CASE REPORT SENIOR CLINICAL CLERKSHIP Period of April 11st May 3rd, 2 11

Na!e NIM

" Na#t$a K%!ara#, S&Ked Ro'a Ma%li#dra, S&Ked (e#i Rosita )e*i, S&Ked " +, -1 1 +, .1 1 / +, -1 1 0 " I1 " )r& H& A& Ra3$!a# 4oyo, SpS5K6

Se!ester Ad2isor

DEPARTMENT OF NEUROLOGY FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY/ RSMH

PALEMBANG 2010 ENDORSEMENT PAGE

Case Report

Suspe ! SOL
Prese#ted 7y" Na#t$a K%!ara#, S& Ked Ro'a Ma%li#dra, S&Ked (e#i Rosita )e*i, S&Ked

+, -1 +, .1 +, -1

1 1 / 1 0

Has 7ee# a33epted as o#e of re8%ire!e#ts i# %#der9oi#9 se#ior 3li#i3al 3ler:s$ip period of April 11st Mei 3rd 2 11 i# )epart!e#t of Ne%rolo9y ;a3%lty of Medi3i#e Sri*i<aya =#i2ersity > RSMH Pale!7a#9&

Pale!7a#9, April 2 11 Ad2isor

)r& H& A& Ra3$!a# 4oyo, SpS5K6

NEUROLOGY MEDICAL RECORD IDENTIFICATION Na!e A9e Se@ Address Reli9io# Ad!issio# )ate " Mr& A " .2#d ?ears Old " Male " Pale!7a#9 " Isla! " April 1, t$ 2 11

ANAMNESIS "Au!# A$%&$es's( 4$e patie#t *as ad!itted to RSMH Ne%rolo9y *ard 7e3a%se $e 3o%ld #ot *al: d%e to t$e *ea:#ess of 7ot$ le9s *$i3$ $appe#ed slo*ly& Si#3e t*o !o#t$s 7efore ad!itti#9 $ospital t$e patie#t 3o!plai# of *ea:#ess i# t$e ri9$t le9 a#d $a#d, t$e patie#t 3o!plai#ed of fre8%e#t dropped a 9lass t$at is $eld o# $is ri9$t $a#d, so!eti!es $e 3a# #ot %se $is ri9$t $a#d to eat, $e also 3o!plai#ed of fre8%e#t loose t$e ri9$t sa#dal *$e# *al:i#9& 4$ese 3o!plai#ts are ofte# a33o!pa#ied 7y $eada3$e, felt i# t$e 3ro*# area& He also ofte# for9ot *$e# $e *a#ts to say so!et$i#9& 4$ere *ere #o 2o!iti#9, sei'%res, a#d 7l%rred 2isio#& 4$e# patie#t *e#t to $ealt$ 3are, a#d t$e# 9i2e# t$ree :i#ds of dr%9s, t*o of t$e! are 2ita!i# A1 a#d A12& Patie#t still felt *ea: i# $is ri9$t le9 a#d ar!& O#e day 7efore ad!itti#9 t$e $ospital t$e patie#t *as dropped *$ile $a#9i#9 3lot$es, t$e patie#t felt *ea: i# 7ot$ le9s& 4$ere *as asy!!etry fa3e& Patie#t 3a# tal: fl%e#tly& Patie#t %se $is ri9$t $a#d do!i#a#tly for $is daily a3ti2ity& 4$ere *as $istory of sei'%re a year a9o& 4$ere *as#Bt $istory of $yperte#sio# a#d dia7etes !ellit%s& 4$e patie#t s%ffered fro! t$is ill#ess for t$e first ti!e&

PHYSICAL E)AMINATION PRESENT STATE I$!e*$%+ S!%!e Se#se N%tritio# P%lse Respiratory rate Alood press%re Cei9$t Hei9$t Ps, -'%!*' s!%!e Attit%de Atte#tio# Neu*#+#.' %+ s!%!e Head S$ape Si'e Sy!etri3 He!ato!e 4%!or "3ooperati2e "#or!al ;a3ial E@pressio# P$ysi3al 3o#ta3t " #at%ral " #or!al " E,M.(+ " s%ffi3ie#t "027eats>!i# "1/ ti!es>!i# "13 >/ !!H9 " +/ :9 " 1.3 3! L%#9s Li2er Splee# E@tre!ities De#ital " #o a7#or!ality " #o a7#or!ality " #o a7#or!ality " #o ede!a " #o a7#or!ality

