Neurology · Year 3 · from Neurology

Case 3: Cerebellar Lesion with Classic Findings

Patient Demographics

  • Age: 52 years
  • Sex: Male
  • Occupation: Carpenter

Chief Complaint

"I'm dizzy and can't walk straight. My hand keeps missing things."

History of Present Illness

Progressive symptoms over 3 weeks of worsening balance, difficulty with fine motor tasks (trouble using tools), and a sensation of the room spinning. He has also noticed morning headaches and nausea. No hearing loss or tinnitus. Past medical history significant for lung cancer diagnosed 6 months ago.

Neurological Examination Findings

Mental Status:

  • Alert, oriented x3
  • Speech: Scanning dysarthria (irregular rhythm, explosive quality)

Cranial Nerves:

  • Nystagmus: Horizontal, worse on right lateral gaze
  • CN VI palsy on right (from increased ICP)
  • Papilledema bilateral

Motor Examination:

  • Strength 5/5 throughout bilateral upper and lower extremities
  • No pronator drift
  • Tone: Hypotonia right upper extremity

Sensory Examination:

  • Intact to all modalities throughout

Reflexes:

  • 2+ symmetric throughout
  • Plantar responses flexor bilaterally
  • Pendular reflexes on right

Coordination:

  • Right finger-to-nose: Dysmetria (past-pointing) and intention tremor
  • Right heel-to-shin: Marked dyssynergia
  • Rapid alternating movements: Dysdiadochokinesia on right
  • Rebound phenomenon positive on right

Gait:

  • Wide-based, ataxic gait
  • Tendency to fall to the right
  • Unable to perform tandem gait

Localization

Lesion Location: Right cerebellar hemisphere

  • Ipsilateral limb ataxia (dysmetria, dysdiadochokinesia, intention tremor)
  • Hypotonia ipsilaterally
  • Scanning dysarthria
  • Nystagmus with fast phase toward lesion
  • Wide-based gait with tendency to fall toward lesion side
  • Note: Cerebellum = ipsilateral findings (unlike cerebral hemispheres)
  • Signs of increased ICP: headache, papilledema, CN VI palsy

Neuro Workup

  • CT Head: 3.5 cm hyperdense mass in right cerebellar hemisphere with surrounding edema and early hydrocephalus
  • MRI Brain with contrast: Enhancing mass in right cerebellar hemisphere, likely metastatic disease
  • MRI complete spine: No spinal metastases
  • LP: Contraindicated due to mass effect

Diagnosis

Right cerebellar metastasis from primary lung cancer with associated obstructive hydrocephalus

Management

  1. Dexamethasone 10mg IV then 4mg q6h for vasogenic edema
  2. Neurosurgery consultation for possible resection vs. shunting
  3. Radiation oncology consultation for stereotactic radiosurgery vs. whole brain radiation
  4. Oncology follow-up for systemic therapy
  5. Fall precautions
  6. Physical therapy for balance training
  7. Palliative care involvement for goals of care discussion

Clinical Image

Image Description: MRI T1-weighted with contrast showing an enhancing mass in the right cerebellar hemisphere consistent with metastatic disease.

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Matt Skalski. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/cerebellar-metastasis-1

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