UPPER MOTOR NEURON HEMIPLEGIAPARAPLEGIA DR NASIR FAROOQ BUTT

UPPER MOTOR NEURON HEMIPLEGIA-PARAPLEGIA DR NASIR FAROOQ BUTT ASSISTANT PROFESSOR DEPARTMENT OF MEDICINE KING EDWARD MEDICAL UNIVERSITY MAYO HOSPITAL LAHORE

• UPPER MOTOR NEURONS (UMN) start from cerebral cortex, passes through internal capsule, corticospinal tracts, and ends at cranial nerve nuclei in brain stem or anterior horn cells of spinal cord at different levels. The axons of upper motor neurons are contained within the pyramidal system, which is composed of the corticospinal (pyramidal) and corticobulbar tracts. • LOWER MOTOR NEURONS (LMN) start from nuclei of cranial nerves or anterior horn cells of spinal cord, extend through cranial /spinal nerves and ends at motor end plate of concerned muscle.

UPPER MOTOR NEURONS LESION (UMNL).

Pyramidal Drift Of An Upper Limb Normally, the outstretched upper limbs are held symmetrically, when the eyes are closed. With a pyramidal lesion, when both upper limbs are held outstretched, palms uppermost, the affected limb drifts downwards and medially. The forearm tends to pronate and the fingers flex slightly. This sign is often first to emerge, sometimes before weakness and/or reflex changes become apparent.

Pyramidal Drift Of An Upper Limb

Weakness And Loss Of Skilled Movement Ø A unilateral pyramidal lesion above the decussation in the medulla causes weakness of the opposite limbs. Ø When acute and complete, this weakness will be immediate and total, a hemiplegia, e. g. following an internal capsule infarct. Ø With slowly progressive lesions (e. g. a hemisphere glioma) a characteristic pattern of weakness emerges – a hemiparesis. Ø There is also loss of skilled movement – fine finger and toe control diminishes.

Changes In Tone And Tendon Reflexes Ø An acute lesion of one pyramidal tract (e. g. internal capsule stroke) causes initially FLACCID paralysis with loss of tendon reflexes. Ø Increase in tone follows, usually within several days due to loss of inhibitory effects of the corticospinal pathways and an increase in spinal reflex activity. Ø SPASTICITY is characterized by sudden changing resistance to passive movement – the clasp-knife effect. Ø Relevant TENDON REFLEXES become exaggerated; Ø CLONUS may emerge.

Changes In Superficial Reflexes Abdominal (and cremasteric) reflexes are abolished on the side affected. The Babinski sign.

Patterns of UMN disorders There are three main patterns: § HEMIPARESIS means weakness of the limbs on one side; it is usually caused by a lesion in the brain and occasionally in the cord. § PARAPARESIS means weakness of both lower limbs and usually diagnostic of a cord lesion; bilateral brain lesions occasionally cause paraparesis. § TETRAPARESIS (syn. quadriparesis) means weakness of four limbs.

Extrapyramidal system The extrapyramidal system is a general term for BASAL GANGLIA motor systems, i. e. corpus striatum (caudate nucleus + globus pallidus + putamen), subthalamic nucleus, substantia nigra and parts of the thalamus. In basal ganglia/ extrapyramidal disorders, two features (either or both) become apparent, in limbs and axial muscles: Ø Reduction in speed (bradykinesia, meaning slow movement) or akinesia (no movement), with muscle rigidity Ø Involuntary movements (e. g. tremor, chorea, hemiballismus, athetosis, dystonia).

Extrapyramidal system • Extrapyramidal disorders are classified broadly into: ØAkinetic-rigid Syndromes where poverty of movement predominates ØDyskinesias where there are involuntary movements. • The most common extrapyramidal disorder is Parkinson’s disease.

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Case Scenario • An 83 -year-old right-handed woman was eating dinner when she suddenly slumped to the right and her speech became slurred and nonfluent. Her vascular risk factors were hypertension and dyslipidemia, and the only other past medical history of interest was long-term hypothyroidism and a curative mastectomy for breast cancer. The patient was on two antihypertensive medications and a statin, and was not receiving any antiplatelet medication. Her husband immediately called the emergency medical services.

