From Brainstem to Stern (Slides)

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Identifier walsh_2020_s1_c2-slides
Title From Brainstem to Stern (Slides)
Creator Neena Cherayil, Angela Viane, Grant Liu, Ali Hamedani
Subject 6th Nerve Palsy, Brain Stem Syndromes, Increased Intracranial Pressure, Intracranial Tumors
History A previously healthy 32-year-old man complained of diplopia and one month of worsening positional headaches. He then acutely developed confusion and chills, prompting ER referral. Further history was limited by altered mental status. On presentation, he was afebrile and encephalopathic. Serum WBC was 16.9/mL. Lactate was 6.2 mmol/L. Head CT was read as normal (Figure 1). Lumbar puncture revealed WBC 48/mL (80% monocytes, 19% lymphocytes, 1% neutrophils), RBC 234/ml, protein >600 mg/dL, and glucose 75 mg/dL. Vancomycin, ceftriaxone, acyclovir, ampicillin, and dexamethasone were started for infectious meningoencephalitis. The following day, he developed progressive obtundation with left mydriasis and ptosis. Head CT revealed evolving hydrocephalus (Figure 2). An external ventricular drain (EVD) was placed emergently. Head MRI showed diffuse leptomeningeal enhancement with expansile pontomedullary T2 hyperintensity (Figure 3). Mental status improved with EVD. Patient reported five months of binocular horizontal diplopia worse in right gaze. Neuro-ophthalmologic examination revealed normal afferent visual function and pupil reactivity. There was a right eye abduction deficit. Fundus examination was normal. Chronicity of diplopia suggested longstanding peripheral or fascicular 6th nerve lesion. Extensive testing for insidious infectious and inflammatory causes of rhombencephalitis was unrevealing. Repeat EVD sampling showed WBC count of 14/mL (89% neutrophils, 10% lymphocytes) and protein 60 mg/dl. Cytology and flow cytometry were normal. EVD was internalized. Listeria rhombencephalitis was presumptively diagnosed given acute decompensation, MRI findings, and inflammatory CSF, all of which stabilized on antibiotics. He was; discharged on 6-week course of ampicillin and gentamicin. A month later, persistent abduction deficit and new hyperreflexia were noted. Repeat MRI brain, cervical, and thoracic spine revealed diffuse subarachnoid space enhancement displacing the spinal cord (Figure 4a,b). Given thickened, infiltrative intra- and extra-axial lesions in a young patient, neurosarcoidosis was suspected. Patient deferred testing given clinical stability. Two months later, he developed painful bilateral leg weakness.
Relation is Part of NANOS 2020: Frank B. Walsh Session 1
Contributor Primary Neena R. Cherayil, MD
Contributor Secondary Angela Viane, Grant Liu, Ali Hamedani
Publisher Spencer S. Eccles Health Sciences Library, University of Utah
Date 2020-03
Format application/pdf
Source 2020 North American Neuro-Ophthalmology Society Annual Meeting
Rights Management Copyright 2020. For further information regarding the rights to this collection, please visit:
Holding Institution North American Neuro-Ophthalmology Association. NANOS Executive Office 5841 Cedar Lake Road, Suite 204, Minneapolis, MN 55416
Collection Neuro-ophthalmology Virtual Education Library: NOVEL
Language eng
ARK ark:/87278/s6f81qvk
Setname ehsl_novel_fbw
Date Created 2020-05-14
Date Modified 2020-05-14
ID 1551204
Reference URL
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