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Progressive subacute central neurological deficit suspicious for an intracranial lesion — MSRA MCQ

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ModerateMRIProgressive subacute central neurological deficit suspicious for an intracranial lesionMSRA

A 49-year-old woman consults her GP because of 6 weeks of gradually worsening difficulty using her right hand. She first noticed impaired handwriting, and now frequently drops keys and struggles to fasten buttons. Her partner has also noticed occasional word-finding difficulty. She has had no sudden onset of symptoms, headache, seizure, visual disturbance, fever, recent head injury or neck pain. She has no history of cancer. Examination shows mildly reduced right-hand fine finger movements, right pronator drift and increased right upper-limb reflexes. Gait, lower-limb examination and fundoscopy are normal. She has no contraindication to MRI. What is the most appropriate next step?

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Correct answer: E — Arrange an urgent direct-access MRI brain scan for suspected brain or central nervous system cancer

This presentation is progressive and subacute, with objective focal upper motor neurone signs (pronator drift and hyperreflexia) and cortical dysfunction (word-finding difficulty). These indicate loss of central neurological function rather than an isolated peripheral nerve lesion. NICE recommends considering an urgent direct-access MRI brain scan in adults with progressive, subacute loss of central neurological function to assess for brain or central nervous system cancer. A routine MRI risks unnecessary delay where an intracranial structural lesion is suspected. CT is an alternative when MRI is contraindicated, but she can undergo MRI and MRI is the recommended first-line modality in this context. An urgent referral without imaging is less appropriate where GP direct-access MRI is available, because NICE specifically supports this pathway. Nerve-conduction studies would be reasonable for symptoms localising to a peripheral neuropathy or entrapment syndrome, but would not explain dysphasia, pronator drift and brisk reflexes. The absence of abrupt onset makes an acute stroke pathway less likely, while the progressive course requires prompt investigation for an intracranial cause.

Reference: NICE NG12: Suspected cancer: recognition and referral — recommendations organised by site of cancer (2015; page current when checked in August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NICE Quality Standard QS203: Brain tumours (primary) and brain metastases in over 16s — Quality statement 1: GP direct access to MRI (2021) — https://www.nice.org.uk/guidance/qs203/chapter/Quality-statement-1-GP-direct-access-to-MRI