" 7ra3$io3ep$aly " #or!o3ep$aly " yes " #o " #o

)efor!ity ;ra3t%re ;ra3t%re pai# (essel P%lsatio#

" #o " #o " #o " #o *ide#i#9 " #o disorder

Neck Positio# " strai9$t 4orti3olis " #o Nape of #e3: stiff#ess " #o

)efor!ity 4%!or (essels

" #o " #o " #o *ide#i#9

CRANIAL NER(ES Olfa3tori%s #er2e S!elli#9 A#os!ia Hypos!ia Paros!ia Opti3%s #er2e (is%al a3%ity Ca!p%s 2isi

Ri9$t No disorder No No No Ri9$t Not e@a!i#ed (&O&)

Left No disorder No No No Left Not e@a!i#ed (&O&S

A#opsia He!ia#opsia O3%li f%#d%s Ede!a papil Atrop$y papil Reti#a 7leedi#9 O33%lo!otori%s, 4ro3$learis a#d A7d%3e#s #er2es )iplopia Eyes 9ap Ptosis Eyes positio# Stra7is!%s E@op$tal!%s E#op$tal!%s )e2iatio# 3o#<%9ae Eyes !o2e!e#t P%pil S$ape Si'e Iso3$or>a#iso3$or Midriasis>!iosis Li9$t refle@ dire3t 3o#se#s%il

No No No No No

No No No No No

Ri9$t No si!etris No No No No No #o a7#or!ality Ro%#d E 3!! iso3$or No F F F

Left No si!etris No No No No No #o a7#or!ality Ro%#d E 3!! iso3$or No F F F +

A33essori%s Ner2e S$o%lder Raisi#9 Head 4*isti#9 Hypo9loss%s Ner2e 4o%#9e S$o*i#9 ;as3i3%latio# Papil At$rop$y )ysart$ria MO4ORIC Ar!s Motio# Po*er 4o#es P$ysiolo9i3al Refle@ Ai3eps 4ri3eps Radi%s =l#a Pat$olo9i3al Refle@ Hoff!a# 4ro!#er Leri Meyer 4rofi: LED Motio# Po*er 4o#es Clo#%s 4i9$ ;oot P$ysiolo9i3al refle@ KPR APR Pat$olo9i3al refle@ Aa7i#s:y C$addo3: Oppe#$ei! Dordo#

Ri9$t si!etris No disorder

Left si!etris No disorder

No de2iatio# #o #o #o

Ri9$t S%ffi3ie#t 3 I#3rease Nor!al Nor!al Nor!al Nor!al No#e No#e No#e No#e Ri9$t S%ffi3ie#t 3 I#3rease Ne9ati2e Ne9ati2e Nor!al Nor!al Ne9ati2e Ne9ati2e Ne9ati2e Ne9ati2e Ne9ati2e

Left S%ffi3ie#t + Nor!al Nor!al Nor!al Nor!al Nor!al No#e No#e No#e No#e Left S%ffi3ie#t + Nor!al Ne9ati2e Ne9ati2e Nor!al Nor!al Ne9ati2e Ne9ati2e Ne9ati2e Ne9ati2e Ne9ati2e

 S3$aeffer Rossoli!o Me#del Ae3$tere* A7do!i#al s:i# refle@ =pper Middle Lo*er Cre!aster refle@ SENSOR? Nodisorder PIC4=RE

Ne9ati2e Ne9ati2e No a7#or!ality No a7#or!ality No a7#or!ality Not e@a!i#ed

Ne9ati2e Ne9ati2e

(EDE4A4I(E ;=NC4ION Mi3t%ritio# " #o a7#or!ality )efe3atio# " #o a7#or!ality Ere3tio# " #ot e@a!i#ed (ER4EARAL COL=MN Kyp$osis " #o Lordosis " #o Di77%s " #o )efor!ity " #o

4%!or Me#i#9o3ele He!ato!e 4e#der#ess

" #o " #o " #o " #o

S?MP4OMS O; MENINDEAL IRRI4A4ION Ri9$t Nape of #e3: stiff#ess Ne9ati2e Ker#i8 Ne9ati2e

