Ahmad Salh Soboh

Final 05.06.2023

Case number + Diagnosis Symptoms Keywords in the Case Localization Differential Diagnosis
• a 60 year-old woman
• Impaired speech
• swallowing
• vertigo
• dizziness
• numbness of the left side
of face.
• She is little confused, but
• Dysphagia
answers all questions
• Hoarseness,
without mistakes.
• Decrease of gag reflex,
• Attempted vomiting 1. Posterior Inferior
• Hiccups.
• History of disease include Cerebellar Artery (PICA)
• Vomiting
several transient ischemic ischemic stroke
• Vertigo,
attacks last two weeks. 2. Posterior Inferior
• Nystagmus Left posterior Inferior cerebellum
• speech is impaired - Cerebellar Artery (PICA)
• Decrease pain and & medulla.
1. PICA dysarthria. hemorrhagic stroke
temperature sensation (Ipsilateral - Right or Left in the
• left side observed 3. Intracerebral
from contralateral body, same side of symptoms)
dysmetria and intention hemorrhage in posterior
and Ipsilateral face.
tremor. fossa
• Ipsilateral Horner
• Superficial sensation loss 4. Cerebral tumor of
syndrome (Ptosis, miosis,
on left side of face posterior fossa
anhidrosis).
• in the trunk and limbs on
• Ipsilateral ataxia,
the opposite side.
dysmetria.
• Gag reflex is decreased,
soft palate is not contacted
on the left side;
• nystagmus, ptosis
• No plantar response is
present.

2. Meningoencephalitis headache, low-grade fever, “Pilot or Aircraft man” + Meningoencephalitis: 1. Meningoencephalitis

 Ahmad Salh Soboh

myalgias, and malaise often

Brain parenchyma (affecting grey
precede the onset of ADEM 2. Tick borne Encephalitis
matter of cerebrum  “polio
and MENINGITIS by a few 3. Lethargic Encephalitis
Meningeal symptoms + NO encephalitis”) + Leptomeninges.
days 4. Viral Meningitis
measles vaccine = Dx:
Meningoencephalitis
• in ADAM clinical signs are or
or
motor deficit, followed by
or
sensory deficits, brainstem 1. Acute Disseminated
Acute disseminated Acute disseminated
signs, and cerebellar signs. Encephalomyelitis
Encephalomyelitis “Pilot or Aircraft man” + Encephalomyelitis (ADEM):
CSF findings are variable, (ADEM)
(ADEM) “Measles vaccine” = Dx: Brain parenchyma (mainly white
normal results were pres- 2. Multiple Sclerosis
ADEM matter) & spinal cord due to
rent in up to 20 percent of 3. Optic nerve glioma
inflammation & demyelination.
patients. Oligoclonal bands 4. Optic neuritis
were positive in over 60 5. Transverse myelitis
percent.
• Dysphagia
• Hoarseness,
A 45-year-old
• Decrease of gag reflex,
• Voice hoarseness
• Hiccups.
• No gag reflex
• Vomiting 1. Posterior Inferior
• difficulty swallowing.
• Vertigo, Cerebellar Artery (PICA)
• right eye miosis
• Nystagmus ischemic stroke
• right eye lid dropping,
• Decrease pain and 2. Posterior Inferior
• loss of pain and Right posterior Inferior
temperature sensation Cerebellar Artery (PICA)
temperature in the right cerebellum & medulla.
3. SCA from contralateral body, hemorrhagic stroke
side of the face. (Ipsilateral - Right or Left in the
and Ipsilateral face. 3. Intracerebral
• Patient also had vertigo, same side of symptoms)
• Ipsilateral Horner hemorrhage in posterior
nystagmus, dysarthria, and
syndrome (Ptosis, miosis, fossa
right-hand ataxia.
anhidrosis). 4. Cerebral tumour of
• His left hand has loss of
• Ipsilateral ataxia, posterior fossa
pain and temperature
dysmetria.
(including the trunk).

4. Lacunar infarct of the Paramedian Lesions 1- • History of TIA. Base of the brainstem at the 1. Tumor in posterior
Pontine arteries Cause: Multiple lacunar • Face is drooping level of pons. fossa.
 Ahmad Salh Soboh

infarcts.
Symptoms and sign:
• Unilateral lesions
(mediolateral or
mediocentral) cause
contralateral paralysis,
especially in the distal limb
on one side of face. Half
muscles.
side facial palsy.
• dysarthria
• Abducens palsy (nose rest
• unilateral or bilateral
position) and contralateral
ataxia.
hemiplegia.
• sometimes contralateral
• TIA history
facial and abducens
palsies.
2- 60-year-old man 2. Hemorrhage in
• Bilateral lesions cause
• presents with weakness posterior fossa
pseudobulbar
on the left side (involving 3. Vertebrobasilar artery
palsy and bilateral
arms, trunk, legs). hemorraghic stroke
sensorimotor deficits.
• On examination, patient 4. Vertebrobasilar artery
had ptosis, paralysis of the ischemic stroke
• Ipsilateral to the facial
face of the right side and
sensory loss.
impaired lateral gaze on
• Loss of all modalities in
the right side.
the limbs (depending on
• Patient temperature is 38
the extent of the lesion).
and BP is 150/98.
• Loss of pain and
temperature on the
opposite side of the face
with or without “muzzle”
area sparing and a lateral
gaze palsy towards that
side

