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Case presentation
This 78 year old right handed white woman had a medical history significant for a cerebellar tumour, removed at age 12 by Dr Harvey Cushing. Reportedly, this was an astrocytoma and the removal was successful. Her balance was never perfect, but she was able to walk unassisted. She lived at home with her husband and had two children who are in good health.
The patient was essentially well until November 1995 when on a trip to Israel she became rather tired and had increased difficulty in walking. On her return from this trip, she complained of fatigue, lethargy, dizziness, and progressive memory loss. In January 1996 she developed bilateral hand tremor, evident both at rest and during action. Her primary care physician made a diagnosis of Parkinson's disease and treated her with levodopa and amantadine, with only temporary benefit. After an increase in the dose of levodopa, she experienced visual hallucinations and worsening tremor, which resolved on discontinuation of the drug.
At the end of March 1996, she had a transient episode in which she suddenly raised her right leg while seated and collapsed on the chair soon after. According to a witness, she lost consciousness for a few seconds. She was admitted to a community hospital where a neurological evaluation was unremarkable aside from a striking memory loss. Diagnostic investigations including head CT, EEG, carotid Doppler, and MRA were essentially negative and she was discharged with a diagnosis of transient ischaemic attack. Since then her balance progressively worsened. Her recent memory and thought processes were poor. Confusion, fatigue, and sleepiness developed, with bradykinesia, urinary urgency, and frequency. She also complained of continuous dizziness. This was present when she was lying, sitting, or standing. She felt as if the room was moving around her.
On our initial neurological evaluation in …