Left Ne9ati2e Ne9ati2e

Lasse8%e Ar%d'i#s:y Ne3: C$ee: Sy!p$isis Le9 I Le9 II DAI4 AN) EG=ILIAIRI=M Dait E8%ili7iri%! a#d Coordi#atio# Ata@ia " #ot e@e!i#ed He!iple9i3 " #ot e@e!i#ed S3issor " #ot e@e!i#ed Prop%lsio# " #ot e@e!i#ed Histeri3 " #ot e@e!i#ed Li!pi#9 " #ot e@e!i#ed Steppa9e " #ot e@e!i#ed AstasiaHA7asia " #e9ati2e Li!7 Ata@ia " #e9ati2e MO4ION AANORMAL 4re!or C$orea " #o At$etosis " #o Aallis!%s " #o )ysto#i " #o Myo3lo#%s " #o LIMAIC ;=NC4ION Motori3 ap$asia " #o Se#sori3 ap$asia " #o Apra:sia " #o A9rap$ia " #o Ale@ia " #o No!i#al ap$asia " #o LAAORA4OR? ;IN)INDS ALOO) H7 "H 9>dL Eritro3yte "H <%ta>!!3 Le%:osit "H >!!3 4ro!7osit "H >!!3

Ne9ati2e Ne9ati2e Ne9ati2e Ne9ati2e Ne9ati2e Ne9ati2e

Ne9ati2e Ne9ati2e Ne9ati2e Ne9ati2e Ne9ati2e Ne9ati2e

Ro!7er9 " #e9atif )ys!etri " #e9atif fi#9er fi#9er " #or!al fi#9er #ose " #or!al $eel H $eel " #ot e@e!i#ed Re7o%#dp$e#o!e#o# " #ot e@e!i#ed )ysdiado3$o:i#esis " #e9ati2e 4r%#: Ata@ia " #e9ati2e

" #o

4otal :olesterol Kolesterol H)L Kolesterol L)L 4ri9liseride

" 2,2 " ,/ " 1" 121

!9>dL !9>dL !9>dL !9>dL

He!ato3rit CKHNAK CKHMA

"H " -1 " 1.

2olI =>I =>I

=re%! Kreati#i# Natri%! Kali%! Calsi%!

" ,. " 1,, " 1,1

!9>dL !9>dL !!olL " 3,. !!ol>L " 2,3, !!ol>L

=RINE Epit$el Le%3o3yte Erito3yte ;ECES Co#siste#3y Sli!e Alood A!oe7a 3oli> Hystoliti3a RESUME

" #ot perfor!ed " #ot perfor!ed " #ot perfor!ed

Protei# Dl%3ose

" #ot perfor!ed " #ot perfor!ed

" #ot perfor!ed " #ot perfor!ed " #ot perfor!ed " #ot perfor!ed " #ot perfor!ed

Erytro3yte Le%3o3yte Cor! e99

" #ot perfor!ed " #ot perfor!ed " #ot perfor!ed

IDENTIFICATION Mr& A>.2 years old> !ale> !arried> Mosle!> stay i# to*#> April 1,t$ 2 111 ANAMNESIS "Au!# A$%&$es's( 4$e patie#t *as ad!itted to RSMH Ne%rolo9y *ard 7e3a%se $e 3o%ld #ot *al: d%e to t$e *ea:#ess of 7ot$ le9s *$i3$ $appe#ed slo*ly& Si#3e t*o !o#t$s 7efore ad!itti#9 $ospital t$e patie#t 3o!plai# of *ea:#ess i# t$e ri9$t le9 a#d $a#d, t$e patie#t 3o!plai#ed of fre8%e#t dropped a 9lass t$at is $eld o# $is ri9$t $a#d, so!eti!es $e 3a# #ot %se $is ri9$t $a#d to eat, $e also 3o!plai#ed of fre8%e#t loose t$e ri9$t sa#dals *$e# *al:i#9& 4$ese 3o!plai#ts are ofte# a33o!pa#ied 7y $eada3$e, felt i# t$e 3ro*# area& He also ofte# $ad for9otte# *$e# $e *a#ts to say so!et$i#9& 4$e# patie#t *e#t to $ealt$ 3are, a#d t$e# 9i2e# t$ree :i#ds of dr%9s, t*o of t$e! are 2ita!i# A1 a#d A12& Patie#t still felt *ea: i# $is ri9$t le9 a#d ar!& O#e day 7efore ad!itti#9 t$e $ospital t$e patie#t *as dropped *$ile $a#9i#9 3lot$es, t$e patie#t felt *ea: i# 7ot$ le9s& 4$ere *as asy!!etry fa3e& Patie#t %se $is ri9$t $a#d do!i#a#tly for $is daily a3ti2ity&

