A frontal syndrome due to a brainstem lesion

Excerpt

A 48-year-old man presented with progressive gait instability over a period of several weeks, during which he sustained a right forearm and right patellar fracture. Neurological examination revealed a vertical nystagmus in all gaze directions, severe slurring of speech, left sided hemiataxia and extensor plantar response. Computed tomography (CT) revealed a large inhomogeneous brainstem lesion with some spontaneous hyperdensity (Fig. 1a, axial CT without contrast). Magnetic resonance imaging (MRI) confirmed a large contrast-enhancing lesion in the lower part of the mesencephalon (Fig. 1b–d) and a second smaller lesion in the left cerebellar hemisphere. Combined CT chest/abdomen revealed a large primary lesion in the left lung and a left adrenal metastasis. Based on these findings, a tentative diagnosis of metastatic lung cancer was made which was further investigated by a percutaneous biopsy of the lung lesion confirming the presence of a large-cell adenocarcinoma.

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