not responsive to verbal stimuli for approximately 10 minutes and presented a retrograde amnesia. No aconuresis was observed. In the first clinical examination, the patient showed an anisocoria with a smaller pupil on the left side and only a partial light reaction. A prominent dysdiadochokinesia could be observed. EEG did not detect any epileptogenic foci but a focal wave slowing compatible with a right parieto-occipital tumor or with an intracerebral bleeding. The consecutive MRI of the neuroaxis showed an intra-axial lesion with solid parts and contrast enhancing, cystic areas (Figs. 1A-B), located in the right occipital lobe. Notably, the skull bone in the proximity of the lesion appeared thinned (Fig. 1B, arrow) but without any signs of infiltration. MRI imaging of the spine was without pathological findings. The family history was not suspicious for cancer predisposition syndromes. The lesion was surgically completely resected (Fig. 1C) and submitted to neuropathological examination (Fig. 2). The postoperative course was uneventful.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

An 11-year-old boy presented with a 10 month history of lumbar back pain and paresthesia in his thighs to the knees bilaterally, left greater than right. This pain exacerbated two weeks after falling out of a pickup truck directly onto his back. The pain was 8/10 in severity, worse at night and while supine, and typically lasted 20 minutes in duration. Relieving factors included warm baths, massage, and acetaminophen or ibuprofen. The pain was not exacerbated with physical activity and no appreciable motor weakness. There was no bladder or bowel incontinence. Since the accident, he noticed the pain was worsening in intensity and duration. Neurological exam did not reveal any objective sensory deficit.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is an 11 year old female who collapsed during an out patient clinic visit. Her past history included a diagnosis of rheumatic heart disease with valvular abnormalities made 5 years ago and she is on regular penicillin prophylaxis along with anti-coagulant and anti-failure treatment. Patient died within few hours and autopsy was performed.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 11-year-old girl was operated on for a severe left thoracolumbar scoliosis (Cobb angle 65°). Pedicular screws insertion and rod positioning was technically successful, but five days later, for signs of an early infection, a surgical wound revision was performed by debridement of necrotic tissues and hydrogen peroxide pressure irrigation of the operative field. Unexpectedly, during such procedure, the patient had two episodes of bradycardia followed by ventricular fibrillation, electromechanical dissociation, and pulmonary edema, and she died despite immediate resuscitation efforts.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

An 11-year-old female with no significant past medical history presented with symptoms suggestive of hyperthyroidism (weight loss, heat intolerance). She has also experienced a decline in grades at school. Family history is significant for thyroid disease in both grandmothers (both on thyroid replacement therapies). The clinician ordered thyroid function tests including Free T4, T3, TSH, anti-TSH receptor antibodies, antithyroglobulin and antithyroid peroxidase antibodies.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

An 18-year-old female presented to the emergency room at Children's Hospital after three episodes of seizure activity involving her entire body, with associated loss of consciousness, followed by a post-ictal state. The first two seizures lasted five minutes each with five-minute period of confusion following; the third episode lasted ten minutes, and was followed by a ten-minute period of confusion. After the second episode the patient's mother called EMS, but the patient refused transport. However, after the third episode the patient was then transported to the ED. She did not have any history of nausea, vomiting, fever, chills or headache. While in the ER the patient experienced another seizure lasting approximately thirty seconds. She has a history of a right supramarginal gyrus brain mass which has been present for approximately one year. She is followed by neurology and neurosurgery, and has repeatedly been scheduled for resection of the mass, but has not been compliant. The patient had been having seizure activity for the past five months, for which she was placed on appropriate medications. The patient was scheduled for resection of tumor on one month later.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

18 year old male with microscopic hematuria of several weeks known duration. He has no family history of renal disease and is currently not taking any medications. On physical exam, his blood pressure is normal (115/70 mmHg) and he has no edema. A renal ultrasound shows the kidneys are of normal size and shape, bilaterally.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

An 18 year-old woman presented to the emergency room with a five-day history of right upper abdominal pain accompanied by nausea with hematemesis, generalized malaise, cephalgia without provocation, fever, and diarrhea. She was a non-smoker, non-drinker and was not taking any medications (prescribed, over-the-counter, or supplements).

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

An 18-year-old nationally-ranked motocross rider presented to the hospital after crashing her motorbike in practice and tumbling over the handlebars. The patient hit her helmeted head on the ground, lost consciousness for a few seconds and then woke up confused. She was taken to the emergency room and observed overnight. Her confusion quickly resolved and her neurological exam was normal. Prior to this accident she did not have any neurological symptoms or significant medical history.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

An 80-year-old female was referred to hospital because of acute deterioration of memory and orientation. Additionally, there was weakness in the left leg. During hospitalization she developed severe neuropsychiatric deficits with auditory and visual hallucinations. Her past medical history was uneventful.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

An 80-year-old man was transferred to our institution with worsening heart failure. His past medical history was significant for Type-2 diabetes mellitus, hypertension, coronary artery disease, chronic obstructive pulmonary disease, emphysema, chronic renal insufficiency and recurrent exacerbations of congestive heart failure. In addition, approximately 5 weeks prior to this admission, he presented at another institution with acute onset of left hemiplegia. Radiographic imaging at the time revealed a right thalamic lesion interpreted to represent acute ischemic changes. He received thrombolytic therapy but showed little improvement in neurological symptoms. He was transferred to a rehabilitation program but there also showed no improvement in neurological symptoms. While in rehabilitation, recurrent heart failure required hospitalization and transfer to this institution. His cardiopulmonary function improved with treatment, but his neurologic status remained unchanged until hospital day ten when he exhibited progressive mental status deterioration. Magnetic resonance imaging (MRI) of the brain showed a ring-enhancing lesion similar to that seen six weeks earlier but now observed to extend into the right basal ganglia and medial temporal lobe with right cerebral hemispheric edema, right-to-left midline shift and asymmetric ventricles (Figure 1, The image has been inverted vertically to correlate with the gross pathologic specimen). These changes were interpreted to be characteristic of a cerebral abscess, but because of the lack of systemic findings, a high-grade intracerebral neoplasm was also considered. Because of his poor clinical status, the patient's family declined a brain biopsy. He died on the eleventh hospital day.