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A 47 year old banker had a sudden onset of vertigo, slurred speech, vomiting, and hiccups. On neurological examination he had a maximal Glasgow coma scale, flaccid dysarthria rotary nystagmus, and right dysmetria. Intermittent drowsiness prompted the placement of a ventriculostomy in an outside hospital. No neurological deterioration occurred, and at morning rounds he was alert and reading the Wall Street Journal. He was rehabilitated but left the hospital walking with a cane and fully independent. The figure shows MRI on admission and 7 days later.
MRI imaging is helpful in delineating brain stem compression from the mass effect of cerebellar infarction. The demonstration of such MR findings may potentially influence the decision to proceed with occipital craniotomy. This case re-emphasises the adage that clinical presentation should preside over neuroimaging studies.
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