Case 351 -- Acute loss of strength in right upper extremity and slurred speech

Contributed by Amilcar A Castellano-Sanchez, MD and Daniel J Brat, MD, PhD
  Department of Pathology and Laboratory Medicine. Emory University School of Medicine. Atlanta, Georgia
Published on line in May 2003


A woman in her 50s presented to the emergency room after her family noticed she was slurring her speech at dinner. She had also experienced a loss of strength in her right arm, which was noticed when she nearly dropped her dinner plate from her right hand. She had never had a similar episode in the past. There was no history of head trauma. Her past medical history included idiopathic hypertrophic subendocardial stenosis (IHSS), arthritis, asthma, congestive heart failure, hypertension and NIDDM.

Physical examination showed normal vital signs. There was no difficulty breathing, chest pain, or headache. Neurologic evaluation demonstrated an awake and alert, right-handed female oriented to person, place, and time. She was noted to have persistent word finding difficulty and was unable to name a pen and a watch. At the time of neurological testing, the patient's motor and sensory function had essentially returned to normal. Cranial nerves were intact bilaterally and deep tendon reflexes were symmetric and slightly reduced. Her gait was unremarkable and Romberg testing was negative.


PCR studies performed on the cerebrospinal fluid (CSF) were negative for CMV, HSV, and tuberculosis. CSF cryptococcal antigen was negative. PPD and HIV tests were negative, as were serologies for Histoplasma and Coccidioides. Hemogram, glucose, and electrolytes were within normal limits.


Computed tomography (CT) and magnetic resonance imaging (MRI) scans with contrast showed widening of the subdural and subarachnoid spaces over the left posterior parietal lobe that was associated with significant contrast-enhancement. Cortical vessels underlying the meningeal enhancement were also prominent and on MRI FLAIR images vasogenic edema was noted in the white matter (Fig. 1). The lesion was bright on T2-weighted images. These findings suggested an infectious or inflammatory process involving the meninges and underlying brain. A questionable contusion involving the right mid parietal lobe was also noted. Thallium-201 spectroscopy demonstrated focally increased activity in the parietal lobe lesion, raising the possibility of a neoplasm, such as meningioma or lymphoma. The patient was admitted with the presumptive diagnosis of transient ischemic attack probably due to her history of heart failure and IHSS, asthma and non-insulin dependent diabetes mellitus.


A left temporo-parietal craniotomy was performed and a portion of the thickened dura and underlying meninges was biopsied. The adjacent brain appeared slightly edematous and congested.



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