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Extensive subcortical white matter, deep grey matter and brainstem oedema in a confused patient: Question
Journal of Clinical Neuroscience 41 (2017) 61–62
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Images
Extensive subcortical white matter, deep grey matter and brainstem oedema in a confused patient: Question Bryony Blakeway a, Steven Law a,⇑, Sanjeev Rajakulendran a,b a b
North Middlesex University Hospital, Sterling Way, London N18 1QX, United Kingdom The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, United Kingdom
A 70 year old female presented with a history of headache, confusion, drowsiness and impaired mobility. Her past medical history was notable for haemolytic anaemia and a left-sided occipital infarct two years previously. On examination she was
noted to be confused with a fluctuating level of consciousness. No focal neurological signs were observed. She was not meningitic. An initial CT head showed an old left occipital lobe infarct. A CSF examination demonstrated a white cell count of 25 109/L
Fig. 1. Initial MRI brain. Axial T2W/FLAIR images at the level of the basal ganglia (A) and midbrain (B) demonstrating extensive subcortical oedema affecting the white matter, basal ganglia, internal and external capsules and midbrain.
DOI of answer: http://dx.doi.org/10.1016/j.jocn.2017.02.059
⇑ Corresponding author at: Neurology Department North Middlesex University Hospital, Sterling Way, London N18 1QX, United Kingdom. Fax: +44 020 8887 4414. E-mail addresses: [email protected] (B. Blakeway), [email protected] (S. Law), [email protected] (S. Rajakulendran). http://dx.doi.org/10.1016/j.jocn.2017.02.031 0967-5868/Ó 2017 Published by Elsevier Ltd.
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(100% lymphocytes), a raised protein of 1.7 g/L and a glucose 3.9 mmol/L. Viral PCR was negative for HSV and VZV. Her conscious level deteriorated culminating in a drop of her Glasgow Coma Scale (GCS) to 7 (E2, V2, M3) necessitating admission to the intensive care unit. She underwent an MRI brain which demonstrated extensive subcortical oedema affecting the white matter tracts, deep grey nuclei, brainstem and cerebellum with several foci of microhaemorrhages (Fig. 1A and B).
MCQ: What is the most likely diagnosis? (a) (b) (c) (d)
Viral encephalitis CNS Lupus Lymphoma Multiple embolic infarcts
Answer on page 174.
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Images
Extensive subcortical white matter, deep grey matter and brainstem oedema in a confused patient: Question Bryony Blakeway a, Steven Law a,⇑, Sanjeev Rajakulendran a,b a b
North Middlesex University Hospital, Sterling Way, London N18 1QX, United Kingdom The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, United Kingdom
A 70 year old female presented with a history of headache, confusion, drowsiness and impaired mobility. Her past medical history was notable for haemolytic anaemia and a left-sided occipital infarct two years previously. On examination she was
noted to be confused with a fluctuating level of consciousness. No focal neurological signs were observed. She was not meningitic. An initial CT head showed an old left occipital lobe infarct. A CSF examination demonstrated a white cell count of 25 109/L
Fig. 1. Initial MRI brain. Axial T2W/FLAIR images at the level of the basal ganglia (A) and midbrain (B) demonstrating extensive subcortical oedema affecting the white matter, basal ganglia, internal and external capsules and midbrain.
DOI of answer: http://dx.doi.org/10.1016/j.jocn.2017.02.059
⇑ Corresponding author at: Neurology Department North Middlesex University Hospital, Sterling Way, London N18 1QX, United Kingdom. Fax: +44 020 8887 4414. E-mail addresses: [email protected] (B. Blakeway), [email protected] (S. Law), [email protected] (S. Rajakulendran). http://dx.doi.org/10.1016/j.jocn.2017.02.031 0967-5868/Ó 2017 Published by Elsevier Ltd.
62
B. Blakeway et al. / Journal of Clinical Neuroscience 41 (2017) 61–62
(100% lymphocytes), a raised protein of 1.7 g/L and a glucose 3.9 mmol/L. Viral PCR was negative for HSV and VZV. Her conscious level deteriorated culminating in a drop of her Glasgow Coma Scale (GCS) to 7 (E2, V2, M3) necessitating admission to the intensive care unit. She underwent an MRI brain which demonstrated extensive subcortical oedema affecting the white matter tracts, deep grey nuclei, brainstem and cerebellum with several foci of microhaemorrhages (Fig. 1A and B).
MCQ: What is the most likely diagnosis? (a) (b) (c) (d)
Viral encephalitis CNS Lupus Lymphoma Multiple embolic infarcts
Answer on page 174.