1. Unsteadiness Year 2 Michaelmas Term 2006

2. The case.. A 56 year old man presented to his GP with a persistent right-sided headache in the occipital-parietal region, requiring analgesia GP thought headache might be due to neck problem and referred him for physiotherapy

3. Then… 2 weeks later GP asked to do a home visit as patient become unsteady and unable to walk Headache more severe and associated with nausea and vomiting He now felt very unsteady and found sitting up in bed distressing The GP arranged hospital admission

4. Other features of the history: Headache worse in the mornings Headache worse if coughs or strains Patient unsteady on walking with tendency to fall to the right No previous history No medication Minimal alcohol Ex-smoker 30 years

5. On examination: Cardiovascular, respiratory, abdominal systems unremarkable Power, tone, reflexes normal Eyeballs jerk to right side when looks to right Right-sided finger-nose test abnormal with past pointing and intention tremor Heal-shin test on right side abnormal Unsteady when standing with tendency to fall to right

6. What causes unsteadiness? (Ataxia)

7. Causes of ataxia Cerebellar ataxia Sensory ataxia (vestibular, visual and proprioceptive defects) Disorders of locomotion: central disorders e.g MS, stroke peripheral disorders e.g. nerve damage, peripheral neuropathy

8. Which is the area of the brain involved in this case?

9. The right side of the cerebellum, because: Abnormal finger-nose test with intention tremor and past-pointing (dysmetria) on R Abnormal heel-shin test on right May also have dysdiadochokinesis on R Could also test for Romberg’s sign- stand with eyes open and closed. Positive Romberg’s= unsteady when close eyes (not specific for cerebellar lesion)

10. What is the medical term for jerky eyeballs?

11. Nystagmus Tends to be worse towards the affected side May also be congenital- can be linked with albinism and Down syndrome May be linked with other eye conditions or a number of neurological disorders, e.g MS, stroke Seen in alcoholic poisoning

12. What processes could be causig the symptoms in this patient?

13. A right-sided cerebellar lesion, due to… Space-occupying lesion: primary or secondary tumour Cerebellar abscess Cerebellar haemorrhage or haematoma Inner ear disease? Demyelination? Long-standing excess alcohol intake?

14. n.b. in cerebellar lesions the symptoms and signs usually involve the same (ipsilateral) side

15. Why has he got a headache and what further examination might help?

16. Headache a sign of raised intracranial pressure Worse in mornings Suggestive of space-occupying lesion Examination of the fundi would demonstrate papilledema

18. Any further investigation required?

19. Further investigation: CT/MRI CXR ?tumour markers ?bronchoscopy ?Biopsy

21. Other results: CXR normal Bronchoscopic washings: small cell carcinoma

22. The patient’s progress Transferred to neurosurgical unit High-dose steroids Lesion excised Commenced radiotherapy Died after 6 weeks