<prompt> A middle aged man presents with progressive atrophy weakness of hand forearms. On examination he is found to have slight spasticity of the leg, genera-lized hyperreflexia and increased signal in the coico-spinal tracts on T2 weighted MRI. The most likely diagnosis is:Multiple SclerosisAmyotrophic lateral sclerosisSubacute combined degenerationProgressive spinal muscular atrophy  <response>: B i.e., Amyotrophic Lateral Sclerosis The presence of both lower motor neuron signs progressive atrophy weakness of hands and upper motor neuron signs spasticity hyperreflexia in the patient with increased signals hyperintensity of coicospinal tracts on T2WI of MRIQ leads us to the diagnosis of Amyotrophic lateral sclerosis. 