Case 22

Basic Human Neuroanatomy

A Clinically Oriented Atlas

Case History #22

Date of Consultation: 11-2-1984

HISTORY OF PRESENT ILLNESS:

This 67-year-old right-handed Hispanic male retired miner was referred for neurological consultation because of recent onset of a new type of headache and syncope. The patient gave a history of quite frequent holocephalic headaches over the previous 50 years. These headaches were previously evaluated, and a diagnosis of chronic
tension-type headache had been established.

However, 3 months prior to consultation, the patient experienced a definite change in his symptoms. Up until that time, he had been running 3 miles a day and often walked as much as 13 miles a day. The patient then began to experience fatigue and weight loss and had lost approximately 30 pounds in the 3 months prior to consultation. He also began having increasing headaches, which seemed to be of somewhat different quality to him than his previous headaches. These were often accompanied by lightheadedness and a woozy sensation. He also was experiencing nausea and vomiting with the headaches, which had not been present previously. Over the previous 2 to 3 months, the patient noted unsteadiness on his feet and a good deal of difficulty with keeping his balance while walking. He would often have to hold on to family members or brace himself against the wall when attempting to walk. On the day of consultation, the patient experienced two episodes of loss of consciousness immediately after arising from a sitting or lying position. He was also having more difficulty with vomiting in the two to three days prior to consultation.

NEUROLOGICAL EXAMINATION:

Mental Status Exam: Intact.

Cranial Nerves: Intact.

Motor System: Intact.

Reflexes: Intact and symmetric. Plantar reflexes were flexor bilaterally.

Sensory System: Intact.

Cerebellar Functions: The patient performed finger-to-nose, heel-to-shin, and rapid alternating movements normally in all 4 limbs. There was some degree of slowness in the performance of the movements but no evidence of intention tremor, dysmetria, or dyssynergia.

Gait and Stance: Regular gait was performed on a widened base and was extremely ataxic. He had a tendency to stagger and lose his balance, although there was no tendency to veer to one side or the other. He was unable to maintain his balance unless he was supported by another person or was able to hold on to an object. The Romberg test was negative

Questions

1. Do you think that the patient's 50 year history of headache is related to his present neurologic condition?

2. What is the significance of the recent onset over 2 to 3 months of increasing headache, dizziness, frequent nausea and vomiting, and loss of consciousness? Do these indicate involvement in a localized area of the brain or some other process? If the latter is true, what type of process is involved?

3. What is the localizing significance of the findings on neurologic examination; especially those having to do with gait and stance?

4. What area of the nervous system is involved by the pathologic process? Which side of the nervous system is involved?

5. In general, what type of pathologic process do you think is involved in this case?

6. What is the most likely pathologic diagnosis?

7. What diagnostic procedure(s) would you undertake at this point?

Answers