1. Presentation
72 yo male, lives at home with wife. Four children, retired engineer
PC: Progressive right-sided weakness
HPC:
Tripped and fell playing tennis 2/52 ago.
No LOC.
No injuries.
Progressive difficulty using L upper extremity
Progressive weakness in L leg
Headaches of progressive frequency and intensity

2. History PMHx: BPH, melanoma PSHx: melanoma removed 5 yrs ago
Allergies: penicillin
Social: Married with four adult children.  Lives at home with his wife.  Retired engineer
Cigarettes: None.
Alcohol: glass of wine nightly

3. Exam O/E Afebrile; BP 136/85; HR 92; RR 16
Alert and oriented to person, place & time;  CNs intact
Healing ecchymosis on the right forearm and thigh.
Increased tone in the left upper extremity.  No associated muscle fasciculation or muscle wasting
Pronator drift is noted on the left side.
Weakness (4/5) is noted in all motor groups of the left upper extremity.
Reflexes are brisk and symmetric throughout the upper and lower extremities.  Extensor plantar response on the left.

4. Pronator drift There are only three causes for drift of the arms:
Upper motor neurone (pyramidal) weakness. The drift of the affected limb(s) here is due to muscle weakness and tends to be in a downward direction. The drifting typically starts distally with the fingers and spreads proximally. There may be slow pronation of the wrist and flexion of the fingers and elbow.
Cerebellar disease. The drift here is usually upwards. It also includes slow pronation of the wrist and elbow.
Loss of proprioception. The drift here (pseudoathetosis) is really a searching movement and usually affects only the fingers. It is due to loss of joint position sense and can be in any direction.

5. Is this an upper or lower MN lesion?
Signs of upper motor neurone (pyramidal) lesions
Weakness
Very little muscle wasting.
Increased tone is present (may be clasp-knife, may have clonus).
The reflexes are increased (except absent superficial reflexes).
Extensor (Babinski) plantar response (upgoing toe).
Signs of lower motor neurone lesions
Wasting is a prominent feature.
Tone is reduced.
Reflexes are reduced
Plantar response is normal or absent.
Fasciculation may be present.

6. DDx
Progressive hemiparesis + progressively worse headaches + fall 2/52 + elderly
How is hemiparesis different to hemiplegia?
What is missing for a diagnosis of acute subdural hematoma?
Has had a melanoma.

7. Differential diagnosis
Hemiparesis – UMN weakness affecting both limbs on one side
Subacute hemiparesis DDx (Harrison’s 17e Chapter 23)
Subdural hematoma (PDx from age and history)
Cerebral abscess, meningitis, parasitic infection
Neoplasm
AIDS (toxoplasmosis, CNS lymphoma)
Others (rare, headache doesn’t fit):
Sarcoidosis, Multiple Sclerosis, Cerebral Lupus

8. Investigations Brain CT or MRI Complete blood count
Consider Spinal MRI if no pathology found
Complete blood count
Coagulation profile
Electrolytes
Type and screen/cross
(Medscape, Harrison’s chapter 23)

9. CT

10. What would we expect to see with an epidural hematoma?

11. Subdural hematoma Aetiology Where do they typically occur?
Head trauma – shearing forces – rupture of bridging veins (arterial rupture 20-30%), more likely in the elderly
Where do they typically occur?

12. Subdural hematoma – Clinical presentation
How large is the hematoma?
Acute
symptomatic mins/hrs after injury, 1/3 lucid, other 2/3 confusion after injury
Unilateral headache, slightly enlarged pupil on same side, vomiting etc..
Subacute
Symptomatic days/weeks after injury
Drowsiness, headache, confusion, mild hemiparesis (contralateral or ipsilateral?)
Chronic
20-30% recall no traumatic event
Headaches, slowed thinking, change in personality, seizure, mild hemiparesis weeks/mths afterwards

13. Subdural hematoma – management and prognosis
Overall mortality if requiring surgery %.
If coma prior to surgery – 57-68%.
Prognostic indicators
GCS
Age
CT findings – thickness, volume etc..
Reverse any anticoagulation (weight up benefit if no surgery…)
To operate or not to operate….
Consider: GCS, stability, comorbidities, CT findings, acuity, neuro exam findings
Sooner is better than later

14. Subdural hematoma – management and prognosis
Acute
Nonoperative if: clinically stable or improving, so signs of herniation, clots thickness < 10 mm, midline shift < 5mm
Otherwise operate if there is potential for recovery.
Chronic
Similar to the above.
Moderate to severe cognitive impairment.

15. Which tumours most commonly metastasise to the brain?
Carcinomas – lung, breast, skin, kidney, GIT
Choriocarcinoma has a very likelihood of metastasising to the brain.
Which are most likely to haemorrhage?
Of those that metastasise to the brain: thyroid papillary carcinoma, hepatocellular carcinoma
Of primary brain tumors: Glioblastoma, pilocytic astrocytomas (?)