Published 30 September 2009, doi:10.1136/bmj.b3940
Cite this as: BMJ 2009;339:b3940

Endgames

OnExamination quiz

Intracranial pathology

The answers to this question, and more questions on this topic, are available from www.onexamination.com/endgames until midnight on Wednesday.

This week’s quiz is on intracranial pathology and is taken from the OnExamination revision questions for the Royal College of Physicians of Ireland part 2 written exam.

A 65 year old Asian woman was referred to the emergency department with a history of nausea, vomiting, and headache that had persisted for several days. She did not speak English and unfortunately there was no one available to translate her history. She had a letter from her general practitioner that showed she had registered with the practice recently, having emigrated from India with her son. She had type 2 diabetes and atrial fibrillation; her regular medications included metformin, digoxin, and warfarin.

On examination, the patient seemed apathetic and drowsy with a Glasgow coma scale of 14-15. Her blood pressure was 145/75 mm Hg, her pulse was 76 beats/min, and her temperature was 36.2 –. She had several bruises on her arms and legs. Heart sounds indicated a harsh pansystolic murmur best heard at the apex, which was displaced. Chest and gastrointestinal examinations were entirely normal.

Neurological examination was difficult given the language barrier; however, fundoscopy showed some nasal blurring in both eyes, impaired upward gaze, and intact pupillary responses. There was no evidence of any facial asymmetry. Peripheral nervous system examination revealed some increased tone affecting the left arm and leg with minimal weakness, but pathologically brisk reflexes and a left extensor plantar response. Sensory function was not assessed.

Further investigations showed (normal ranges in brackets):

Haemoglobin: 10.2 g/l (11.5-16.5)

White cell count: 11 x 10⁹/l (4-11)

Platelets: 357 x 10⁹/l (150-400)

C reactive protein: 14 mg/l (<10)

Activated partial thromboplastin time: 47 seconds (30-40)

Prothrombin time: 18.5 seconds (11.5-15.5)

Glucose: 5.2 mmol/l (3.0-6.0)

A chest radiogram was normal. A non-enhanced computed tomogram was taken and is shown in the figure.

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A lumbar puncture was performed following interpretation of the computed tomogram. Analysis of the cerebrospinal fluid found the following:

Opening pressure: 18 cm H₂0 (4-18)

White cell count: 7 cells per ml; 90% lymphocytes (<5)

Red cell count: 100 cells per ml

Protein: 0.20 g/l (0.15-0.45)

Glucose: 3.7 mmol/l (3.3-4.4)

Xanthochromia: present

Please note: An actual or suspected supratentorial mass is an absolute contraindication to lumbar puncture. This patient’s lumbar puncture should not have been performed and represents bad clinical practice.

Given the history and investigations so far, what is the most likely diagnosis in this patient?

A Cerebral abscess

B Chronic subdural haematoma

C Primary cerebral lymphoma

D Subarachnoid haemorrhage

E Tuberculoma

Cite this as: BMJ 2009;339:b3940

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Endgames quiz is worrying

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This article has been cited by other articles:

• Eralil, G. (2009). Endgames quiz is worrying. BMJ 339: b4181-b4181 [Full text]  
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