A 45-year-old woman presented with weakness in her right extremities over the past 10 days and difficulty speaking for the past 2-3 days. A clinical examination revealed paresis and sensory issues on the right side of her body as well as sensory aphasia. Imaging studies including a CT scan and MRI were ordered, with the MRI showing a lesion suspected to be a glioma in the left hemisphere of the brain. She was started on antioedema therapy but only showed slight improvement. Her case presents a diagnostic challenge due to the atypical time course of her symptoms.

1. A Baffling
Case
Mihail Petrov

2. Case History
The Patient is a 45-year-old woman
that presents at the emergency
neurosurgery department with a weakness
in her right extremities that started 10 days
ago. Since around 2 to 3 days she has
started experiencing difficulty talking. This is
why she is brought by her husband to the
department.

3. Clinical Examination
 The clinical examination reveals paresis for the
right extremities much more severe for the
arm.
 Paresis of the right CN VII and CN XII.
 Sensory aphasia
 Sensation in the left and right part of the body
was tested – the patient refused to have a
difference in sensation BUT because of the
aphasia we can’t be 100% sure of that result.
 No pathological reflexes

4. Our hypothesis
 The clinical examination leads us to think that there is some
kind of a process in the LEFT hemisphere – including the
precentral gyrus(explains the paresis), possible inclusion of
the postcentral gyrus, and the supramarginal gyrus(this
explains the aphasia).
 First a CT scan was order as it was the fastest possible study.
 The symptomatology is consistent with a stroke BUT not the
time frame of the process – we have a history of 10 days of
weakness.
 The lack of high temperature excludes infectious etiology.
 No history of a diagnosed neoplasia gives us evidence to
suspect a brain metastasis.
 The symptoms and their evolution makes us think it is more
likely a tumor that is causing brain swelling and for the last
10 days the oedema has made those symptoms worse.
 Shortly after the CT scan was conducted its result made us a
bit confused and we ordered an MRI to enlighten us. So in
this presentation will be shown slides from this MRI study.

5. T1 axial T1 axial

6. T1 coronal T1 coronal

7. T2 sagittal T2 sagittal

8. T2 axial T2 axial

10.  After the MRI study there is a suspicion of
a Glioma.
 An antioedema therapy was started.
Unfortunately with a slight improvement
on the third day.
 The type of operation is still being
discussed.

11. As a neurosurgical intern I found the course
of Prof. Mason in coursera.org extremely helpful
for a deeper understanding of the basics of
neuroscience and neurology. Every time I read or
hear parts of neuroscience from different sources
it helps me take a look at the matter from a
different perspective, which step by step helps me
to look in to the matter even further.
The assumptions made just after the clinical
examination are to some extend influenced by
the things learned in the course.
Thank You Prof. Mason for the dedication
and for the enthusiasm.