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Suspected brain or central nervous system cancer — MSRA MCQ

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HardMRISuspected brain or central nervous system cancerMSRA

A 61-year-old man presents to his GP with 7 weeks of increasing clumsiness of his left hand and a tendency to catch his left foot when walking. His wife has also noticed reduced initiative and occasional word-finding difficulty. The symptoms have progressed gradually, without a discrete onset. He has no headache, vomiting, seizure, visual disturbance, fever, recent head injury or history of malignancy. Examination shows a left pronator drift, reduced fine finger movements in the left hand, mildly increased tone in the left leg and an extensor left plantar response. Fundoscopy is normal. He is independently mobile and there is no immediate concern about airway, breathing or circulation. He has no contraindication to MRI. What is the most appropriate next investigation and referral plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Arrange an urgent direct-access MRI brain to assess for brain or central nervous system cancer

Explanation lettering: D = shown as A · E = shown as C · C = shown as D · A = shown as E

This is progressive, subacute loss of central neurological function: evolving unilateral upper-motor-neurone signs localise to the brain, while the accompanying executive/language change supports a cerebral rather than peripheral process. The gradual progression over 7 weeks, without a sudden maximal onset, makes an acute stroke pathway less appropriate. NICE advises considering urgent direct-access MRI brain (or CT if MRI is contraindicated) in adults with progressive, subacute loss of central neurological function to assess for brain or central nervous system cancer. ([nice.org.uk](https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer?utm_source=openai)) A is attractive because CT is rapidly available, but MRI is the preferred investigation here and CT is the alternative when MRI cannot be performed. C inappropriately delays assessment of a progressive focal neurological deficit. D would be appropriate for a sudden-onset focal deficit suggestive of acute stroke, particularly if the patient were within a time-critical treatment window; that is not this presentation. E risks delay because the relevant NICE recommendation is urgent direct-access imaging rather than referral alone.

Reference: NICE NG12: Suspected cancer: recognition and referral — Recommendations organised by site of cancer (2015; amended 2023) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer