Jenna is a 27 year old teacher in Ingham who collapsed in her classroom today . She was seen by her pupils to ‘ shake all over ’.
Brought to ED by paramedics, accompanied by teaching colleague. Collapsed approx 30 mins ago.
(Aim: The aim of this CPC is to get students to initially look at a broad range of differential diagnoses for a witnessed, generalized tonic- clonic seizure . Then get them to focus on idiopathic epilepsy , convulsion secondary to infection ( meningitis ), and convulsion secondary to brain tumour . get them to discuss ‘what if’ questions; outlined below are a variety of scenarios for you to draw from.
please remind students re. importance of accurate collateral history in seizure description
In every person who comes near you look for what is good and strong; honor that; try to learn it, and your faults will drop off like dead leaves when their time comes. --John Ruskin Look for good in others “No one is without faults and everyone has some good qualities…!”
Pathology of CNS Tumors Dr. Venkatesh M. Shashidhar, MD Associate Professor & Head of Pathology
Contusion of the inferior temporal lobe (blue arrow) has resulted in diffuse edema. (compressed and flattened gyri on the right).
This has resulted in subfalcine herniation of the cingulate gyrus (red arrow), with a secondary hemorrhagic infarction above that (black arrow). A midline shift from right to left is also present, as is uncal herniation (yellow arrow).
Inferior view, The herniated uncus is bulging over the position of the tentorium (black arrows) and compressing the midbrain. The two mammillary bodies (blue arrows) have been shifted to the patients right due to the pressure.
Transtentorial herniation at the base of the brain. A prominent groove surrounds the displaced parahippocampal gyrus (arrow). The adjacent 3rd nerve (N) is compressed and distorted and the ipsilateral cerebral peduncle (P) is distorted with small areas of haemorrhage.
Cerebral Herniation: Pathogenesis Decerebrate posture Cardiorespiratory failure Death Acute obstruction of CSF pathway Decerebrate posture Cardiorespiratory failure Death Brainstem compression and haemorrhage Foramen magnum Decerebrate posture Cardiorespiratory failure Death Brainstem compression and haemorrhage Upper motor neurone signs Cerebral peduncle compression Occipital infarction Cortical blindness Posterior cerebral artery compression Horizontal diplopia, convergent squint Ipsilateral 6th cranial nerve compression Ipsilateral fixed dilated pupil Ipsilateral 3rd cranial nerve compression Transtentorial Clinical consequence Effect Site of herniation
Decorticate posturing, with elbows, wrists and fingers flexed, and legs extended and rotated inward.
Look for good in others… no one is without faults and everyone has some good qualities! BK.
60y smoker, chronic bronchitis complains of difficulty walking. PE: stiff, expressionless face. A tremor of his fingers is apparent but ceases when he tries to reach for something. Image shows brain stem . Diagnosis?
54y woman dies 48 hours after suffering severe head injuries in an automobile accident. Just before her death, her left pupil becomes fixed and dilated. An inferior view of the patient's brain at autopsy is shown. Most likely cause of death?
Diffuse axonal shearing
Thrombosis of sagittal sinus
48y male, Frontal lobe tum, What is the most likely diagnosis?
This 50 year-old female smoker known for hypertension and diabetes mellitus type 2 was in her usual state of health until 2 years ago, when she began to have morning headaches that would usually go away by themselves. Year later began to have hearing problem on her left side. Recently, she noticed intermittent loss of sensation of the left side of her face. She is taking a thiazide diuretic, captopril, glyburide, and metformin. She has no known allergies.
Physical exam: Slight drooping in the left mouth and lower eyelid. Incomplete closure of the left eyelid with corneal touch. Reduced pain and light touch on the left side. Fundoscopic exam revealed bilateral papilledema.
2-year history of loss of initiative, depression. He had slowly lost his drive to win all the big deals he always done so well at work. 3 months ago he began to experience headache, which did not respond to acetaminophen or aspirin. His wife noticed that his lethargic state had increased in the past few months. 3 days ago his right arm began to convulse uncontrollably for 1 minute. 1 day ago the patient began again violently shaking his right arm, and the right side of face began to twitch at the dinner table. No fever.
Physical exam: Bilateral papilledema, increased deep tendon reflexes of the right bicep, tricep, +ve babinski sign on the right foot, reduced leg strength on the right.
Constant crying and not interacting with other children at daycare since 1m. Mother noticed that he was pointing to his head often. Family physician who stated that he was developing normally, and that the “ terrible two’s” are difficult period for parents. Recently started vomiting on a daily basis and started wobbling even though he learned to walk 6 months ago.
Physical: Bilateral papilledema and gait ataxia was noted on the physical exam.
Morning headache 2y, Progressive right upper limb weakness. She woke up this morning obtunded, and did not initially respond to her husband’s cries. She screamed to her husband that she could not see anything to her right, and that she that her left arm and leg were very weak. At this point her husband rushed her to the nearest hospital.
Physical Exam: left lid ptosis, left-pupillary dilation, and failure of her left eye to constrict to light directly or consenually. Patient had bilateral lower limb weakness, with increased deep tendon reflexes on the left side, and a +ve babinski on the left side. Bilateral Papilledema. Homonymous hemianopia of the right side. Visual acuity was corrected to 20/20 with glasses.
Serious automobile accident and sustained a close head injury,she does not immediately seek medical attention, but is brought to the emergency room two hours later by her brother,on physical examination there is mydriasis and loss of pupillary light reflex,several hours later she is unable to follow a flash light with her eyes,which of the following herniation is most likely occuring in this patient???? A)cerebellar tonsils into the forman magnum B)cerebellum upward past the tentorium C)singulate gyrus under the falx D)medulla into the foramen magnum E)temporal lobe under the tentorium