Headscratcher-CasesT2 T2 Diffusion Axial w/ ADC 5 mo later When in doubt, go back to the case...
Transcript of Headscratcher-CasesT2 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
RightInternuclear 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 PontomedullaryJunction = 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
XX
Bilateral Cuneus Lobe Lesions of Occipital Lobes!
X X
Courtesy of Dr. Ellen NguyenNew Orleans, LA
5/19/2016
11
OS OD
XX
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
TwoOne
2 lesions total! )
Midbrain Blood Supply…
• Posterior Cerebral Artery & Its Branches
Occipital Lobe Blood Supply…
• Posterior Cerebral Artery & Its Branches