A*******s
发帖数: 9638 | 1 An EMS guy, 41 yrs old, previous healthy, had a sudden onset blurry vision
out of right eye for 1 min, resolved completely. 30 mins later, he had
another episode of left cheek numbness for 5 mins, better afterwards. 1
hour later he suddenly noticed he could open his right eye. His wife said
his right eye could not move towards the nasal side.
He was otherwise normal.
On exam, he has a pupillary sparing third nerve palsy.
ER physician was very nervous about missing something so he went ahead for
MRI of brain w/wo gad.
What is the most likely finding on MRI?
★ 发自iPhone App: ChineseWeb 8.6 | d**o
发帖数: 618 | 2 The most likely MRI finding in this situation is no finding, totally normal,
lol | A*******s
发帖数: 9638 | 3 Why?
normal,
★ 发自iPhone App: ChineseWeb 8.6
【在 d**o 的大作中提到】
: The most likely MRI finding in this situation is no finding, totally normal,
: lol
| M***D
发帖数: 249 | 4 Right cavernous sinus lesion.
【在 A*******s 的大作中提到】
: An EMS guy, 41 yrs old, previous healthy, had a sudden onset blurry vision
: out of right eye for 1 min, resolved completely. 30 mins later, he had
: another episode of left cheek numbness for 5 mins, better afterwards. 1
: hour later he suddenly noticed he could open his right eye. His wife said
: his right eye could not move towards the nasal side.
: He was otherwise normal.
: On exam, he has a pupillary sparing third nerve palsy.
: ER physician was very nervous about missing something so he went ahead for
: MRI of brain w/wo gad.
: What is the most likely finding on MRI?
| A*******s
发帖数: 9638 | 5 An EMS guy, 41 yrs old, previous healthy, had a sudden onset blurry vision
out of right eye for 1 min, resolved completely. 30 mins later, he had
another episode of left cheek numbness for 5 mins, better afterwards. 1
hour later he suddenly noticed he could open his right eye. His wife said
his right eye could not move towards the nasal side.
He was otherwise normal.
On exam, he has a pupillary sparing third nerve palsy.
ER physician was very nervous about missing something so he went ahead for
MRI of brain w/wo gad.
What is the most likely finding on MRI?
★ 发自iPhone App: ChineseWeb 8.6 | d**o
发帖数: 618 | 6 The most likely MRI finding in this situation is no finding, totally normal,
lol | A*******s
发帖数: 9638 | 7 Why?
normal,
★ 发自iPhone App: ChineseWeb 8.6
【在 d**o 的大作中提到】
: The most likely MRI finding in this situation is no finding, totally normal,
: lol
| M***D
发帖数: 249 | 8 Right cavernous sinus lesion.
【在 A*******s 的大作中提到】
: An EMS guy, 41 yrs old, previous healthy, had a sudden onset blurry vision
: out of right eye for 1 min, resolved completely. 30 mins later, he had
: another episode of left cheek numbness for 5 mins, better afterwards. 1
: hour later he suddenly noticed he could open his right eye. His wife said
: his right eye could not move towards the nasal side.
: He was otherwise normal.
: On exam, he has a pupillary sparing third nerve palsy.
: ER physician was very nervous about missing something so he went ahead for
: MRI of brain w/wo gad.
: What is the most likely finding on MRI?
| d**o
发帖数: 618 | 9 "EMS guy" just like "nurse" is a red flag for munchausen, lol
Seriously, the vision problem is clearly pre-chiasm and not a brain
parenchymal stroke for which MRI is useful. Yes cavernous sinus may be
implicated as both CN 3 and 5 are affected, but the symptoms are too acute
and transient for anatomical MRI to pick up something, in the *most likely*
scenario.
【在 A*******s 的大作中提到】
: Why?
:
: normal,
: ★ 发自iPhone App: ChineseWeb 8.6
| A*******s
发帖数: 9638 | 10 Very good. The CN 3 palsy is persistent though.
★ 发自iPhone App: ChineseWeb 8.6
【在 d**o 的大作中提到】
: "EMS guy" just like "nurse" is a red flag for munchausen, lol
: Seriously, the vision problem is clearly pre-chiasm and not a brain
: parenchymal stroke for which MRI is useful. Yes cavernous sinus may be
: implicated as both CN 3 and 5 are affected, but the symptoms are too acute
: and transient for anatomical MRI to pick up something, in the *most likely*
: scenario.
| A*******s
发帖数: 9638 | 11 The MRI is normal.
This is a real case. MRI is defensive medicine and I was compromised on that
. This case has Right CN2 involvement as well as Left CN5 and right CN3
symptoms. The latter is persistent so the patient will have diplopia for a
while. Where is the localization? Brain, of course.
I was joking with the ER Doc that CN2 + CN5 + CN3= CN10. There is no such a
disease. Stroke? maybe, but MRI is negative. And I have never seen a stroke
with pure pupillary sparing CN 3 palsy.
So the diagnosis has to be Migraine. Yes, it is a migraine, ophthalmoplegic
migaine. This is the 2nd case I have seen within 3 months. The first
patient has a h/o migraine and diplopia resolved after 48 hrs. This patient
has no headache.
Medicine is just interesting, isn't it? |
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