Case Scenario On Examination Pulse is 84/min (regular), BP: 180/105 mm Hg. Angle of mouth is deviated towards left (UMN type Right 7 th CN) Tone is decreased in right upper and lower limb, Power is 2/5 in right upper and lower limb, Reflexex are absent in right upper and lower limb. Right Planter is upgoing. Tone, power, reflexes are normal on left side with downgoing planter What is your Diagnosis? ?

STROKE This patient has had STROKE causing Right sided uncrossed Hemiplegia with UMN type Facial Nerve Palsy which can be caused by a vascular event such as thrombosis, embolism or hemorrhage or by neaplasm of brain (aetiology). The patient is limited by hemiplegia (functional status)

Stroke DEFINITION: Stroke is defined as a syndrome of rapid onset of cerebral deficit (usually focal) lasting >24 h or leading to death, with no cause apparent other than a vascular one.

Stroke Ischaemic stroke/infarction (80%) Ø Thrombotic Ø Cardio-embolic Ø Large artery stenosis Ø Small vessel disease Ø Hypoperfusion Haemorrhagic stroke (17%) Ø Intracerebral hemorrhage (12%) Ø Subarachnoid hemorrhage (5%) Other (3%), e. g. arterial dissection, venous sinus thrombosis, vasculitis

Types of Stroke Depending upon the rate of developing and reversibility, stroke can be of following types: § Transient Ischemic Attack (TIA): means a brief episode of neurological dysfunction due to temporary focal cerebral or retinal ischemia without infarction, e. g. a weak limb, aphasia or loss of vision, usually lasting seconds or minutes with complete recovery. § Stroke-in-Evolution: If neurological deficit increases by step wise progression or there is slow uninterrupted progression, it is called stroke-in-evolution. It may take 12 weeks to complete § Complete Stroke: It means complete hemiplegia § RIND (Reversible Ischemic Neurological Deficit): It is a term that is not widely used anymore. It means a stroke that the patient was able to fully recover from within a few weeks.

Types of Stroke Depending upon the blood supply of affected area of brain, stroke can be of following types: § ANTERIOR CIRCULATION STROKE: Carotid system § POSTERIOR CIRCULATION STROKE: Vertebrobasilar system

Risk Factor For Ischemic Stroke § Hypertension § Diabetes § Smoking § Lifestyle § Alcohol § High cholesterol § Atrial fibrillation § Obesity § Severe carotid stenosis § Sleep apnoea

Rarer Causes Of Stroke § Hyperviscosity states. ØThrombocythaemia, ØPolycythaemia ØThrombophilia § Anti-cardiolipin and lupus anticoagulant antibodies § oral contraceptive. § Migraine § Vasculitis ØSystemic lupus erythematosus (SLE), ØPolyarteritis ØGiant cell arteritis ØGranulomatous CNS angiitis

Rarer Causes Of Stroke § § § Amyloidosis. Hyperhomocysteinaemia Neurosyphilis Mitochondrial disease Drugs Ø Sympathomimetic drugs Ø cocaine Ø Vasoconstrictors Ø neuroleptics • CADASIL (cerebral dominant arteriopathy with subcortical infarcts and leucoencephalopathy)

Clinical Features of Stroke § SYMPTOMS: § § § § Weakness of one half of body Onset – Sudden, can be gradual Headache, vomiting, fits Unconciousness Past H/O TIAs H/O smooking, HTN, DM or IHD Family H/O Stroke

Clinical Features of Stroke § SIGNS: § § § § PULSE: Irregular (At. Fib), Slow (Raised ICP) BP: High Unconciouness Pupils: Small or Dilated EYES: Devited towards on side (conjugate gaze) Cranial Nerves may be involved Dysphasia, Dysarthria Initially limbs may be flaccid with absent reflexes (Spinal Shock). This may persist for days, weeks or months and then Classical UMNL signs develop

Clinical Features of Stroke § SIGNS: Hemiplegic weakness of upper limb affects the shoulder abductor, elbow extensors, wrist and finger extensors and small musles of hand Hemiplegic weakness of lower limb affects hip flexors, knee flexors and dorsiflexors and evertors of the foot

Clinical Features of Stroke § SIGNS: • Signs of meningial irritation (SOMI) – Subarachnoid Hemorrhages • Fundoscopy: Diabetic or Hypertensive Retinopathy • Carotid Pulsation: weak, bruit • CVS Exam: Murmur eg Mitral stenosis • Homonymous hemianopia and sensory inattention • Speech defects

