Salient Features: SUBJECTIVE2 y/o maleSudden onset of severe headacheNumbness of the right side of the faceUpward rolling of the eye & rigidity of all extremities associated with loss of

consciousnessTwitching of the right side of the faceDysarthriaDysphagia(-) Fever(-) Trauma(+) Family history of Neurocysticercosis(+) Family history of Stroke, HPN, DM(-) Family history of TBUsually eats raw fish and meat

Salient Features: OBJECTIVE

DysarthicShallow right nasolabial foldTongue 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

crossed motor paralysis

Levelization

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: cerebrumLateralize: leftLocalization: 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 Ring-enhancing 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 Ring-enhancing 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 Ring-enhancing 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 Ring-enhancing 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 Ring-enhancing 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 Ring-enhancing 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 overviewLekha Pandit Department of Neurology, KS Hegde Medical Academy, Mangalore-575018, Karnataka, India

Differential Diagnoses for Ring-enhancing 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 overviewLekha 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) Metastases(2) Primary brain tumor(3) Abscess(4) Neurocysticercosis(5) Tuberculoma

Salient Features: SUBJECTIVE2 y/o maleSudden onset of severe headacheNumbness of the right side of the faceUpward rolling of the eye & rigidity of all extremities associated with loss of

consciousnessTwitching of the right side of the faceDysarthriaDysphagia(-) Fever(-) Trauma(+) Family history of Neurocysticercosis(+) Family history of Stroke, HPN, DM(-) Family history of TBUsually eats raw fish and meat

Impression

• Complex Focal Seizure secondary to an intracranial mass lesion on the left frontal lobe probably secondary to Neurocysticercosis