LESIONS

A Guide to Localisation in Neurology

Case 17 - Slurred speech

Outcome

Urgent MRI head, skull base and neck were performed. These showed multiple bony metastases to the skull, including the basal occipital bone involving the left hypoglossal canal. There was also a malignant deposit in the soft tissue within the scalp. Body imaging showed pelvic disease including recurrence within the rectum and involvement of gynaecological and nodal tissues.

Palliative radiotherapy was given including to the skull. However, the patient very rapidly deteriorated and died within two months of diagnosis.

Left hypoglossal palsy due to skull base metastasis affecting the hypoglossal canal, due to recurrence of previously-treated rectal cancer – with rapidly fatal outcome.

1. The hypoglossal nerve runs a path from the lower medulla through the skull base to the tongue, passing through the carotid space along the way
2. Many causes for lesions exist, but tumours (skull base, neck and sublingual), carotid dissection and meningeal pathologies are major considerations
3. A high proportion of hypoglossal palsies are labelled idiopathic – this is appropriate after exclusion of important causes (including skull base imaging and neck vessel angiography)