BACKGROUND
A 24-year-old man presents to the clinic with acute weakness in the left upper and lower extremities, blurred vision, headache, dizziness, and disequilibrium lasting 3 days. He was previously healthy but reports a history of mild exertion in the past week. His family history is unremarkable.
MRI reveals no evidence of aneurysm or arteriovenous malformation, but cerebellar and occipital infarcts are depicted. Physical examination reveals that the patient is awake and coherent, with no dysarthria but with significant hoarseness. Left miosis, ptosis, and left facial hypesthesia are observed. Funduscopic findings are difficult to assess. The patient's uvula and tongue are midline. He has left-sided weakness with prominent ataxia, which is revealed during the left finger–to–nose test. Hypoesthesia is observed on the right hemibody, and the deep tendon reflexes are normoactive with flexor plantar response. He has a severe gait imbalance. His right pupil is larger than the left (3 vs 2 mm). Radiography is performed.
What is the diagnosis?
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Hint
This is a bone problem.
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Author:
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Philip Ong-Hai MD, Neurologist, San Antonio, Texas, and Winston W. Tan, MD, FACP, Assistant Professor, Department of Hematology Oncology, Mayo Clinic Jacksonville
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eMedicine Editor:
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Sat Sharma, MD
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Associate Professor, University of Manitoba, Department of Medicine, Division of Pulmonary Medicine
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eMedicine Case
