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Endgames Picture Quiz

An acquired source of seizures

BMJ 2012; 344 doi: (Published 03 May 2012) Cite this as: BMJ 2012;344:e2991
  1. Laura Azzopardi, core medical trainee year 21,
  2. Jennifer Quirk, neurology consultant1
  1. 1South London Healthcare NHS Trust, Department of Medicine, Princess Royal University Hospital, Orpington BR6 8ND, UK
  1. Correspondence to: L Azzopardi laura.azzopardi{at}

A 35 year old man came to our hospital by ambulance after a first generalised tonic-clonic seizure witnessed by his wife, with further seizures in the ambulance. Earlier that day he had noticed transient left limb weakness with tremor. He had no symptoms of infection, headache, sore throat, or photophobia. He was independent, otherwise well, had no medical history of note, and was taking no regular drugs, although he had used steroids and protein supplements for body building purposes. He had moved to the United Kingdom from Nepal 12 years earlier but had not recently travelled. There were no other features in the history to suggest risk of immunosuppression.

On assessment, vital signs were within the normal range, with a temperature of 36.2°C. Cardiorespiratory and abdominal investigations were unremarkable. Neurological examination showed an unsteady gait but no neurological deficit. Full blood count, renal function, electrolytes, bone profile, liver function, C reactive protein, and retroviral testing were all normal. Figures 1 and 2 show neuroimaging scans. Lumbar puncture performed after brain scan showed an opening pressure of 20 cm of water, with normal cerebrospinal fluid biochemistry and negative microbiology analysis.

Fig 1 Post-gadolinium axial fluid attenuated inversion recovery (FLAIR) magnetic resonance image

Fig 2 Post-gadolinium coronal T1 weighted magnetic resonance image


  • 1 What do the neuroimaging scans show?

  • 2 What is the most likely diagnosis?

  • 3 Which diagnostic procedures support the diagnosis?

  • 4 How would you manage this patient?


1 What do the neuroimaging scans show?

Short answer

A solitary cystic lesion is seen at the junction of the right frontal and parietal lobes, with an eccentric nodule within.

Long answer

Magnetic resonance imaging shows a well defined lesion at the junction of the right frontal and parietal lobes, with a smooth thin rim of enhancement and a small amount of surrounding oedema (fig 3). The lesion follows the …

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