4$ere *as#Bt $istory of $yperte#sio# a#d dia7etes !ellit%s& 4$ere *as $istory of sei'%re a year a9o& 4$e patie#t s%ffered fro! t$is ill#ess for t$e first ti!e& E1AMINA4ION Prese#t State Se#se Alood press%re P%lse Respiratory rate 4e!perat%re N%tritio#

" 3o!pos !e#tis 5DCS 1+" E,M.(+6 " 13 > / !!H9 " 02@>!i#%te " 1/@>!i#%te " 3.,+o C " s%ffi3ie#t

Ne%rolo9i3al state !otori Motori3 f%#3tio# Motori3 f%#3tio# Motio# Po*er 4o#es Clo#%s P$ysiolo9i3al refle@ Pat$olo9i3al refle@ Se#sory f%#3tio# (e9etati2e f%#3tio# Li!7i3 f%#3tio# A7#or!al Mo2e!e#t Dait J Sta7ility Me#i#9eal Irritatio# Ri9$t S%ffi3ie#t 3 I#3rease

Ar! Left S%ffi3ie#t + Nor!al Nor!al H Ri9$t S%ffi3ie#t 3 I#3rease H Nor!al H

Le9 Left S%ffi3ie#t + Nor!al H Nor!al H

Nor!al H " Nor!al " Nor!al " No a7#or!ality " 5H6 " #ot e@a!i#ed " 5H6

LAAORA4OR? ;IN)INDS 5April 1,, 2 116 C$olesterol4otal Kolesterol H)L =re%! " 2,2 !9>dL " ,/ !9>dL 5K++6 " ,. !9>dL 51+H306

)IADNOSIS

Cli#i3al )ia9#osti3 " He!ip$arese de@tra spasti3 type F Parese N& (II de@tra 3e#tral type F Parese N& 1II de@tra 3e#tral type 4opi3al )ia9#osti3 " 4e!poroHO33ipital Etiolo9i3al )ia9#osti3" S%spe3t SOL I#tra3ra#ial

MANADEMEN4 No# Medi3atio# " H I!!o7ilisatio# Medi3atio# " I(;) NaCl 9tt 11>!i# (ita!i# A1, A., A12 3@1 ta7 Citi3oli#e 2@1+ !9 )e@a!et$aso#e 3@2a!p

PLANIND H C4 S3a# Cra#i%! H LP H MRI Cra#i%! PRODNOSIS " G%o ad 2ita! G%o ad f%#3tio#a! " 7o#a! " d%7ia ad !ala!

11

CASE ANALYSIS A&4opi3al )iffere#tial )ia9#ose Te&p#*%+ +#/e 4e!poral lo7e lesio#s ofte# prese#t *it$ rat$er 2a9%e psy3$olo9i3al pro7le!s&

4$ere !ay 7e deperso#ali'atio#, e!otio#al 3$a#9es, a#d dist%r7a#3es of 7e$a2ior& 4$ere 3a# 7e $all%3i#atio#s of s!ell, taste, so%#d a#d si9$t& 4$ere !ay 7e Dj vu i# *$i3$ t$ere is a feeli#9 of fa!iliarity as if t$e prese#t $as $appe#ed 7efore&

)ysp$asia !ay 7e #oted& (is%al field defe3ts i#2ol2e t$e 3o#tra lateral %pper 8%adra#t& 4$ere !ay 7e 3o#2%lsio#s& Ot$er psy3$olo9i3al pro7le!s i#3l%de for9etf%l#ess, f%9%e 5a dist%r7ed state of 3o#s3io%s#ess i# *$i3$ t$e patie#t see!s to perfor! a3ts i# f%ll a*are#ess 7%t %po# re3o2ery 3a##ot re3olle3t t$e!6, f%#3tio#al psy3$osis a#d fear or ra9e& 4$ere !ay 7e i#appropriate se@%al 7e$a2ior 7%t t$e Kl%2erHA%3y sy#dro!e is e@tre!ely rare&

