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הצגת מקרה . מחלקה נוירולוגית אסף הרופא. A young woman with hypoesthesia of the face. 27-year-old woman, sport teacher Hypoesthesia of the left face and tongue of one month duration Dizziness on getting up in the morning and during body turns

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slide1

הצגת מקרה

מחלקה נוירולוגית

אסף הרופא

a young woman with hypoesthesia of the face
A young woman with hypoesthesia of the face
  • 27-year-old woman, sport teacher
  • Hypoesthesia of the left face and tongue of one month duration
  • Dizziness on getting up in the morning and during body turns
  • No gustatory, visual or hearing symptoms, no limb weakness or sensory changes
  • Past history: Fe-def. anemia
examination
Examination
  • Normal visual acuity, normal fundi, no MG
  • Normal speech
  • Full eye movements, gaze evoked nystagmus on lateral and up-gaze
  • Hypoesthesia to pinprick over the left face, mainly cheek and tongue, decreased lt corneal reflex
examination cont
Examination (cont.)
  • Normal power, tone and sensation
  • Lively reflexes in lower limbs
  • No pathological reflexes
  • Finger-nose and heel-knee test normal
  • Normal gait including tandem
  • Negative Romberg test

???

auxilliary examinations
Auxilliary examinations
  • Blood tests normal
  • X-chest ray normal
  • Carotid duplex normal
  • Eye exam- normal
  • Gyn.exam- no evidence of genital ulcers
  • Audiogram-normal
  • VEP-normal, SSEP-normal, BERA- latency of wave I normal, prolonged wave III,V latencies

???

slide6
CT brain (without contrast): hypodense lesion in the left pons causing compression of the IVth ventricle

???

slide7
Brain MRI:

Lt vestibular schwannoma

vestibular schwannoma vs
Vestibular schwannoma (VS)
  • 6% of intracranial tumors
  • No race or sex predilection
  • Incidence 10 per million per year (USA, Denmark)
  • - Sporadic (95%, unilateral, midlife)

- associated with NFII (5%,bilat, younger age)

- NFI (in 2%, unilateral)

pathogenesis
Pathogenesis
  • VS arises from the Schwann cells of the superior or inferior division of the VN
  • Most VS arise from the VN at the level of the IAC, just outside the porus
  • Growth rate- no correlation with gender, symptoms, manifestations or size

generally slow (0.1-0.2 cm per year)

atypical symptoms
Atypical symptoms
  • Sudden HL - 26% VS, sometimes reversible, but only 1-2% of patients with SHL have VS
  • Normal hearing – up to 4% VS
  • Trigeminal neuralgia (but facial hypoesthesia occurs in up to 50% of VS>2cm)
  • Motor dysfunction of the NV (masseter and lateral temporal muscle atrophy)
atypical symptoms cont
Atypical symptoms (cont.)
  • Facial weakness uncommon, but facial twitching in 10%VS
  • Intratumoral hemorrhage- triggered by trauma or exercise, - sudden HL, facial spasm, facial sensory disturbances, hoarseness, long tract signs, somnolence
  • Extratumoral bleeding -SAH
moffat d clinical acumen and vs
Moffat D: Clinical acumen and VS

Am J Otol, 1998, 19: 82-87

  • Atypical presentations of VS
  • 473 patients with VS – 10% atypical presentation – larger tumors, shorter history, better preserved hearing
  • Facial numbness in 6.4%