A case of cva in the rvh er
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A case of CVA in the RVH ER…. Chenjie Xia (PGY-3) AHD Interactive Case Wednesday, Feb. 23 rd , 2011. On call at the RVH…. RVH ER page at 9:30PM Code purple, please see stroke patient for admission…. Patient Background. ID: 74M, right handed RFC: stroke

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A case of CVA in the RVH ER…

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A case of cva in the rvh er

A case of CVA in the RVH ER…

Chenjie Xia (PGY-3)

AHD Interactive Case

Wednesday, Feb. 23rd, 2011


On call at the rvh

On call at the RVH…

  • RVH ER page at 9:30PM

  • Code purple, please see stroke patient for admission…


Patient background

Patient Background

  • ID: 74M, right handed

  • RFC: stroke

  • Social history: Chinese origin, retired real estate agent, lives with wife


Patient background1

Patient Background

  • PMHx:

    • HCC with cirrhosis

      • Dx since 2006, s/p radiofrequency ablation, RTX

      • Episodic encephalopathy

      • Esophageal varices

    • Diabetes

    • HTN

    • Left putamen lacunar infarct

      • Right sided parkinsonian Sx, now resolved

      • ASA discontinued due to bleed from esophageal varices

    • Gout

    • Right parotid tumour (biopsy 2008  pleomorphic adenoma)


Patient background2

Patient Background

  • Meds

    • Allopurinol, MVI, Ca/Vit D, Mg, Remeron, HCTZ, Nadol, lactulose, Flagyl, lantus

    • Recently added: Celebrex, Dilaudid, Lyrica

  • All:

    • NKDA

  • Habits

    • Non-smoker, non-drinker


History

History

  • Woke up this AM and notes new right facial weakness, i.e. right mouth droop


What more do you want to know on history

What more do you want to know on history?


More history

More history

  • Isolated right facial droop, i.e. no arm or leg weakness, no sensory change, no speech difficulties

  • Feels lips “thickened” and right eyelid “stuck to eyeball”

  • Right ear deaf for many years, no change

  • No change in taste noted

  • No vertigo, no n/v


More history1

More history

  • Right sided headache x few months

  • Increased pain in right parotid tumour x Nov. 2010.

  • Consulted multiple MDs (GP, ENT, neurologist)

  • Ultrasound shows stable right parotid mass?

  • Suboptimal pain control despite Celebrex, Dilaudid and Lyrica


What is your differential at this point

What is your differential at this point?


Differential diagnosis

Differential Diagnosis

  • Idiopathic facial nerve palsy (Bell’s palsy)

  • Facial nerve palsy from other causes (e.g. infectious, autoimmune, granulomatous, neoplastic, etc)

  • Stroke

    • Right brainstem (pons)

    • Left hemisphere


On exam

On exam

  • Looks well, non toxic, head drooped (because “the light is bothering my right eye”)

  • BP 155/70, HR 62 (reg), RR 20, 100% (RA), 36.1oC

  • No carotid bruit, normal S1, S2


What more do you want to know on exam

What more do you want to know on exam?

Be specific…


More exam findings

More exam findings

  • No aphasia

  • Large, palpable, firm, tender right parotid mass

  • Pupils 21mm (bilat), VFs normal, EOMs (saccadic SP, otherwise normal)

  • Normal sensation (LT/PP)

  • Right facial droop (frontalis, orbicularis oculi, and orbicularis oris involved)


How do you differentiate between umn and lmn facial palsy

How do you differentiate between UMN and LMN facial palsy?


Can you name the main motor branches of the facial nerve

Can you name the main motor branches of the facial nerve?


Muscles innervated by the facial nerve

Muscles innervated by the Facial Nerve

  • The: Temporal branch

  • Zebra: Zygomatic branch

  • Bit: Buccal branch

  • My: Mandibular branch

  • Carrot: Cervical branch

  • (Stapedius and post. auricular branches)


More exam findings1

More Exam Findings

  • Taste: decreased on right hemi-tongue

  • Hearing: No lateralization on Weber, decreased air conduction on Rinne on the right

  • Palate, SCM, trap, tongue mvts normal

  • Rest of exam (tone, strength, reflexes, sensation, coordination, gait) unremarkable


What is your top differential diagnosis at this point

What is your top differential diagnosis at this point?


