NIRVE Rounds St Michael s Hospital Toronto Ontario Canada

NIRVE Rounds St Michael’s Hospital Toronto, Ontario, Canada ADAM MACLELLAN PGY 4 ADULT NEUROLOGY OCTOBER 1 ST 2015

Patient SS Identification 76 year old male from home Past Medical History HTN, CRF (baseline Cr ~140), Atrial Fibrillation Medications Rivaroxaban 20 mg daily, Perindopril 8 mg daily Allergies none Social History Former smoker (10 pk years), rare Et. OH consumption, no drugs; high functioning with job in theatre advertising Family History nil significant

Patient SS History of Presenting Illness Presented to ER with family report of 2 -3 week history of altered cognition Slowly progressive difficulty with speaking (stuttering, difficulty finding words) Increased time to do simple tasks like dressing, using objects wellknown to him Difficulty reading, finds it hard to re-direct gaze when changing lines Reports simple math is more challenging Generally reports feeling “slower”

Patient SS History of Presenting Illness Recent car accident (2 -3 days prior) “spaced out” while driving at 20 km/h and hit a parked taxi No LOC, no injury, no post-ictal state Family feels since then his deficits have worsened more rapidly Review of systems Denies focal weakness/sensory changes or other focal neurologic deficits No vision changes Denies behaviour/personality changes, no history of cognitive impairment No history seizure, stroke, or syncope No recent illness, constitutional symptoms, or systemic symptoms

Patient SS Physical Examination 190/106, HR 88 (NSR), Afebrile CN II- XII normal with full VF to threat (some difficulty with finger counting), VA 20/30 -2 R, 20/25 -1 L Normal tone/bulk/power bilaterally with symmetric 2+ reflexes Normal sensation LT/PP/Prop/Vib; slow but correct graphesthesia/stereognosis testing Normal FTN/HTS/RAM Slow narrow-based gait

Patient SS Language/Cognition Oriented to person/time/place Speech fluent with some word-finding difficulties, circumlocution, phonemic paraphasias Normal comprehension simple + commands Intact naming to high frequency words but difficulty identifying objects (esp. fingers) Repetition impaired to complex sentences Simple spelling mistakes when writing; difficulty reading (incl. his own writing) Difficulty with calculations Normal registration (5/5), impaired recall (0/5) Hand-as-tool testing of praxis No frontal reflexes but perseveration on Luria sequence

Patient SS Based on the examination, what possible localizations could explain the patient’s findings? What is your differential diagnosis and what tests would you order?

CT BRAIN

MRI BRAIN (FLAIR)

MRI BRAIN (GRE)

MRI BRAIN (DWI)

Patient SS What are the imaging findings? What further investigations would you order?