NEUROLOGY CHALLENGE.. A 78-year-old man is brought to the emergency department by his family owing to sudden onset of an inability to speak or swallow. Three years earlier, he had a left frontal ischemic stroke with right hemiparesis and motor aphasia, from which he had completely recovered. His history also includes a left cerebellar infarct, asymptomatic lacunar infarcts, stage 3 hypertension, atrial fibrillation, ischemic cardiomyopathy, and dyslipidemia. Current medications include aspirin, ramipril, indapamide, isosorbide dinitrate, digoxin, and rosuvastatin. Neurologic examination reveals a wide-based gait with small steps, mild ataxia of the left limbs, brisk tendon reflexes on the right side, and a right Babinski sign. Sensation is unremarkable. On cranial nerve assessment, he has bilateral loss of voluntary movement of muscles supplied by cranial nerves V, VII, IX, X, and XII. The patient is anarthric, unable to volitionally open his mouth or smile; he can minimally move his tongue in the mouth but cannot protrude it. The mouth is slightly open. The patient is drooling and has severe dysphagia. The jaw jerk is increased, and the gag reflex is absent. The automatic movements of the face are preserved. The patient can open his mouth and retract his tongue with yawning. Cranial nerves I-IV and VI are normal. Taste, corneal reflex, trapezius, and sternocleidomastoid muscles are unremarkable. The patient communicates by writing, with intact grammar, and he understands spoken and written language. He is emotionally appropriate, without involuntary laughter or crying. Following are MRI IMAGES.. DIAGNOSE THIS CHALLENGING NEUROLOGICAL CONDITION..

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Answer is.. Pseudobulbar paralysis caused by bilateral opercular lesions, or Foix-Chavany-Marie syndrome (FCMS), was diagnosed on the basis of the patient's neurologic signs and neuroimaging findings. The clinical manifestations indicating paralysis of volitional facial, masticatory, pharyngeal, and lingual muscle movements, with preserved movement of these muscles with autonomic functions and emotion, are the defining features of FCMS. The cortical form of pseudobulbar palsy is distinguished from a noncortical pseudobulbar palsy by the absence of emotional lability or pathological laughter and crying and the absence of bladder and bowel incontinence. Furthermore, brain MRI confirmed the presence of ischemic lesions in both anterior opercula. FCMS is a rare form of pseudobulbar paralysis caused by bilateral lesions of the anterior opercular cortex.
You have not uploaded brainstem and posterior fossa images He has probably infarcts in his pons and medulla on left side mostly. T2 , diffusion and Flair images of posterior fossa are needed

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