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Problem solving in clinical practice: an unusual cause of multifocal brain lesions
  1. Joshua Mark Hodgson1,
  2. Catherine Douch1,
  3. Louise Hartley1,
  4. Ashirwad Merve2,
  5. Abel Devadass2,
  6. Fiona Chatterjee3
  1. 1 Paediatric Neurology, Royal London Hospital, London, UK
  2. 2 Pathology, Great Ormond Street Hospital for Children, London, UK
  3. 3 Radiology, Royal London Hospital, London, UK
  1. Correspondence to Dr Joshua Mark Hodgson, Paediatric Neurology, Royal London Hospital, London E1 1FR, UK; josh_hodgson{at}

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We present an interesting neurological case reinforcing our understanding of neurological anatomy, diagnosis and management but, most importantly, of compassion and humanity.

A 14-year-old left-handed young man of African heritage attended the emergency department with a 4-week history of left-sided limp and 3 days of facial asymmetry and slurring of his speech. He reported a decline in the quality of his handwriting at school during this period. He had no history of fevers, trauma, pain, headaches, vomiting, neck stiffness, visual problems, breathing or swallowing difficulties. He had a background of alopecia totalis treated with topical steroid cream. He had no other medical history, medications nor allergies. He was fully immunised and family and social histories were unremarkable with no recent travel.

On examination, he demonstrated mild left-sided facial weakness sparing the forehead and slow, slurred speech. The remaining cranial nerves were normal. In his left upper limb, he had dysdiadochokinesia, marked past pointing, pronator drift and 4/5 power with normal tone and reflexes. He had a left-sided hemiplegic gait with an upgoing plantar reflex on the left and normal tone. His right upper and lower limb examinations were normal. Sensation was normal throughout. Remaining systems examinations and vital signs were normal.

Multiple choice questions

Which area(s) of the nervous system are affected?

  1. Cortex.

  2. Cerebellum.

  3. Cortex and cerebellum.

  4. Spinal cord.

  5. Peripheral nerves (including cranial nerves).


c. The signs localise to the upper motor neuron pathway of the right hemisphere and left cerebellum.

What is the most definitive next investigation?

  1. Basic blood tests (full blood count, renal/liver/bone profiles and C reactive protein).

  2. Brain CT.

  3. Brain MRI.

  4. Lumbar puncture.

  5. Electroencephalogram.


c. Brain MRI is most likely to provide contributory information. If presenting to a hospital without MRI scanning capacity, such a case of subacute focal neurology would warrant semiurgent transfer. If the presentation were more acute, then—in accordance with Royal College of Paediatrics and Child Health guidance on Childhood Stroke1 …

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  • Contributors JMH and CD contributed equally to this paper. LH supervised the report. AM and AD produced the histopathology images and report. FC produced the radiology images and report.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.