Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case...

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5/19/2016 1 Avg RNFL: OD 53 μm OS 66 μm

Transcript of Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case...

Page 1: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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Avg RNFL:

OD 53 μm

OS 66 μm

Page 2: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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HVF

24-2

Page 3: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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ipsilateral MLF

midbrain

pons

Page 4: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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One-And-Half Syndrome

Left One & Half Syndrome

RightInternuclear Ophthalmoplegia

Right Abducens Nucleus (Gaze) Palsy

Right Abducens Nerve Palsy

Page 5: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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A. Lower motor neuron lesion = half of face involved• Nuclear/fascicle/ nerve lesion

B. Upper motor neuron lesion = lower 1/4 face involved• Supranuclear lesion

• Forehead is the key!

• My patient can be localized to lower motor neuron based on total right side of face involvement.

Inferior Medial Pons = location of lesion

• Decussation of corticospinal tract = upper medulla!

Page 6: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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} Millard-Gübler Syndrome

ventral paramedian pons

• Ipsilateral Abducens nerve or gaze palsy• Ipsilateral CN VII/Facial palsy• Horner’s Syndrome• Analgesia of face (CN V)• Peripheral deafness (VIII)• Loss of taste (V-mandibular branch)• Lesion = dorsolateral pons• Only V, VI, VII, VIII are involved

Case History… Initial Exam…

Page 7: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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Dilated Fundus Exam

• Is there more than one location???

Considerations???

• Is there any one location that could cause all of the symptoms?

• CVA occurring at/near the level of the pontomedullary junction where both CNVI and CNVII origins arise; including MLF , abducens nucleus, medial lemniscus and facial colliculus

• MRI results requested in plan to confirm suspected lesion(s) location

Left PontomedullaryJunction = lesion location

yellow arrow

MRI Results

yellow arrow

MRI Results

yellow arrow

MRI Results

Page 8: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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Lesion in Left Lower Pons (Transverse Cross Section)

Lateral Lemniscus

What about the contralateral hemiplegia???

• Corticospinal fibers are responsible for voluntary limb movement• Origin: motor cortex of precentral

gyrus in frontal lobe

• Decussation fibers = upper medulla!• Inferior to lesion in this case!• Left pons lesion would lead to right-

sided hemiparesis as in this case!

https://en.wikipedia.org/wiki/Upper_motor_neuron_lesion

•4 components

Quick Re-cap…

1 ½ + 7 + 8 + ½ = 17 “Seventeen” Syndrome

• Vascular

• Demyelinating

Causes/Lesions of OAAH Syndromes

} Most common causes• 8%

• 30% *

• 10% *

• 30% *

• 35% *

Stats of One-And-A-Half Syndromes

Wall M, Wray SH. Neurology (Cleveland). 1983;33:971-80.

* = this patient’s clinical findings

Page 9: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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8 ½ Syndrome

9 Syndrome

13 ½ Syndrome

15 ½ Syndrome

17 Syndrome

Additional Labwork to Consider if CWS Linger …

3 month follow-up exam…

• Nine Syndrome findings slightly improved but still present

• Cotton wool spots resolved with improved systemic control

• Therefore, no lab work ordered at this time

• Follow up x 6 months.

Page 10: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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XX

Bilateral Cuneus Lobe Lesions of Occipital Lobes!

X X

Courtesy of Dr. Ellen NguyenNew Orleans, LA

Page 11: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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OS OD

XX

X X

Left Cuneus Lobe Lesion AND Right Lingual Gyrus Lesion!!!

Page 12: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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https://en.wikipedia.org/wiki/Middle_cerebral_artery

https://vimeo.com/77627635

Page 13: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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T1 Axial

T1 Axial + C

T1 Axial +

FLAIR

T1 Coronal

T2 Axial

T2 Diffusion Axial w/

ADC

5 mo

later

When in doubt, go back to the case history!

(90-95%)

(5-10%)• Candida

https://en.wikipedia.org/wiki/Tricuspid_valve

https://en.wikipedia.org/wiki/Tricuspid_valve

https://en.wikipedia.org/wiki/Infective_endocarditis

Page 14: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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1. Blood Cultures

4. Echocardiograms

• DOC = Amphotericin B

• Flucytosine (second DOC)

• Stroke

• Mycotic aneurysms

• Intracranial (15%)

• Subarachnoid hemorrhage

• Intracerebral hemorrhage

• Seizures

• Oslerian MA

Page 15: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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• MCA

} Most common• Candida species } Most common fungi

Fungal Endocarditis Candida albicans

-- --immunosuppression work up = negative

Mycotic Aneurysm Hemorrhagic CVA

Inf Quad Defect Right Side & Left Sided Hemiparesis

Page 16: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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Page 17: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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82% of cases

• Coronal high-field T1-weighted

10.6 mm and 17.4 mm

Wagner AL, et al. Measurement of the normal optic chiasm on coronal MR images. Am J Neuroradiol. April 1997;18:723-6

7.5 mm

16.4 mm

Normal T1 + C Coronal

Abnormal T1 + C Coronal

Case #10:

Page 18: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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Weber’s Syndrome

Page 19: Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history! (90-95%) (5-10%) ... Fungal Endocarditis Candida albicans ... 10.6 mm and 17.4

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TwoOne

2 lesions total! )

Midbrain Blood Supply…

• Posterior Cerebral Artery & Its Branches

Occipital Lobe Blood Supply…

• Posterior Cerebral Artery & Its Branches

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