A 48 year male presented to the ER with severe headaches which were episodic in nature and which had been present for several weeks. Patient had a history of traumatic head injury (TBI) several years prior. Otherwise, he was in good health with no significant past medical or surgical history.

On physical exam, patient was oriented x 3 with an intact cranial nerve exam. He had significant upper and lower extremity spasticity with mild hand intrinsic weakness. His motor exam was otherwise unremarkable. His gait was very spastic. He had sustained lower extremity clonus, upgoing toes, and increased tone in the upper and lower extremities. His sensation was intact to light touch, pinprick, proprioception and temperature.

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