5. Subarachnoid SAH can include sudden and SAH  Bleeding in subarachnoid 1. Subarachnoid
hemorrhage severe headache, nausea and space (between arachnoid Hemorrhage
or vomiting, sensitivity to light, matter and pia matter) 2. Meningitis
 Ahmad Salh Soboh

confusion, loss of
consciousness, seizures, and
neck stiffness.
+ Actually meningeal
symptoms:
I. Neck stiffness
II. Kernig’s sign
III. Brudzinski’s sign
Meningitis
1. Syndrome of infection
disease (General infectious
symptoms):  This can be
fever, general fatigue, aching
pain in muscles, inflammatory
changes in peripheral blood
2. Meningeal syndrome
A. General cerebral
symptoms: Headache, Meningitis  Leptomeninges
3. Meningismus
Meningitis vomiting, psychomotor (pia and arachnoid matter) in the
agitation, photophobia, 4. Meningoencephalitis
brain and spinal cord, due to
impaired consciousness, and infection.
seizures.
B. Actually meningeal
symptoms are divided into
general hyperesthesia and
hypersensitivity of the sense
organs, reactive pain
phenomena and tonic muscle
tension.
Manifestations of tonic muscle
tension include:
I. Neck stiffness
II. Kernig’s sign
III. Brudzinski’s sign
3. Syndrome of inflammatory
changes in CSF

6. Guillain-Barre Syndrome # Their onset is 1–4 weeks In Case (”Influenza Virus” + Schwann cell degeneration – 1. Amyotrophic Lateral
after a respiratory or “coffee cup” + “knife”) leading to demyelination of Sclerosis.
gastrointestinal infection in peripheral nervous system 2. Multiple Sclerosis
 Ahmad Salh Soboh

two-thirds of all cases.

• Ascending weakness +
loss of reflexes = GBS.
• Symmetrical weakness
3. Myasthenia Gravis
• Areflexia (polyneuropathy)
4. ADEM
• Paresthesiae
• Cranial nerve deficits (VII,
often bilateral; III, IV, VI, IX,
X)
1.
2.
7. 3.
4.

1.
2.
8. 3.
4.

“Cape-like” or “Jacket-like”
loss of pain and
9. Syringomyelia
temperature sensation in
bilateral upper extremities.
1. Syringomyelia
2. Hematomyelia
3. Intramedullary tumor
Syrinx cavity in the central canal 4. Arnold-Chiari
26 yo woman , clumsiness ,
of spinal cord at the level of C5– malformation Type 1 
burn hand not feel.
C8 or T1-T2. [Associated with spinal
cavitations
(syringomyelia)]
5. Disc herniation

10. Myasthenia Gravis Observed pathology of 1-Pt. has diplopia, drooping Nicotinic ACH receptors on post- 1. Myasthenia Gravis
extraocular muscles eyelid, muscle weakness synaptic membranes of skeletal 2. Lambert-Eaton
diplopia (double vision) and with repetitive movement. muscle at the Myasthenic Syndrome
ptosis (drooping 2-Diplopia,morning and neuromuscular junction 3. Multiple Sclerosis
 Ahmad Salh Soboh

worsens as time
passes,extra ocular muscle
of eyelid)
not working,no oculomotor 4. Thymic Hyperplasia
Feel weak and tired at the
Damage 5. Thymoma (Thymus
end of the day, especially
3- Diplopia ptosis.  Tumor)
after repetitive movements
symptoms are not in
morning
1.
2.
11.
3.
4.
1.
2.
12.
3.
4.
• Staggering gait  Posterior column (posterior 1. Hereditary Friedrich’s
• Frequent falling, bulbothalamic tract) ataxia.
21-year-old with mild
• Nystagmus dysarthria  Lateral column ( anterior and 2. Pierre-Marie ataxia
scoliosis, pes cavus and
13. Hereditary Friedrich’s • Pes cavus posterior cerebellar tract and 3. Charcot Marie Tooth
hammer toes, mild
ataxia • Hammer toes lateral corticospinal tract) disease
dysarthria, gait disorders,
• Diabetes mellitus 4. Peripheral Ataxia
falling.
• hypertrophic Degeneration of:
cardiomyopathy.  Lateral corticospinal tract
• A 12-year-old boy (spastic paralysis).
• gait disorder  Spinocerebellar tract
• play and has been falling (ataxia).
• from Russia  Dorsal columns (decrease
Exam: vibratory sense, proprioception).
• Mild scoliosis  Dorsal root ganglia
• Pes cavus with hammer (loss of DTRs).
toes.
• He is mildly dysarthric.
• Bilateral horizontal
nystagmus.
• Absent vibration and
proprioception in the LE
 Ahmad Salh Soboh

• Positive Romberg sign.

