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

download Headscratcher-Cases T2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case history!

of 19

  • date post

    15-Jul-2020
  • Category

    Documents

  • view

    0
  • download

    0

Embed Size (px)

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

  • 5/19/2016

    1

    Avg RNFL:

    OD 53 μm

    OS 66 μm

  • 5/19/2016

    2

    HVF

    24-2

  • 5/19/2016

    3

    ipsilateral MLF

    midbrain

    pons

  • 5/19/2016

    4

    One-And-Half Syndrome

    Left One & Half Syndrome

    Right Internuclear Ophthalmoplegia

     Right Abducens Nucleus (Gaze) Palsy

    Right Abducens Nerve Palsy

  • 5/19/2016

    5

    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!

  • 5/19/2016

    6

    } 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…

  • 5/19/2016

    7

    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 Pontomedullary Junction = lesion location

    yellow arrow

    MRI Results

    yellow arrow

    MRI Results

    yellow arrow

    MRI Results

  • 5/19/2016

    8

    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

  • 5/19/2016

    9

    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.

  • 5/19/2016

    10

    X X

    Bilateral Cuneus Lobe Lesions of Occipital Lobes!

    X X

    Courtesy of Dr. Ellen Nguyen New Orleans, LA

  • 5/19/2016

    11

    OS OD

    X X

    X X

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

  • 5/19/2016

    12

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

    https://vimeo.com/77627635

  • 5/19/2016

    13

    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

  • 5/19/2016

    14

    1. Blood Cultures

    4. Echocardiograms

    • DOC = Amphotericin B

    • Flucytosine (second DOC)

    • Stroke

    • Mycotic aneurysms

    • Intracranial (15%)

    • Subarachnoid hemorrhage

    • Intracerebral hemorrhage

    • Seizures

    • Oslerian MA

  • 5/19/2016

    15

    • 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

  • 5/19/2016

    16

  • 5/19/2016

    17

    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:

  • 5/19/2016

    18

    Weber’s Syndrome

  • 5/19/2016

    19

    Two One

    2 lesions total! )

    Midbrain Blood Supply…

    • Posterior Cerebral Artery & Its Branches

    Occipital Lobe Blood Supply…

    • Posterior Cerebral Artery & Its Branches

    cborgman@sco.edu

    mailto:cborgman@sco.edu