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Amaurosis fugax • Refers to a transient loss of vision in one or both eyes due to embolism in retinal artery. • This is a feature of TIA in carotid circulation

ISCHEMIC STROKE Cerebral Thrombosis: § § § Occurs when patient is asleep Atherosclerotic narrowing of blood vessel Middle cerebral art is commonly involved Patient usually remain conscious HTN is a major risk factor Clinical Features: ØPt can not move one half of body ØDysphasia ØUncrossed hemiplegia ØHigh BP ØCarotid Bruit

ISCHEMIC STROKE Cerebral Embolism: § Sudden onset § Past history of TIAs § Source of Embolism q Carotid artery atheroma (weak carotid pulse, bruit) q Atrial Fibrillation or other arrythmias q Recent Myocardial Infarction q Valvular Heart Disease q Infective Endocarditis § Clinical Features: Ø Sudden loss of power in one half of body Ø Conciouness may be lost Ø Dysphasia Ø Uncrossed hemiplegia Ø Irregular Pulse Ø Signs of valvular heart disease Ø Carotid Bruit

HEMORRHAGIC STROKE Primary Intracerebral Hemorrhage: § H/O HTN § Internal capsule is most common site. Other sites: subcortical white matter, pons, and cerebellum. § Occurs when pt is engaged in some activity § Causes: HTN, Saccular Aneurysm, AV Malformation, Bleeding Disorders § Clinical Features: ØSudden loss of power in one half of body ØHeadache, vomiting and loss of Conciouness ØUncrossed hemiplegia ØFundoscopy: Papilledema

HEMORRHAGIC STROKE Subarachnoid Hemorrhage: § Primary: Bleeding occurs directly into subarachnoid space. § Causes: Saccular Aneurysm, AV Malformation, Bleeding Disorders, Vasculitis § Clinical Features: ØSudden onset of severe Headache with or without vomiting ØSOMI are present ØFocal neurological signs ØFundoscopy: Subhyloid hemorrhage, Papilledema Secondary: Extension of intracerebral hemorrhage into subarachnoid space

SPACE OCCUPYING LESION Lesion which occupy the cranial cavity and displace or destroy existing structures Causes: Tumour, Abscess, Hematoma, Tuberculomas Symptoms: H/O gradual onset of weakness developing over weeks to months. Headache and vomiting There may be H/O trauma (Hematoma) H/O waxing and waning of concious level (Subdural Hematoma) H/O fever and ear discharge suggest an abscess. Signs: In addition to motor deficit, following signs may be present: Bradycardia Fundoscopy……Papilledema Investigations: CT scan (with contrast), MRI

Localization of Lesion UNCROSSED HEMIPLEGIA: Cranial nerves involvement and hemiplegia are on the same side Lesion is above brainstem on the side opposite to the hemiplegia CROSSED HEMIPLEGIA: Cranial nerves are involved on one side and hemiplegia is on the other side Lesion is in brainstem on the side of cranial nerve involvement. HEMIPLEGIA WITHOUT CRANIAL NERVES INVOLVEMENT: Lesion is in spinal cord above C 5 on the side of paralysis.

Localization of Lesion UNCROSSED HEMIPLEGIA: Lesion can be in Motor cortex, Corona Radiata or Internal Capsule Motor cortex: Specific manifestation due to lesion of various lobes: § Parietal Lobe § Temporal Lobe § Occipital Lobe § Frontal Lobe

Localization of Lesion PARIETAL LOBE: Sensory cortex (Precentral Gyrus) demage only affects special sensory functions • Loss of cortical sensations: q Two point discrimination q Astereogonosis (inability to identify common objects by palpation with one hand while senses are intact) • Homonymous lower quadrantanopia • Apraxia (inability to perform a learned act in the absence of significant motor weakness. • Additional Features of Dominant Hemisphere q Gerstmann’s synd: Inability to calculate, write, distinguish between right and left, to recognize different fingers. q Alexia (inability to read), Bimanual astereognosis, Sensory dysphasia

Localization of Lesion PARIETAL LOBE: Additional Features of Non- Dominant Hemisphere Ø Sensory inattention (when both side are touched separately patient can recognize them, but when they are touched simultaneously, side opposite to affected parietal lobe is ignored) Ø Indifference to illness Ø Anosognosia (pt is unaware of paralysis) Ø Autopagnosia (pt ignores paralyzed body) Ø Spatial disorientation ( Pt is unable to find his way around)

