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Recurrent cerebral haemorrhage in a 65 year old man: advanced clinical neurology course, Edinburgh, 1997
  1. Nicolas U Weira,
  2. Jan van Gijnc,
  3. G Alistair Lammieb,
  4. Joanna M Wardlawa,
  5. Charles P Warlowa
  1. aDepartment of Clinical Neurosciences, bNeuropathology Laboratory, Department of Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh, UK, cDepartment of Neurology, University of Utrecht, Box 85500, 350GA Utrecht, The Netherlands
  1. Dr Nicolas U Weir, Department of Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, Scotland, UK. Telephone 0044 131 343 6630; fax 0044 131 332 5150; email nuw{at}skull.dcn.ed.ac.uk

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Case presentation

A 65 year old, right handed, retired police inspector presented to hospital as an emergency. That afternoon, while decorating, he had complained of a headache, although it did not prevent him from continuing with his work. Three hours later, however, his wife found him unable to speak, with a drooped right face and shortly afterwards, complete right sided paralysis. He was known to have hypertension and, 3 months earlier, he had been investigated for weight loss and painless obstructive jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) had shown an impacted gall stone and appearances consistent with a periampullary tumour, although no histology was obtained. Sphincterotomy had led to improvement and the diagnosis had not been pursued further. Routine screening had also disclosed a lymphocytosis of 8.25×109 /l, which was confirmed to be due to an asymptomatic, early chronic lymphocytic leukaemia. His medications consisted of 100 mg atenolol daily, 25 mg mefruside daily, and 400 mg cimetidine twice daily. He smoked 15 cigarettes a day and drank alcohol rarely.

On examination, he was drowsy with conjugate deviation of gaze to the left, and had dysphasia, a right homonymous hemianopia, and total right sided paralysis. Fundoscopy was normal. Other than mild jaundice, cardiovascular and general examination was normal. Brain CT (fig 1) showed a large, left frontoparietal haematoma with moderate mass effect and he had a leucocytosis of 21.2×109 (lymphocytes 9.75×109) with a normal haemoglobin and platelet count, and a bilirubin of 28 mmol/l.

Figure 1

Brain CT (without contrast) on first presentation shows a large left frontoparietal haematoma (white) with some mass effect. Note that the haematoma extends out through the cortex to the surface of the brain.

After admission, his wife mentioned that he had been having word finding difficulties for about a year, although it was not clear if this …

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