12/4/2015 Five diagnoses you cannot I have no financial interest in the afford to miss contents of this talk � Andrew G. Lee, MD � Chair Ophthalmology, Houston Methodist Hospital, Professor of Ophthalmology, Neurology, & Neurosurgery, Weill Cornell Medical College; Adjunct Professor: Baylor College of Medicine, U. Iowa & Clinical Professor, UTMB Galveston, UT MD Anderson Cancer Center, U. Buffalo, SUNY I will not be discussing any On July 20, 1969, I was 5 years old, off label uses of drugs the moon landing was on tv…. 1
12/4/2015 The artery on the side of my Overview: Lee’s “A”s: The five chances to save the life of your next head hurts neuro-ophthalmology patient Arteritis (Giant cell) 1. Apoplexy (Pituitary) 2. Abscess (Mucor) 3. I have GCA Aneurysm (pupil involved third nerve palsy) 4. Arterial (carotid or vertebral) dissection 5. Beware any head pain in Temporal arteritis does NOT have to involve the temple elderly � Face pain � Neck pain � Eye pain � Ear pain � Tongue pain � Jaw pain � Headache 2
12/4/2015 Initial symptoms in GCA (n = 100 ) And the MRI of head was normal….. � WHY? There are five things to remember about acute visual loss in the elderly � One is GIANT CELL ARTERITIS…. � And the other four are Giant Cell Arteritis 3
12/4/2015 Holiday Headache � 22 y/o woman � Severe headache � 20/50? Effort (blurred vision) � Fundus normal OU � HVF: “unreliable” � Friday 4:45 PM Perform a confrontation field � Beware acute bitemporal field loss � “Unreliable HVF” = “I have no visual field on this patient!” Life threatening diagnosis? 4
12/4/2015 Acute ophthalmoplegia in Pituitary apoplexy a diabetic � Acute onset � 35 y/o WM with diabetes � Usually severe headache � History of diabetic ketoacidosis � Bitemporal hemianopsia � Complete left ptosis � Apoplexy can kill (8%) � Acute onset almost complete left sided � Hypopituitarism (cortisol) ophthalmoplegia � Emergent scan � What should be the evaluation? biocomp.stanford.edu Life threatening diagnosis? 5
12/4/2015 Case from Iowa � 76-year-old woman with with acute myelogenous leukemia (AML) � Induction chemotherapy (day 13) � Two day history of worsening right- sided periorbital swelling & erythema http://webeye.ophth.uiowa.edu/eyeforum/cases/108-Orbitorhinocerebral-Mucormycosis.htm http:// webeye.ophth.uiowa.edu/eyeforum/cases/108-Orbitorhinocerebral-Mucormycosis.htm Intraoperative endoscopic photos Is this orbital inflammatory showing pale, necrotic tissue pseudotumor? Tolosa Hunt? � Wicked good pearl: Don’t give patients who are immunosuppressed the diagnosis of autoimmune disease! http://webeye.ophth.uiowa.edu/eyeforum/cases/108-Orbitorhinocerebral-Mucormycosis.htm 6
12/4/2015 And the MRI of head was normal….. � WHY? http://webeye.ophth.uiowa.edu/eyeforum/cases/108- Orbitorhinocerebral-Mucormycosis.htm YOU NEED CONTRAST. DISTINCTIVE SIGN = SINUS ENHANCEMENT! Aspergillosis of orbital apex http://www.mayoclinicproceedings.com/inside.asp?AID=230&UID= http://www.mayoclinicproceedings.com/inside.asp?AID=230&UID= 7
12/4/2015 What is Fat suppression What happens if you don’t (“fat-sat”)? technique give contrast?.... � T1 weighted signal � Increase contrast (light and dark) between structures � Fat is “too bright” on T1 My house at NIGHT!!! No fat suppression Can you tell if this nerve is enhancing? 8
12/4/2015 And the MRI of head was Polar bear in a snowstorm normal….. � WHY? What’s wrong with this Tell your technicians…. picture? � 60 y/o diabetic man � If the patient’s complaint is diplopia or ptosis or…. � New onset ptosis right � If you have to lift a ptotic lid to put in the dilating � Right adduction, elevation, & depression deficit drops then…. � STOP, come get the doctor before dilating � 45 exotropia (XT) � Diagnosis: “Ischemic third nerve palsy” � Plan: “Return 6 weeks” 9
12/4/2015 Rule of the pupil � A pupil involved third nerve palsy � Aneurysm of posterior communicating artery until proven otherwise Acute pupil involved third n. palsy Life threatening diagnosis? And the MRI of head was You need an “A” (angiogram) to find an “A” (aneurysm) normal….. � CTA (computed tomographic angiogram) � MRA (magnetic resonance angiogram) � WHY? � DSA (digital subtraction catheter angiogram) � There is no “A” in “MRI” 10
12/4/2015 CTA: R posterior communicating a. aneursym http://www.cedars-sinai.edu Acute painful anisocoria after car accident Life threatening diagnosis? 11
12/4/2015 As if death weren’t And the MRI of head was enough…. normal….. � WHY? Summary � List five potentially life threatening diagnosis in neuro-op � Define “rule of the pupil“ � Define best imaging study for the 5 dx � Show key clinical or radiographic features for the above 5 dx 12
12/4/2015 What does your “list” look like? Bottom line: Its your job Acute HA in elderly with visual loss: A rteritis 1. Acute orbital apex syndrome in DM: A bscess 2. Acute painful anisocoria (big pupil): A neurysm or (small 3. A rterial dissection pupil: Horner syndrome) A poplexy Acute painful bitemporal 4. A rterial dissection Acute painful homonymous: 5. End with a philosophical question & two On July 20, 1969, I was 5 years old, really quick cases Why are you here… because you believe as the moon landing was on tv…. we all do that you can….? 13
12/4/2015 “Houston” was the first Houston is home to JSC NASA word spoken from the moon April 1970: “Houston, we’ve had a problem”—Jim Jim Lovell Lovell 14
12/4/2015 Half the spacecraft panel Apollo fuel cell lost Most of the computing power It was human brain power that brought Apollo 13 home…. was human brains at NASA 15
12/4/2015 Thanks for your time & attention � Andrew G. Lee, MD � Chair Ophthalmology, Houston Methodist Hospital, Professor of Ophthalmology, Neurology, & Neurosurgery, Weill Cornell Medical College; Adjunct Professor: Baylor College of Medicine, U. Iowa & Clinical Professor, UTMB Galveston, UT MD Anderson Cancer Center, U. Buffalo, SUNY 16
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