Cases for finals #6 – History

38 year old man

  • right neck pain for a weak
  • abrupt onset vertigo, nausea & vomiting (resolved)
  • right facial droop
  • left arm and leg weakness
  • double vision
  • very unsteady


“acute neurological presentation characterised by neck pain, diplopia, right facial weakness, left hemiplegia with associated unsteadiness and vertigo”



All a bit confusing this with crossed signs – right face; left body.

When you see this, think “brainstem” until proven otherwise. You might be wrong, but it’s a decent place to start.

Now, can you prove it?

Vertigo, nausea and vomiting are often a brainstem symptom (but be careful to get a decent vertigo story – not just “dizziness”). Facial innervation spouts forth from the brainstem, and there are oodles of motor and sensory “long tracts” passing up and down. They cross in various spots, so you can get a lesion that gives you ipsilateral facial weakness and contralateral limb weakness.

I’m sure there are neurologists who think it is important that you have the anatomy of the brainstem committed to memory, but they are outnumbered by those that Google it (other search engines are available).

If we spent less time hammering pointless brain slices at undergraduates, and more time talking about conditions and general approaches, we wouldn’t have the shortages of neurologists that we currently suffer (I appear to have strayed off topic – sorry).

Basically, a weird mix of stuff is often brainstem, and nothing in this case disproves that working hypothesis.

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