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Short Case Presentation. Dr. Sania Khalid. Background. Young female developed quadriplegia over a year Bed-ridden for 2 months Loss of bowel and bladder control We will be showing you few clinical tests performed on this lady. Name the sign and interpret.

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Short Case Presentation

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Short case presentation

Short Case Presentation

Dr. Sania Khalid


Background

Background

  • Young female developed quadriplegia over a year

  • Bed-ridden for 2 months

  • Loss of bowel and bladder control

  • We will be showing you few clinical tests performed on this lady.


Name the sign and interpret

Name the sign and interpret.


A sagittal t1 weighted mr image scan

A sagittal T1 weighted MR image scan


Mri cervical and thoracic spine

MRI cervical and thoracic spine.


Axial t2 weighted mr image showing c4 5 level

Axial T2 weighted MR image showing C4-5 level


Mri cervical and thoracic spine1

MRI cervical and thoracic spine.

  • MRI of cervical spine and thoracic spine showed a bilobed mass like lesion in the left intervertebral foramina at C4-C5 level with an intraspinal component showing severe compressionover the spinal cord at this level. Post Gandolinium sacn showed intense heterogenous enhancement.

  • Impression: was of a dumb-bell shaped neurofibroma at left intervertebral foramina of C4-C5 causing severe external compression over the spinal cord.


Histopathology

Histopathology:

  • On histopathology :

    Spindle shaped neoplasm, cells having wavy nuclei with tapering ends.Hyper and hypocellular areas were scene. In few areas verrucay bodies present. No mitosis or atypia noted. Most like a benign peripheral nerve sheath tumor or schwanomma.


Case 2

Case 2

Myriad of deficits: Diagnosing Topsy-turvey Cases

Dr. Muhammad Zaman Khan

Resident Department of Medicine

Jinnah Hospital Lahore


Closely observe this examination and answer following questions

Closely observe this examination and answer following questions

  • Write down three most important findings.

  • What three steps are important in relevant examination?

  • Write down a list of differential diagnosis?

  • How would you investigate this patient?


Observe

Observe…………


Left complete blepheroptosis

Left Complete Blepheroptosis


Left complete extra occular ophthalmoplegia

Left Complete Extra-occular Ophthalmoplegia


Anisocoria

Anisocoria


Short case presentation

  • Complete loss of vision in left eye

  • Fundoscopic examination is unremarkable

  • Rest of neurological examination is unremarkable except for absent left corneal reflex and loss of left forehead sensations.


Nerves involved

Nerves involved

  • Left

    • II

    • III

    • IV

    • V1

    • VI

      Right

      XII


Causes of multiple cranial nerve palsies

Causes of multiple cranial nerve palsies

  • Cavernous sinus Pathologies

  • Orbital apex syndrome

  • Tumors

  • Inflammation (viral, fungal, bacterial, granulomatous, vasculitis)

  • Diabetes

  • Ophthalmoplegic migraine


Workup

Workup

  • Complete blood count

  •  Electrolytes

  •  Glucose and hemoglobin A1C

  •  Renal and liver function tests

  •  Angiotensin converting enzyme

  •  Antinuclear antibody

  •  Anti-dsDNA antibody

  •  Anti-Sm antibody

  •  Antinuclear cytoplasmic antibody

  •  Fluorescent treponemal antibody test

  •  Lyme serologies

  •  Serum protein electrophoresis

  •  Erythrocyte sedimentation rate (ESR)

  •  C reactive protein


Short case presentation

  • CSF analysis

  • MRI Brain with Gadolinium


Diagnostic criteria for tolosa hunt syndrome

Diagnostic criteria for Tolosa Hunt Syndrome

  • One or more episodes of unilateral orbital pain lasting for weeks (untreated)

  •  Third, fourth, and/or sixth cranial nerve palsy and/or granuloma detected by magnetic resonance imaging (MRI) or biopsy

  •  Cranial nerve palsy begins within two weeks of onset of orbital pain

  •  Symptoms resolve within 72 hours when treated with sufficient corticosteroids

  •  Other etiologies are excluded by appropriate investigation


Short case presentation

  •   Tessitore E, Tessitore A. Tolosa-Hunt syndrome preceded by facial palsy.Headache 2000; 40:393.

  • Adams AH, Warner AM. Painful ophthalmoplegia: report of a case with cerebral involvement and psychiatric complications. Bull Los Angeles Neurol Soc 1975; 40:49.


Treatment

Treatment

 • Prednisone 80 to 100 mg daily for three days.

• If the pain has resolved, taper to 60 mg daily, then 40 mg, then 20 mg, then 10 mg every two weeks.


After 1 week

After 1 week


After few months

After Few Months


Thank you

Thank You


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