Biopsy or no??

47 year old man presents with nausea and is found to have a cerebellar lesion. No frank cerebellar signs. Included in no particular order is: FLAIR, DWI, ADC, and post contrast T1W image. Do you biopsy?

Rapidly expansive mass

A 42 year old man presents to an outside ED with the acute onset of facial numbness and dysarthria. His is without significant risk factor for stroke except for borderline hypertension. He is given diagnosis of stroke. A week after the initial symptom he has worsening symptoms with some arm tingling and worsening dysthria. Scan #1 was performed, has a unhomogenous enhancement with contrast. MS, stroke, cystercircosis is considered. He is seen in neurosurgery clinic and a repeat scan is performed scan #2 only 5 weeks after scan #1. LP is performed with elevated protein and no WBC. A week after scan #1 he was worsening symptoms and develops a plegic arm on the right. He is admitted to neurosurgery and biopsy performed. Biopsy showed significant infiltration of macrophages. Demyelination vs chronic stroke. PET negative.

Vertebro-Basilar insufficency

66 year old woman status post numerous cervical spinal surgeries develops new "dizziness" after three months of most recent cervical spine surgical procedure. She describes that three months after the surgery she developed "dizziness" with rotation of the head to the left or with extension of the neck. Neck extension causes the most severe symptoms. She notes that when she puts her head back she feels "lightheaded" like she is going to pass out or go to sleep. There is no illusion of movement, or vestibular dysfunction. The spells are easily reproducible and on examination during a spell her pulse and blood pressure is normal, she has no nystgamus she just feels very "light headed". Of note she is known to have a chronic left vertebral occlusion and a normal right vertebral artery.


Here is angiography before neck extension (top) and after neck extension (bottom). True vertebro-basilar insufficiency is rare but does happen with bilateral vertebral artery compression or unilateral compression with occluded or congenitally atretic contralateral vertebral artery. Of interest this patient denied vertigo during spells, probably as she was hypoperfusing the entire reticular activating system with neck extension.

Fibrocartilaginous Embolism

38 year-old female with a history of DM2, hyperlipidemia, hypothyroidism and migraines who presented with a chief complaint of bilateral upper extremity weakness. On the day prior to presentation, around 10:30 pm she noticed pain in the back of her neck and she denied any associated trauma. She used the bathroom, and went to bed. Around 3:00 am she awoke to use the bathroom again and noticed she couldn’t bend her fingers, and developed numbness and paresthesias in her bilateral upper and lower extremities. Her legs felt unsteady and she had to balance herself against the walls, and denied any dizziness or light-headedness. She returned to bed hoping the symptoms would go away. When she awoke around 7:30 am she had difficulty rising from a seated position, and that morning appreciated a tightness around her abdomen, and was having difficulty urinating that morning.

On exam the patient had bilateral UE weaknes distal > proximal and mild LE weakness, C8 sensory level with decreased pain and temperature, with sparing of vibration and proprioception, and, and urinary retention.