Localization of Lesion TEMPORAL LOBE: Auditory or Olfactory hallucination Auditory or Visual hallucination Homonymous upper quadrantanopia of opposite side Deja vu phenomenon (feeling of undue familiarity with surroundings) • Automatism (lip smacking, swallowing, walking aimlessly or unconscious performance of highly skilled activity like driving a car) • • OCCIPITAL LOBE: • Visual hallucination • Homonymous hemianopia of opposite side

Localization of Lesion PRE-FRONTAL LOBE : • Lack of initiative and concentration • Lack of concern of consequences of any action • Micturition disturbance • Grasp Reflex is +ve PRECENTRAL GYRUS (FRONTAL LOBE): • Weakness of of opposite half of the body • Jacksonian fits • Expressive, motor or non-fluent dysphasia if lesion is in the dominant hemisphere.

Localization of Lesion UNCROSSED HEMIPLEGIA: CORONA RADIATA: Although Weakness is more marked in one limb, whole half is involved to some extent INTERNAL CAPSULE: Motor and sensory fibere are very closely packed…so lesion cause Ø Dense complete hemiplegia Ø Facial nerve palsy of same side Ø Cortical sensory loss and hemianopia may occur

Localization of Lesion Midbrain: CROSSED HEMIPLEGIA: Ø 3 rd /4 th CN are involved on one side and hemiplegia of opposite side Pons: Ø 5 th, 6 th, 7 th and 8 th CN nuclei are present in pons. Ø One or more of these CNs are paralyzed on one side and hemiplegia is on the other side. Ø Pupils are pinpoint but reactive to light Ø Hyperpyrexia may be present Medulla Oblongata: Ø 9 th, 10 th, 11 th and 12 th CN nuclei are present in medulla. Ø One or more of these CNs are paralyzed on one side and hemiplegia is on the other side.

Localization of Lesion SPINAL CORD. Brown-Sequard syndrome (BSS) is a rare neurological condition characterized by a lesion in the spinal cord which results in weakness or paralysis (hemiparaplegia) on one side of the body and a loss of sensation (hemianesthesia) on the opposite side. Causes: • Trauma • Non-traumatic: Tumor (primary or metastatic), Multiple sclerosis, Disk herniation, Epidural hematoma, Vertebral artery dissection, Transverse myelitis, etc •

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MIDDLE CEREBRAL ARTERY • Supplies lateral surface of frontal, perital and temporal lobes • Most of the motor and sensory cortex Ecxept the part on medial side and control lower limb, internal capsule Total Occlusion: • Uncrossed hemiplegia • Hemianesthesia • Global Dysphasia • Homonymous hemianopia • Apraxia, Agnosia Partial occlusion: • Any of the above features. • Lower limb is either not or minimally involved

ANTERIOR CEREBRAL ARTERY • Supplies MEDIAL surface of hemisphere • Motor and sensory cortex on medial side which control lower limb • Soon its origin it gives a penetrating branch (Heubner’s artery) which supply internal capsule (containing fibers of upper limb and face) Occlusion at the origin: Features are similar to total occlusion of MCB Occlusion of Heubner’s artery : • Weakness of upper limb and face Occlusion after the origin of Heubner’s artery : • Weakness of lower limb • Loss of cortical sensory function in lower limb

POSTERIOR CEREBRAL ARTERY • Branch of Basilar artery • Supplies occipital lobe which include visual cortex Occlusion: • • Visual field loss Homonymous hemianopia Visual agnosia Disorders of reading Disorders of color vision Memory impairment Motor dysfunction

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LATERAL MEDULLARY SYNDROME • Also called posterior inferior cerebellar artery (PICA) thrombosis and Wallenberg’s syndrome) • Acommon example of brainstem infarction presenting as acute vertigo with cerebellar and other signs. It follows • Thromboembolism in the PICA or its branches, vertebral artery thromboembolism or dissection. • Features depend on the precise structures damaged. MEDIAL MEDULLARY SYNDROME • Characterized by a set of clinical features resulting from occlusion of the anterior spinal artery. This results in the infarction of medial part of the medulla oblongata.

