A 67-Year-Old Man With Headaches, Gait Changes, and Altered Mental Status

Abstract

A 67-year-old right-handed man was referred to a tertiary care center for headaches, changes in cognition, and gait imbalance. His symptoms began 3 months prior when he developed an unremitting, left-sided, parietal headache. The headache was unusual for him and was not associated with nausea, photophobia, or phonophobia. He had a history of prior headaches that began after minor head trauma in a skiing accident. However, those headaches were infrequent and invariably resolved after 1 day.Shortly after the onset of headache, he began experiencing intermittent scotomas and scintillations in the right visual field. The visual phenomenon would resolve after several minutes. Around the same time, he began having word-finding difficulties and deficits in his short-term memory. There were no clear deficits in long-term memory or changes in mood, behavior, or emotional stability.Within a few weeks, he began to feel unstable when walking. He had several falls due to what he described as a feeling of ''being stuck to the floor'' and then falling forward when he was finally able to move. His family noted a shuffling gait but no listing to either side. He had to start using a walker.Two months after the onset of symptoms, his visual phenomenon resolved without any intervention. However, he then developed stereotyped, olfactory hallucinations consisting of 20-second episodes of smelling a foul odor. His gait also continued to decline with increased bradykinesia and shuffling. The headaches were still persistent.He was seen at a local hospital 2 weeks after the onset of symptoms, where he underwent a lumbar puncture as part of his workup. Following the lumbar puncture, his gait temporarily improved.His past medical history was significant for diabetes, hyperlipidemia, and hypertension. There was no significant family history. He had smoked 1 pack per day for 37 years, but quit 5 months prior to presentation. There were no systemic symptoms including fevers, night sweats, or rashes. Neurologic ExaminationOn general examination, the patient was well appearing. He was afebrile. Blood pressure was 130/75 mm Hg. Heart rate was 68 beats/min and respiratory rate was 12 breaths/min. On mental status testing, he was fully oriented and attentive with a digit span of 7 forward and 5 backward. Naming and repetition were intact. He could name only 3 D-words and 13 animals in 1 minute (normal ¼ !16 D-words and !23 animals). There was no neglect. He scored 30 of 30 on the Mini-Mental Status Examination. The cranial nerve examination was normal including visual acuity, visual fields, and fundoscopy. On motor examination, there was mild spasticity in the bilateral upper extremities. He had a subtle right pronator drift. Power was full on confrontational testing in all the 4 limbs. Sensation was intact to all modalities with a negative Romberg. Reflexes were symmetrical and 2þ in the biceps, triceps, brachioradialis, and patellas. Ankle jerks were absent bilaterally. Plantar responses were flexor. He had a shuffling, wide-based gait, and coul...