A 56-year-old man attended the emergency department with his wife, who reported that his speech had become slurred (he denied this) and that he may be having a stroke. The patient described only occasional swallowing difficulty. He had a 10-year history of progressive hearing loss requiring bilateral hearing aids. When aged 11 years, he had undergone resection and radiotherapy for a posterior fossa astrocytoma. He smoked cigarettes and took a statin for hyperlipidaemia. On examination, he had dysarthria and bilateral ptosis. CT scan of head showed no acute changes. He was admitted for 3 days under the stroke team, and his symptoms improved. An MR scan of brain 5 days later showed the previous posterior fossa surgery with cerebellar atrophy, chronic small vessel disease but no acute infarction. He was referred to neurology. In neurology outpatients, we obtained a 10-year history of worsening ptosis and vertical diplopia. In the preceding 12 months, there had been occasional slurred speech, swallowing difficulty, loss of balance and an abnormal sensation over the right upper lip. His symptoms would worsen towards the end of the day. His wife had noticed that his slurred speech had notably worsened on the evening he attended the emergency department. There was no limb weakness or sphincter problem. His hearing had progressively deteriorated over 10 years, for which he had attended an ENT clinic. Two MR scans of brain, 5 years apart had identified evidence of previous surgery, left cerebellar hemisphere atrophy, and enlargement of the fourth ventricle and cisterna magna. On examination, he had bilateral hearing aids and a scar from a previous posterior fossa craniotomy. There was bilateral ptosis without fatigability. His eye movements were full but with vertical separation of images on right horizontal gaze. His speech was nasal in character. There was a spastic catch in the right arm, but …

中文翻译：

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 构音障碍和上睑下垂


一名 56 岁的男子与他的妻子一起到急诊室就诊，妻子报告说他的言语变得含糊不清（他否认了这一点），并且他可能患有中风。患者描述仅偶尔出现吞咽困难。他有 10 年渐进性听力损失史，需要双侧助听器。 11岁时，他接受了后颅窝星形细胞瘤切除和放射治疗。他抽烟并服用他汀类药物治疗高脂血症。经检查，他患有构音障碍和双侧上睑下垂。头部CT扫描未见急性变化。他在中风小组住院三天，症状有所改善。 5天后的脑部磁共振扫描显示，先前的后颅窝手术伴有小脑萎缩、慢性小血管疾病，但没有急性梗塞。他被转诊至神经科。在神经内科门诊患​​者中，我们获得了 10 年上睑下垂恶化和垂直复视的病史。在此之前的12个月里，他偶尔会出现言语不清、吞咽困难、失去平衡以及右上唇感觉异常的情况。他的症状在一天结束时会恶化。他的妻子注意到他的口齿不清在他去急诊室的那天晚上明显恶化。没有四肢无力或括约肌问题。 10 年来，他的听力逐渐恶化，为此他前往耳鼻喉科诊所就诊。相隔 5 年进行的两次脑部 MR 扫描发现了先前手术、左小脑半球萎缩以及第四脑室和小脑延髓池增大的证据。经过检查，他戴着双侧助听器，并有先前颅后窝开颅手术留下的疤痕。双侧眼睑下垂，无疲劳感。 他的眼球运动很充分，但右侧水平凝视时图像垂直分离。他的讲话带有鼻音。右臂出现痉挛，但是……