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Clinical Pathologic Conference |

A Rare Adult Cause of Dizziness

Francy Shu, MD1; Robert Oberle, MD1; Emily Herndon, MD1; Kimmo Hatanpaa, MD, PhD1; James Battiste, MD, PhD1; Steven Vernino, MD, PhD1
[+] Author Affiliations
1Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas
JAMA Neurol. 2014;71(3):360-363. doi:10.1001/jamaneurol.2013.5839.
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A 55-year-old man was seen with progressively worsening dizziness over 10 months. The initial assessment with unremarkable laboratory and imaging studies suggested a peripheral vestibular disorder. He was then lost to follow-up but later was seen with worsening ataxia. Additional imaging studies showed subtle parenchymal lesions in the posterior fossa. The differential diagnoses included nutritional deficiencies, autoimmune disorders, systemic malignancies, and intracranial tumors. The final diagnosis was confirmed by a biopsy.

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Figure 1.
Brain Magnetic Resonance Imaging (1.5 T) and Corresponding Finding in Magnetic Resonance Spectroscopy

A and B, Initial magnetic resonance imaging showed nonspecific fluid-attenuated inversion recovery hyperintensities in the right superior cerebellar hemisphere. C and D, Follow-up magnetic resonance imaging of the brain showed interval enlargement of ill-defined areas of T2 hyperintensity in the right cerebellar hemisphere. E and F, Diffusion-weighted image (E) and corresponding apparent diffusion coefficient map (F) showed a nodular area of mildly restricted diffusion in the right cerebellum. Although most commonly associated with cytotoxic edema, restricted diffusion can also be seen in hypercellular tumors. G and H, Single-voxel magnetic resonance spectroscopy with voxel placed over the area of abnormal fluid-attenuated inversion recovery signal in the right cerebellar hemisphere demonstrated a markedly elevated choline (Cho) to N-acetylaspartate (NAA) ratio, which could be associated with hypercellular tumor or tumefactive demyelination.

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Figure 2.
Histopathological Findings From Biopsy of the Right Cerebellum

A, Neoplastic cells invaded the subarachnoid, subpial, and Virchow-Robin spaces (hematoxylin-eosin, original magnification ×100; size bar = 100 μm). B, These cells showed a clear to vacuolated cytoplasm and rounded nuclei with stippled chromatin (hematoxylin-eosin, original magnification ×400; size bar = 50 μm).

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