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How good at neurology are you?

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1. What is the likely pathology?

A 70-year-old man was evaluated for parkinsonism; routine neurological systems inquiry was also revealing—in reply to “Do you have any numbness or tingling?” he described paraesthesia over the dorsum of the right foot, whenever he touched a lump behind his knee. There were no complaints of pain or weakness. After investigation (fig 1: proton density, fat suppressed saggital MRI of the right knee) he declined to have the lesion surgically explored.

2. What is illustrated?

Study the clinical photograph and the early generation T2 axial MR image (fig 2).

3. Study the angiogram (fig 3)

  1. Which vessel has been filled with contrast?

  2. What is this abnormality?

  3. Suggest a cause.

4. Follow up this case

A 73-year-old retired judge presents with a spontaneous, non-disabling left hemisphere subcortical ischaemic stroke, left facial pain and a left Horner’s syndrome. Normal heart and blood pressure. The CT angiogram (fig 4) is a follow-up image, performed six months after his initial investigations and treatment.

  1. What caused his stroke?

  2. What are the two abnormalities on the CT angiogram?

  3. What treatment was given?

Andrew Chancellor, Tauranga, New Zealand

Answers on page 204

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