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A 72-year-old gentleman with a background of skin melanoma presents with a progressive subacute history of dysphonia and dysphagia.
On examination, you note left-sided tongue deviation, uvula deviation to the right and dysphonia. His left eyelid appears drooped and his right pupil is 6mm and left 4mm.
Where is the lesion likely to be?
A 74-year-old male presented to outpatient neurology with electric shock-like pains. He reports allodynia and dysesthesia in the right half of the mandibular region. He also reported ear pain deep in the right ear.
Examination revealed a right facial droop.
What is the likely diagnosis?
A 74-year-old female was referred to The Outpatients Department’ following a 4-month history of unexplained anaesthesia across her left chin and lower lip. She has been seen by her dentist and ENT without an explainable cause. She has a past medical history of Paget’s disease, xerophthalmia and polymyalgia rheumatica requiring long-term steroids.
Examination reveals reduced sensation across the aforementioned area with no additional neurological abnormalities. The patient was edentulous.
What is the most likely cause?
A 72-year-old man had noticed a 2-week history of a droopy right eyelid. His past medical history includes hypertension, iatrogenic hypothyroidism and type 2 diabetes mellitus. He was an ex-smoker of 20-pack-years.
On examination, he has right-sided ptosis and anisocoria, more pronounced in the dark, with the right pupil smaller than the left. Testing with 0.5% aproclonidine reversed the anisocoria but 1% topical hydroxyamphetamine did not cause pupillary dilatation.
Which of the following is the most likely cause of his signs?
A 69-year-old female presents with new left-eyelid drooping, dysphonia, unsteadiness, self-rotary vertigo, nausea and vomiting. Her past medical history includes hypertension, hyperlipidaemia, Arnold-Chiari decompression and breast cancer in remission, the latter treated with a wide local excision and adjuvant radiotherapy.
On examination she has a left eyelid ptosis ~2mm with anisocoria and left eye miosis more marked in the dark. She also has ipsilateral ataxia, dysmetria and dysdiadochokinesia. There is additional diminished pain and temperature sensation over the left hemi-face and right limbs and trunk.
What is the most likely diagnosis?
What is the most common cause of an oculomotor nerve palsy?
What is the most common cause of a trochlear nerve palsy?
What is the most common cause of an abducens nerve palsy?
A 60-year-old female presents to the Emergency Department with intermittent and recurrent throat and neck pain with associated dysphagia.
On further questioning she reports pain around the left-side of the neck radiating into the left ear, ipsilateral tongue, tonsil and throat. This was not responding to NSAIDs and paracetamol, precipitating admission. There was no relevant history and no history of weight loss or B symptoms.
A CT-brain and CT-neck revealed a left-sided elongated styloid process.
What is the unifying diagnosis?
An 82-year-old male is admitted under the medical team with unstable blood sugars and confusion. During his admission, he develops acute right-sided facial weakness and you have been asked to review him. He has a past medical history of brittle type 2 diabetes for which he requires insulin, dementia, recurrent otitis externa, non-metastatic prostate cancer and a previous right-sided subdural haematoma.
An MRI-brain is normal before you arrive.
On your examination he has weakness of the right-lower face, orbicularis oris and ipsilateral frontalis. He is wincing with pain localised to the right ear and you suspect base of skull osteomyelitis secondary to necrotising otitis externa causing an ipsilateral facial nerve palsy.
What is the likely pathogen to cause this?
A 54-year-old lady presents to the emergency department with a 2-week history of left sided headaches, intermittent left ptosis and diplopia. She has a past medical history of obesity, type 2 diabetes mellitus and migraine.
On examination she had a complete left ptosis. There was abduction and depression of the left eye, mydriasis of the left pupil and a sluggish left pupillary response.
What is the most appropriate initial investigation?
A 54-year-old woman presented to the Neurology Outpatient Clinic with a 6-month history of episodes of excruciating right-sided facial pain. The episodes are brief and described as an “electric shock” across the right side of her face. The episodes are frequently triggered by brushing her teeth and applying makeup. Her GP has prescribed Carbamazepine with limited benefit.
An MRI scan of her brain with trigeminal root entry zone sequences was performed, which demonstrated contact between the right superior cerebellar artery (SCA) and the right trigeminal nerve.
What is the next most appropriate management strategy?
Which of the following clinical tests is most useful in confirming a trochlear nerve palsy?
A 55-year-old male presents with sudden, painless vision loss in one eye.
Examination reveals optic disc swelling with a hyperaemic appearance with peripapillary splinter haemorrhages and evidence of a relative afferent pupillary defect. The contralateral eye has a small cup-to-disc ratio.
What is the most likely diagnosis?
A 55-year-old male presents with sudden vision loss in one eye, preceded by general aches and pains over several weeks.
Examination reveals optic disc swelling with a chalky white appearance, evidence of a relative afferent pupillary defect and altitudinal field defect in the affected eye.
What is the initial management?
A 68-year-old female presents with a progressive dysarthria and swallowing difficulties.
On examination, you notice tongue deviation to the left with hemi-tongue wasting and fasciculations.
What is the likely cause of this presentation?
Which of the following conditions is characterised by limited eye movement in one or both directions, a head turn to compensate for this, and retraction of the eyeball on attempted adduction?
A 32-year-old female presents with subacute unilateral visual loss.
On examination, you note optic disc swelling and the presence of a macular star.
Which of the following is the most commonly identified cause of this condition?
You are asked to review a 42-year-old lady on the respiratory unit with right-sided blurred vision and diplopia. She has a past medical history of migraine, viral meningitis and a new lower respiratory tract infection and small pulmonary embolism. Her medications include topiramate, sumatriptan, IV amoxicillin and IV heparin.
On examination, she has a fever of 37.8°C, ptosis on the right with a near complete ophthalmoplegia. There is chemosis and proptosis but no orbital bruit. Visual acuity is 6/24 in the right eye. There is no fatigability. She looks as if she is in pain.
Her blood tests reveal a thrombocytopaenia.
What is the investigation that would most likely clinch the neurological diagnosis?