Intended for healthcare professionals

Endgames Picture Quiz

A weak leg

BMJ 2012; 344 doi: (Published 14 May 2012) Cite this as: BMJ 2012;344:e2712
  1. Jonathan Colledge, specialist trainee, radiology,
  2. Shaun Quigley, specialist trainee, radiology,
  3. Shilpa Liyanage, specialist registrar, radiology
  1. 1Barts and the Royal London NHS Trust, London E1 1BB, UK
  1. Correspondence to: J Colledge jonathancolledge{at}

A 50 year old right handed man presented with weakness of his right leg and arm of two months’ duration. The symptoms had come on over several days, during which he described a “dead leg” and he noticed his foot dragging while walking. On examination he had right lower limb pyramidal type distal weakness with a foot drop, power was graded at 4/5, and he had an upgoing plantar reflex. A computed tomogram of the brain showed a left parietal lesion with surrounding oedema but no midline shift, so contrast enhanced magnetic resonance imaging was undertaken (figs 1 and 2). Analysis of the cerebrospinal fluid showed raised protein with normal cell counts, normal angiotensin converting enzyme values, oligoclonal bands, IgG of 185 mg/L (normal value <40), and a negative viral polymerase chain reaction. Serum immunoglobulins and vitamin B12 values were normal; viral antibodies and antibodies for spirochetes were negative. He had no history of a neurological deficit.

Fig 1 Axial fluid attenuation inversion recovery (FLAIR) magnetic resonance image at the level of the superior aspect of the lateral ventricles

Fig 2 Contrast enhanced T1 weighted magnetic resonance image at the same level as fig 1


  • 1 What does magnetic resonance imaging show?

  • 2 What term best describes the clinical picture?

  • 3 What is the relevance of the contrast enhancement?

  • 4 What is the prognosis?


1 What does magnetic resonance imaging show?

Short answer

The fluid attenuation inversion recovery (FLAIR) sequence shows multiple foci of periventricular high signal and a larger area of high signal in the left centrum semiovale (fig 1), which …

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