This patient is a 49 year old
right handed woman with known metastatic adenocarcinoma of the lung, who
presented to the Emergency Department with difficulty speaking.
She had
undergone chemotherapy and radiation therapy for her cancer 1 year previously,
and was recently found to have liver metastases. A head CT done one month prior
to admission as part of her oncology workup was negative for metastases.
She
described having the "words in mind" but could not get her
"mouth to work properly". On admission, she was hypophonic and mildly
dysarthric. Examination of language function revealed very slow, spontaneous
verbal output, but she was able to string together 5 words into a sentence.
She
could repeat short phrases correctly, name high and low frequency objects, and
read out loud. She had difficulty writing a simple sentence and had spelling
errors. She had a mild right facial droop, but no right pronator drift or other
motor signs.
MR images revealed multiple bilateral foci of restricted
diffusion, involving the cerebellar hemispheres, the occipital and parietal
lobes, and the left frontal lobe. The best views of these lesions are with
FLAIR images, in which they are seen as faint foci of T2 prolongation. MRA and
MRV were negative. These image fidings likely represent multiple embolic
infarcts.