• Cerebellar examination
shows him to be ataxic,
• DTR (Deep tendon
reflexes) are absent
• Bilateral Babinski sign.
1.
2.
14. 3.
4.

1.
2.
15.
3.
4.
1.
2.
16.
3.
4.
1.
2.
17.
3.
4.
1.
2.
18.
3.
4.
1.
2.
19.
3.
4.
20. Spinal cord 1- 45yo male, car accident, Hemi-section of spinal cord at 1. Spinal cord
compression due to conscious but sedated, due the level of C5-C6, on the left trauma/compression
trauma to severe back ache, he side (presenting as Brown- 2. Spinal cord contusion
shows both sensory and Sequard syndrome). 3. Spinal cord
 Ahmad Salh Soboh

pathologic weakness of left

upper limb along with loss
of tendon reflex, central
palsy in left lower limb. On
opposite side loss of pain, concussion
temp and tactile. 4. Brown-Sequard
syndrome
2- 45-year-old, car
accident, opposite side loss
pain

1- 50 y/o woman, irregular

21. Huntington disease
22.
23. Viral (HSV) Encephalitis
Symptoms typically movements of hands &
manifest between age 30 legs, increased tone of
and 50: limbs, dystonia (torsion
• Chorea (sudden, jerky, dystonia)
purposeless movement). used to forget daily work,
• Athetosis (writhing, snake slow thinking, speech
like movement). issues.
• Personality changes. 2- 46 y/o man,
• Aggression, deteriorative cognitive
• Depression function, started to do
• Dementia (sometimes think slowly, speech
initially mistaken for problems, personality
substance use). changes, fidgeting at night,
memory loss
1-60 yr old women,
• high fever,
• she got tonic-clonic
seizure and fell into coma.
• After 2-3days/ not sure of
days) she recovered from
1. Huntington’s disease
 Neurodegeneration of
2. Parkinson’s disease
Caudate nucleus and Putamen in
3. Alzheimer’s disease
the Basal Ganglia.
4. Wilson disease
1.
2.
3.
4.
 Panencephalitis therefore 1. Viral Encephalitis
affects both the grey and white caused by Herpes
matter of the brain parenchyma Simplex Virus
(bodies of neurones) Inferior 2. Tick borne
frontal and temporal lobes Encephalitis
3. Lethargic Encephalitis
 Ahmad Salh Soboh

coma....
• NEW VISION hospital.
Neurological exam results:
• Lower limb paralyzed and
cannot walk,upper can't
take object and move.
• Confused
• difficulty with
communication.
4. Viral Meningitis
(Herpes)
2-Wife husband 9 months
illnes
• Loss consciousness
several days again
consciousness
• NVU hospital
• problem with gait
specech
• Seizures
1.
2.
24.
3.
4.

1.
2.
25.
3.
4.

26. Middle Cerebral Artery • Contralateral weakness of
(MCA) Ischemic Stroke upper extremities and face.
• Contralateral sensory loss
of upper extremities and
face.
• Contralateral visual field
cut.
69-year-old woman has
hypertension and Diabetes
mellitus, she has weakness
in her right arm and face
(right side paresis) and this
afternoon her husband said
that she had drunken
 Middle and lower part of the
precentral gyrus of frontal lobe
on Left side.
Drunken speech (Aphasia) Left
MCA
1. Middle Cerebral
Artery (MCA) Ischemic
Stroke
2. Middle Cerebral
Artery (MCA)
Hemorrhagic Stroke
3. Intracerebral

Left MCA  Aphasia.
Right MCA  Left sided
neglect.
• Damage of Broca's area
causing defects in language
expression.
• Damage of Wernicke's
area, causing defects in
language comprehension.
Can compress 4th ventricle,
causing noncommunicating
hydrocephalus 
27. Sub-tentorial tumour
headaches, papilledema.
Can involve the cerebellar
vermis  truncal ataxia.
28.
Ahmad Salh Soboh
speech, drooping in the
corner of her mouth and
haemorrhage
no loss of vision.
4. Subarachnoid
hemorrhage
Diabetes , HTN , speech
problems
• 7-year-old
1. Sub-tentorial tumour
• Migraine
2.Tumor in The posterior
• HAs over the past 3
fossa
months.
Below the tentorium Cerebelli 3. Cerebellar hematoma
• Not responded to
affecting the: (compresses the
ibuprofen.
1. Cerebellum brainstem) or
• Vomiting
2. Pons (VI) Hemorrhage in the
• Blurry vision
3. Medulla posterior fossa
• Mild papilledema
4. Roof of fourth ventricle 4. Pineal tumour
• Bilateral CN VI nerve
5. Medulloblastoma
palsies.
(need Biopsy for
• Mildly dystaxic (but not
diagnosis)
dysmetric)
1.
2.
3.
4.