Severson Cases

Question 1

Sx: Progressive loss of sensation in both upper extremeties over three years. Loss of pain and temp over affected areas. Atrophy of small muscles of both hands. Normal cranial nerves, gait, and reflexes.

Answer 1

Spinal
Midline
Mass
Neoplasm

Dx: Syringiomyelia

Pathophys: Cyst or cavitation of spinal cord compressing anterior white commisure affecting STT at level of lesion and +/- 2 dermatomes due to ascension/descension of Lissauer’s tract.

Question 2

Sx: Sudden weakness in right upper and lower extremeties. Increased right DTR. Babinski on right, decreased proprioception on right and tongue protrusion to left.

Answer 2

Posterior fossa
Left
Nonmass
Vascular

Dx: Stroke of anterior spinal artery (Middle medullary Syndorme)

Segmental: Tounge deviates left.

Question 3

Sx: Sudden onset of nausea and vertigo. Hoarse voice. Anxious and perspiring, except on the left side of her face. Left miosis and ptosis. Horizontal and rotary nystagmus. Left side of palate was drooping, and left gag reflex was absent. Normal muscle strength and DTRs. Moderate incordination of left upper and lower extremities. Loss of pain and temp in right upper extremity, trunk, and lower extremity. Loss of pain and temperature on left side of her face. Epicritic touch and vibration in touch on entire body.

Answer 3

Posterior Fossa
Left
Nonmass
Vascular

Dx: Left PICA stroke (Lateral medullary syndrome) (Wallenberg Syndrome)

Segmental signs:
Gag relex, palate drooping, hoarsness (CN X)
Vertigo, nausea, dizziness, nystagmus (CN VIII)
Poor coordination (Spinocerebellar tract)
Loss of pain and temp on left face (spinal nucleus of Trigeminal Nerve)

Question 4

Sx: Gradual onset of tingling in feet and later shooting leg pain. Six months ago she developed neck pain, coughing and sneezing aggravated the pain. Three months ago the pain became worse and she has trouble walking in the dark. When walking in the light she has to look at the ground to stop from falling to the ground. One month ago she noticed decreased ability to perceive objects in her hands.

No muscle weakness or atrophy. No patellar tendon reflex. Hypotonia. Loss of sense of proprioception, vibration bilaterally in upper and lower extremities. Loss of two point discrimination.

Answer 4

Peripheral/Spinal
Diffuse
Nonmass
Degenerate.

Rx: Tabes Dorsalis secondary to tertiary syphilis

DORSALIS:
Dorsal column degeneration
Orthopedic pain (legs)
Reflexes decreased
Shooting pain
Argyll-Robertson pupils
Locomotor ataxia
Impaired proprioception
Syphillis

Rx: Penicillin and Opiates.

Question 5

Sx: Sudden left facial paralysis and left facial and right body numbness. Difficulty using left hand. Inability to wrinkle forehead or smile on left side. Decreased sensation to pinprick over the left face and right body. Ptosis and miosis of left eye, and decreased coordination of left hand and leg. Muscle strength and DTRs normal.

Answer 5

Posterior Fossa
Left
Nonmass
Vascular

Dx: Lateral pontine syndrome. AICA stroke

Key difference between lateral pontine and lateral medullary syndrome is cranial nerves involved (Spinal V and VII vs X)

Tracts lost: 
Spinal Trigeminal
Spinothalamic
CN VII
Hypothala-reticulospinal (sympathetic)
 inferior cerebellar peduncle

Question 6

Sx: Ataxia. History of “pins and needles” in feet and hands that spread to knees and elbows. Past 18 months progressive gait incoordination and leg weakness. Positive Romberg. Weak leg flexors. Reflexes decreased in arms and absent in legs. Positive babinski. Decreased proprioception. Vibration absent to the iliac crest. Touch, pain, and temp are not significantly impaired. Anal reflex and tone normal. EMG shows absent sensory potentials in lower extremeties.

Answer 6

Spinal
Diffuse
Nonmass
Degenerative

Segmental signs: Feet and hands

Dx: Vitamin B12 Defeciency

Tests to order: B12 level, CBC, LFT

Question 7

9 month insidious onset of progressive weakness and atrophy involving lower extremeties. Feet can’t be lifted off ground, but dragged by hips. Similar but lesser involvement of upper extremeties.

Exam revealed widespread muscular atrophy and weakness of all extremeties. Twitching seen under skin. 3+ reflexes except 2+ right achilles and 0-1 left achilles. Clonus bilaterally. Positive babinki. Sensory and cerebellar examinations were normal.

Answer 7

Spinal
Diffuse
Nonmass
Degenerate

Dx: Amyotrophic Lateral Sclerosis (ALS)

Ppy: Degeneration of cortical spinal tracts and anterior horns. (Upper and Lower motor neurons)

Question 8

Sx: Sudden double vision and weakness of the left side of body. Right eye ptosis, mydriasis, and positioned down and out. Left sided hemiparesis and left-sided hyperreflexia. Left babinski is positive. Patient could wrinkle his forehead, but when asked to smile the left lower side of mouth drooped. When asked to protrude his tonge it deviated left.

Answer 8

Posterior Fossa
Right
Nonmass
Vascular

Dx: Weber Syndrome (stroke in paramedian branch of PCA ventromedian midbrain)

Segmental signs: R. eye ptosis, dilation, deviation down and out –> occulomotor nerve.