Investigations - STROKE The purpose of investigations in stroke is: • To confirm the clinical diagnosis and distinguish between hemorrhagic and thromboembolic infarction; • To look for underlying causes and to direct therapy; • To exclude other causes, e. g. tumour. • Sources of embolus should be sought

Investigations of Stroke Ø Brain Computed Tomography (CT) Scan Ø Magnetic resonance imaging (MRI) Ø Computed Tomography Arteriogram and Magnetic Resonance Arteriogram: Aneurysm, AV malformation Ø Carotid Ultrasound Ø ECG and Echocardiography Ø Lumber Puncture: Subarachnoid Hemorrhage

Investigations - STROKE Ø Routine bloods (for ESR, polycythaemia, infection, vasculitis, thrombophilia, syphilitic serology, clotting studies, autoantibodies) Ø Blood Sugar Level Ø Fasting Lipid profile Ø Chest X-ray Ø ECG and Echocardiography Ø Carotid Doppler studies Ø Lumber Puncture: Subarachnoid Hemorrhage

Investigations - STROKE • Imaging in Acute Stroke. • Non-contrast CT: will demonstrate haemorrhage immediately but cerebral infarction is often not detected or only subtle changes are seen initially.

CASE SCENARIO A 40 year old male presented in OPD with C/O gradually progressive weakness of both legs for the last one month. He is also C/O backache. There is no H/O Trauma. There is H/O Numbness and paresthesias in legs. He is unable to control his urine.

CASE SCENARIO On Examination Pulse is 84/min (regular), BP: 180/105 mm Hg. Bulk is normal in both legs Tone is increased in both legs, Power is 3/5 in right leg and 2/5 in left leg. Knee and Ankle Reflexex are Brisk bilaterally. Both Planters are upgoing. Ankle Clonus is present on both sides. Upper limbs are normal. Tenderness at back of chest. What is your Diagnosis? ?

This patient has SPASTIC PARAPLEGIA (Lesion) at T 10 spinal level due to Cord compression (aetiology). It is complicated by bladder involvement (functional status)

SPASTIC PARAPLEGIA HISTORY: • • • Ask about onset, duration and course of symptoms Back pain: whether localized Ask about radicular pain Numbness and parasthesia particularly below the level of lesion Weakness: whether gradual or sudden Sphincter control and bladder sensation Functional status: wheelchair transfers, walking aids, orthotic shoes and whether house has been modified for the patient’s disability Take a family history (hereditary spastic paraplegia) Take a history of birth anoxia (cerebral palsy) History of urinary infections, pressure sores and deep venous thromboses.

SPASTIC PARAPLEGIA EXAMINATION: • Increased tone in both lower limbs, Hyperreflexia, Ankle clonus • Weakness in both lower limbs • Then proceed to: ØCheck the sensory level ØExamine the spine (spinal tenderness or deformity) • Tell the examiner that you would like to do the following: Ø Check sacral sensation Ø Examine the hands to rule out involvement of upper limbs Ø Check for cerebellar signs (multiple sclerosis, Friedreich’s ataxia).

SPASTIC PARAPLEGIA EXAMINATION: Try to localize the level of lesion using the following: Ø UMNL signs in lower limb and LMNL signs in upper lims: lesion of C 5–T 1. Ø UMNL signs in lower limb and Wasting of small muscles of hand: lesion of C 8–T 1). Ø Spasticity of the lower limb alone: lesion of thoracic cord (T 2 –L 1). Ø Flaccid Paraplegia: Lesion below L 1

SPASTIC PARAPLEGIA • Paraplegia means UMN type weakness of both lower limbs. • CAUSES: • • • Spinal Cord Compression Transverse Mellitus Subacute combined degenration of spinal cord Friedreich’s Ataxia Amyotrophic Lateral Sclerosis (MND) Spinal cord infarction Hereditary Spaatic parapresis Tabes dorsalis (Neurosyphilis) Syringomyelia Intracranial Lesions ØParasagital Meningioma ØThrombosis of Sagittal Sinus

SPINAL CORD COMPRESSION • A. EXTRADURAL: 1. 2. 3. 4. 5. CAUSES Vertebral Traumatic Fracture Myeloma Tuberculosis of Spine Metastases (breast, prostate, lungs) Traumatic and degenerative lesions of disc • B. EXTRAMEDULLARY: 1. Meningioma 2. AV Malformation • C. INTRAMEDULLARY: Spinal Cord Tumors