T-'s p%!'e$!0 No deperso#ali'atio# No $all%3i#atio# of s!ell, taste, so%#d a#d si9$t 4$ere is a dysp$asia No 2is%al disorder 4$ere *as a $istory of 3o#2%lsio# 4$ere is for9etf%l#ess, f%9%e i# t$is patie#t

Te&p#*%+ +#/e %$ $#! /e e1 +u2e2

F*#$!%+ +#/e

;ro#tal lo7e t%!ors 3a# 3a%se a#os!ia& 4$is is espe3ially si9#ifi3a#t if it is %#ilateral&

12

4$ere !ay 7e a 3$a#9e i# perso#ality *it$ t$e perso# 7e3o!i#9 i#de3e#t, i#dis3reet or dis$o#est& )ysp$asia 3a# o33%r if Aro3aLs area is i#2ol2ed& He!iparesis or fits !ay affe3t t$e 3o#tra lateral side&

P%*'e!%+ +#/e Parietal lo7e lesio#s 3a# prod%3e a 2ery i#teresti#9 #e%rolo9i3al pi3t%re& 4$ere !ay 7e $e!ise#sory loss& )e3reased t*oHpoi#t dis3ri!i#atio#& Astereo9#osis is t$e i#a7ility to re3o9#i'e a fa!iliar o7<e3t pla3ed i# t$e $a#d& E@ti#3tio# 3a# 7e de!o#strated 7y as:i#9 t$e patie#t to 3lose $is eyes a#d to%3$ o#e side of $is 7ody& As: $i! to poi#t to *$ere yo% to%3$ed& Repeat t$is 7%t to%3$i#9 7ot$ sides si!%lta#eo%sly& He *ill a3:#o*led9e o#ly o#e side& 4$e patie#t !ay syste!ati3ally i9#ore o#e side of $is 7ody, 3alled se#sory i#atte#tio#& If yo% as: $i! to dra* a 3lo3: fa3e, $e o!its t$e $alf 3o#tralateral to t$e lesio#& )ysp$asia !ay o33%r& Derst!a##Ls sy#dro!e 3a# 7e 3o#9e#ital or a38%ired& 4$e , 3o!po#e#ts are" o A9rap$ia or dys9rap$ia o A3al3%lia or dys3al3%lia o ;i#9er a9#osia o LeftHri9$t disorie#tatio# O 'p'!%+ +#/e (is%al field defe3ts are dis3%ssed else*$ere& A lesio# i# fro#t of t$e opti3 3$ias!a *ill affe3t <%st o#e eye& A lesio# at t$e opti3 3$ias!a, s%3$ as a pit%itary ade#o!a, 3lassi3ally 3a%ses a 7ite!poral $e!ia#opia 5as de3%ssati#9 fi7res are affe3ted6& A lesio# posterior to t$e opti3 3$ias! *ill 3a%se a 3rossed $o!o#y!o%s field defe3t

13

5e&9& left opti3 tra3t lesio# 3a%si#9 a ri9$t $o!o#y!o%s $e!ia#opia6& A lesio# i# t$e 2is%al 3orte@ *ill 3a%se 3o#9r%e#t 3o#tralateral 2is%al field defe3ts& A 2is%al field defe3t fro! t$e eye or opti3 #er2e *ill 7e see# as a 7la3: area 7%t loss of t$e 2is%al 3orte@ ofte# leads to i9#ori#9 t$e affe3ted area& Ce*e/e++#p#$!'$e %$.+e 4$e 3o!!o#est pat$olo9y $ere is a# a3o%sti3 #e%ro!a& Co!!o# feat%res i#3l%de"

Ipsilateral deaf#ess 4i##it%s Nysta9!%s Red%3ed 3or#eal refle@ ;a3ial a#d tri9e!i#al #er2e palsies Ipsilateral 3ere7ellar si9#s

