Intended for healthcare professionals

Endgames Picture Quiz

A pain in the neck

BMJ 2010; 340 doi: (Published 07 April 2010) Cite this as: BMJ 2010;340:c1001
  1. Judith A Finegold, foundation year 2 trainee,
  2. Rosemary Belcher, specialist trainee year 4,
  3. Shahid Noor, consultant stroke medicine,
  4. Dominic Mort, consultant neurologist
  1. 1Chase Farm Hospital, London EN2 8JL
  1. Correspondence to: J A Finegold judyfinegold{at}

    A 49 year old right handed builder presented to the emergency department after an episode of vomiting and unsteadiness, with falling to the right side. This resolved after 10 minutes, but was followed 30 minutes later by pins and needles in the right face, arm, and leg. The symptoms had been preceded by bilateral neck stiffness for the previous three days, after the patient experienced minor trauma to the neck. His medical history was of well controlled essential hypertension. His family history was relevant—his father had a stroke in his 50s.

    At initial assessment the patient was found to have right sided paraesthesia, with no evidence of weakness. He had no cranial nerve lesions and no higher cortical dysfunction. Initial observations were normal, with a blood pressure of 135/90 mm Hg. A 12 lead resting electrocardiogram showed sinus rhythm. Computed tomography of the head on admission showed no abnormality.

    The next day the patient had residual paraesthesia in his right hand only. Fasting glucose and cholesterol concentrations were within normal limits, and his erythrocyte sedimentation rate was 10 mm/h. He underwent magnetic resonance imaging (fig 1) and magnetic resonance angiography (fig 2).

    Fig 1 Magnetic resonance imaging of the brain

    Fig 2 Magnetic resonance angiography


    • 1 What two abnormalities are seen on the magnetic resonance images?

    • 2 What is the diagnosis?

    • 3 What are the causes of this condition?

    • 4 How should the patient be managed?


    1 What two abnormalities are seen on the magnetic resonance images?

    Short answer

    An intraluminal clot in the right vertebral artery and infarction of the right medullary pyramid can be seen on the magnetic resonance images.

    Long answer

    The axial T1 weighted magnetic resonance image shows a focal …

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