SPINAL CORD COMPRESSION Symtoms: • H/O Backache, aggrevated by coughing, sneezing and straining • Pain in the distribution of nerve root • H/O Trauma • Weakness is usually gradually progressive except in trauma when it is of sudden onset. • Numbness and paresthesia in lower limbs • Micturation-urgency or hesistancy Signs: • Local examination of the vertebral column may reveal deformity or tenderness • Sensory loss with definite upper limit

SPINAL CORD COMPRESSION Investigations: • X- Rays of vertebral column may show reduce disc space, bony errosions, osteolytic or osteosclerotic lesions, vertebral collapse or fracture. • MRI • Routine Investigations

TRANVERSE MYELITIS • Inflamation of spinal cord • Can present with paraplegia or quadriplegia • Respiratory paralysis can occur • Causes: • Unknown 60 % (viral infections or postinfectious? ? ) • Remaining 40 % associated with autoimmune disorders such as multiple sclerosis, neuromyelitis optica, systemic lupus erythematous, Sjogren’s syndrome and sarcoidosis

TRANVERSE MYELITIS 4 classical Symptoms: 1. Backache/discomfort is first symptoms 2. Rapidly progressive weakness of lower limbs 3. Sensory symptoms such as numbness or tingling 4. Sphincter disturbances (Bladder/bowel) are common Signs: • UMN signs in lower limbs • Sensory Level Investigations: Lumber Puncture with CSF Exam Lymphocytosis X-Ray and MRI to rule out Cord compression

Subacute Combined Degeneration Of Spinal Cord • Due to Vit B 12 Deficiency • Degeneration of Posterior columns and pyramidal tract • Peripheral Neuropathy Symptoms: • Symptoms of anemia • Gradual progressive weakness of legs • Numbness, tingling and hyperesthesias Signs: • Pallor • Paraplegia, Ankle Jerk Absent, Up going planters. • Sense of position and vibration are lost

Subacute Combined Degeneration Of Spinal Cord Investigations: • Peripheral Blood Film: Macrocytosis (MCV is raised), Hypersegmented Neutrophils • Pancytopenia • Mild unconjugated hyperbilirubinemia (du to ineffective erythropoisis. • Serum B 12 is low. Elevated LDH, • Bonemarrow biopsy: Megaloblasts • Schilling Test • Causes of Vit B 12 Deficiency: • Nutritional def, , Pernicious anemia, Bacterial overgrowth and blind loop syndrome, Diverticulosis, Diphyllobothrium latum infestation, diseases of terminal ileum (Crohn’s disease, ileocecal TB)

Friedreich’s Ataxia Ø Familial Autosomal Recessive Ø Slowly progressive degeneration of • Posterior columns, • Pyramidal tracts, • Spinocerebellar tracts and • Peripheral nerves Ø Age of onset: 8 – 16 years Ø Slowly progressive weakness of legs and unsteadiness on walking Ø UMN type weakness of legs Ø Absent Ankle jerk Ø Planters up going Ø Sense of position and vibration are lost

Friedreich’s Ataxia Ø Sensory Ataxia, Romberg’s sign may be +ve Ø Cerebellar Signs (nystagmus, scanning speech, intension tremors) may be present Ø Associated features: § Pes cavus (high arched foot) § Kyphoscoliosis § Spina Bifida § Hypertrophic Obstructive Cardiomuopathy (HOCM)

Pes Cavus Causes: • Hereditary Motor and Sensory Neuropathy Type 1 (Charcot-Marie-Tooth disease) • Friedreich's Ataxia

Causes Of Absent Ankel Jerk And Up Going Planters: • • • Friedreich's ataxia Subacute combined degeneration of the spinal cord Motor neurone disease Syphilis (taboparesis) Combined conus medullaris and cauda equina lesions Combination of common problems e. g. diabetic peripheral neuropathy and cervical spondylosis

CASE SCENARIO A 65 year old male presented in OPD with complains of slowly progressive weakness of legs with numbness, tingling and hyperesthesias. He is a strict vegetarian. On examination he has spastic parapresis with absent ankle jerk and upgoing planters. Sense of position and vibration are lost. His hemoglobin is 6 gm/dl. What is most likely diagnosis?

CASE SCENARIO Answer: Subacute Combined Degeneration Of Spinal Cord