C#*pus %++#su& 4$is is a# i#teresti#9 part of t$e 7rai# t$at 3o!!%#i3ates 7et*ee# t$e t*o sides& Lesio#s %s%ally 3a%se se2ere rapid i#telle3t%al deterioratio# *it$ fo3al si9#s of ad<a3e#t lo7es& 4$ere !ay 7e si9#s of loss of 3o!!%#i3atio# 7et*ee# t$e lo7es s%3$ as i#a7ility of t$e left $a#d to 3arry o%t 2er7al 3o!!a#ds& M'2/*%'$ 4$e follo*i#9 feat%res s%99est a !id7rai# lesio#" =#e8%al p%pils I#a7ility to dire3t t$e eyes %p or do*# A!#esia for re3e#t e2e#ts *it$ 3o#fa7%latio# So!#ole#3e

1,

B3 E!'#+#., D'44e*e$!'%+ D'%.$#se 0 Tu&#* '$!*% *%$'%+ "SOL( Heada3$e te#ds to 7e 8%ite a late feat%re& It is %s%ally se2ere a#d is t$e *orst feat%re i# $alf of patie#ts& It rese!7les a te#sio# $eada3$e i# !ost 3ases 7ei#9 *orst i# t$e !or#i#9 a#d *orse o# 7e#di#9 or (alsal2a !a#oe%2re are ofte# a7se#t& A 3$a#9e i# t$e patter# of $eada3$es is a 3a%se for 3o#3er#3 Heada3$e is !ore 3o!!o# i# posterior fossa t%!o%rs a#d rapidly 9ro*i#9 t%!o%rs& It !ay 7e a !ore i!porta#t feat%re i# 3$ildre# t$a# i# ad%lts& (o!iti#9 !ay o33%r& 4$is !ay 7e *it$o%t a33o!pa#yi#9 #a%sea& Na%sea !ay 7e a feat%re A 3$a#9e i# !e#tal stat%s or 7e$a2ioral 3$a#9e is a 3a%se for 3o#3er# 4$ere !ay 7e *ea:#ess, ata@ia or dist%r7a#3e of 9ait t$at $appe# 3$ro#i3 pro9ressi2e E2e# defi3its of spee3$ or 2isio# !ay 7e poorly lo3ali'i#9 si9#s 4$ere !ay 7e 9e#erali'ed 3o#2%lsio#s S!*#5e Cli#i3al !a#ifestatio# of dist%r7a#3e of fo3al or 9lo7al 3ere7ral f%#3tio# *it$ s%dde# o#set, rapid pro9ressio# to !a@i!a defi3it a#d persit !ore t$a# 2, $o%rs or ter!i#ated 7y deat$, *it$o%t a#y 3a%se e@3ept 2as3%lar& I$ !-'s p%!'e$!0 History of $eada3$e C$a#9e !e#tal a#d stat%s 7e$a2ioral C$ro#i3 pro9ressi2e *ea:#ess )efi3it of spee3$ 4$ere *as $istory of 3o#2%lsio#s a year a9o No 2as3%lar disease Etilo9y of t$is patie#t 3o%ld 7e SOL "Sp% e O up,'$. Les'#$(

1+

REFERENCE 1& ;orsyt$ PA, Pos#er MAN Heada3$es i# patie#ts *it$ 7rai# t%!ors" a st%dy of 111 patie#ts& Ne%rolo9y& 1003 SepN,3506"1.-/H/3& Oa7stra3tP 2& P%rdy RA, Kir7y SN Heada3$es a#d 7rai# t%!ors& Ne%rol Cli#& 2 , ;e7N22516"30H+3& Oa7stra3tP 3& Na99ara O, Ara!iHQyl7er7er9 ;, Rodri9o S, et al N I!a9i#9 of i#tra3ra#ial !etastases i# ad%lts& M Radiol& 2 . M%#N/-5. Pt 26"-02H/ .& Oa7stra3tP ,& N9%ye# 4, )ea#9elis LMN 4reat!e#t of 7rai# !etastases& M S%pport O#3ol& 2 , SepHO3tN25+6", +H1 N dis3%ssio# ,11H.& Oa7stra3tP +& Soffietti R, Cor#% P, )elattre M?, et al N E;NS D%ideli#es o# dia9#osis a#d treat!e#t of 7rai# !etastases" report of a# E;NS 4as: ;or3e& E%r M Ne%rol& 2 . M%lN135-6".-,H/1& Oa7stra3tP

1.