Differential diagnosis1

Differential Diagnosis

  • Idiopathic facial nerve palsy (Bell’s palsy)

  • Facial nerve palsy from other causes (e.g. infectious, autoimmune, granulomatous, neoplastic, etc)

  • Stroke

    • Right brainstem (pons)

    • Left hemisphere


Differential diagnosis2

Differential Diagnosis

  • Idiopathic facial nerve palsy (Bell’s palsy)

  • Facial nerve palsy from other causes (e.g. infectious, autoimmune, granulomatous, neoplastic, etc)

  • Stroke

    • Right brainstem (pons)

    • Left hemisphere


Findings

Findings

CT head: old left putamen lacune, nil acute


Question

Question

  • Does the decreased taste favor Bell’s palsy or facial nerve injury secondary to parotid lesion?


A case of cva in the rvh er

Facial nerve enters parotid gland after it exits the stylomastoid foramen; fibers carrying taste and subserving lacrimation should NOT be affected.

However, in malignant lesion, extension of lesion may very well invade nearby nerve branches


Question1

Question

  • Can you name the 4 functional categories of the facial nerve and briefly describe what they do?


Answer

Answer

  • 1) Branchial motor

    • Muscles of facial expression

    • Stapedius muscle

  • 2) Parasympathetic

    • Lacrimal glands

    • All salivary glands (e.g. submaxillary, submandibular) except parotid

  • 3) Visceral sensory (special)

    • Taste from anterior 2/3 of tongue

  • 4) General somatic sensory

    • Sensation from small region near external auditory meatus


Question2

Question

  • With the help of the diagram, can you point out the nerves and ganglia involved in each of the functional categories?


Branchial motor

Facial nucleus

Facial nerve exits at CPA

Traverses internal auditory meatus

Turns at genu

Exits at stylomastoid foramen

Passes through parotid gland

Divides into branchial motor branches

Branchial motor


Branchial motor1

Facial nucleus

Facial nerve exits at CPA

Traverses internal auditory meatus

Turns at genu

Exits at stylomastoid foramen

Passes through parotid gland

Divides into branchial motor branches

Branchial motor


Parasympathetic 1

Superior salivatory nucleus

GT petrosal nerve leaves genu

Reach the sphenopalatine ganglion

post-ganglionic fibers  lacrimal glands

Parasympathetic (1)


Parasympathetic 11

Superior salivatory nucleus

GT petrosal nerve leaves genu

Reach the sphenopalatine ganglion

post-ganglionic fibers  lacrimal glands

Parasympathetic (1)


Parasympathetic 2

Superior salivatory nucleus

Chorda tympani branches off before the stylomastoid foramen

Goes through petrotympanic fissure

Joins lingual nerve

Submandibular ganglion

postganglionic fibers  submandibular and sublingual glands

Parasympathetic (2)


Parasympathetic 21

Superior salivatory nucleus

Chorda tympani branches off before the stylomastoid foramen

Goes through petrotympanic fissure

Joins lingual nerve

Submandibular ganglion

postganglionic fibers  submandibular and sublingual glands

Parasympathetic (2)


Visceral sensory special

Sensory fibers carrying taste from anterior 2/3 of tongue

Cell bodies in geniculate ganglion

Synapse onto secondary neurons in the rostral nucleus solitarius

Travel via CTT  VPM nucleus of thalamus  cortical taste area (inferior margin of postcentral gyrus, extends into parietal operculum and insula)

Visceral sensory (Special)


Visceral sensory special1

Sensory fibers carrying taste from anterior 2/3 of tongue

Cell bodies in geniculate ganglion

Synapse onto secondary neurons in the rostral nucleus solitarius

Travel via CTT  VPM nucleus of thalamus  cortical taste area (inferior margin of postcentral gyrus, extends into parietal operculum and insula)

Visceral sensory (Special)


General somatic sensory

Region near external auditory meatus

Synpase in spinal trigeminal nucleus

General Somatic Sensory


General somatic sensory1

Region near external auditory meatus

Synpase in spinal trigeminal nucleus

General Somatic Sensory


F u imaging

F/U Imaging

  • CT neck (compared to Nov 2010)

    • Significant increase in mass size compared to Nov.

    • Peripheral enhancement, central area of necrosis

    • Extension into deep lobe

    • Possibility of malignant transformation


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