A 41-year-old man presented to the emergency department with a sudden onset severe headache, diplopia, photophobia, nausea, vomiting and fever. Physical examination revealed right eye ptosis and cranial nerve palsies. Imaging showed a pituitary mass with hemorrhage consistent with pituitary tumor apoplexy. The patient underwent surgery and hormone replacement therapy. MRI is the best test to diagnose pituitary apoplexy but may be preceded by CT to screen for hemorrhage.
This document discusses neuromodulation techniques for psychiatric disorders, including deep brain stimulation (DBS) and vagus nerve stimulation (VNS). It provides an overview of DBS and VNS indications for various psychiatric conditions such as OCD, depression, Tourette's syndrome, and more. The document also describes specific DBS and VNS cases from Italy for conditions like OCD, depression, and chronic pain. It discusses the state of the field and guidelines for ethical surgery for psychiatric disorders.
This document provides information about induced hypothermia for anoxic brain injuries. It begins with the speaker's credentials and affiliations. The bulk of the document discusses advances in cooling patients using induced hypothermia after cardiac arrest or brain injuries. It provides details on the indications, contraindications, and methods for inducing hypothermia, both in the field and in-hospital. External cooling methods like ice packs and blankets as well as internal cooling methods using intravenous catheters are described.
Step up to bat and practice dictating complex cases a residents guide to effe...TriMed Media Group
Findings:
There is a normal appendix
visualized in the RLQ. The
small bowel appears normal
without evidence of
diverticulum.
The document provides guidelines for effective radiology reporting, noting that residency training focuses
Impression:
little on dictation skills. It highlights the importance of concise, clinically relevant reports that answer the
No evidence of Meckel
diverticulum. Normal exam.
clinical question. The guidelines emphasize organizing findings logically, providing a clear impression, and
focusing reports on the clinical history and diagnosis rather than just describing images.
This document presents 4 case studies to discuss barriers to correct diagnosis in neurology. Case 1 describes a woman misdiagnosed with back pain who later presented with spinal epidural abscesses. Case 2 involves a man diagnosed with labyrinthitis who later had a cerebellar infarct. Case 3 is about a woman discharged with headaches who returned with a cerebellar infarct. The document emphasizes considering alternative diagnoses and thorough neurological exams to avoid missed diagnoses.
Post dural puncture headache is a complication that can occur after a lumbar puncture or spinal anesthesia procedure. It is caused by leakage of cerebrospinal fluid through the puncture site in the dura mater, resulting in a decrease in intracranial pressure. Risk factors include being young, female, having a history of migraines or prior PDPH. Symptoms include frontal or occipital headache that worsens with upright position and improves with lying down. Treatment options range from bed rest, fluids and medications to more definitive treatments like epidural blood patch.
The document discusses the pathophysiology of post-dural puncture headache (PDPHA). There are two main mechanisms proposed for PDPHA - excessive loss of cerebrospinal fluid (CSF) leading to intracranial hypotension and traction on pain-sensitive structures, and loss of CSF causing compensatory intracranial venodilation per the Munro-Kellie doctrine. The rate of CSF leak through the dural puncture can exceed the rate of CSF production, especially with larger gauge needles. Factors like needle size, design, and bevel orientation can affect the amount of CSF lost. Reinserting the stylet may help reposition arachnoid tissue and reduce leaks.
This document discusses neuromodulation techniques for psychiatric disorders, including deep brain stimulation (DBS) and vagus nerve stimulation (VNS). It provides an overview of DBS and VNS indications for various psychiatric conditions such as OCD, depression, Tourette's syndrome, and more. The document also describes specific DBS and VNS cases from Italy for conditions like OCD, depression, and chronic pain. It discusses the state of the field and guidelines for ethical surgery for psychiatric disorders.
This document provides information about induced hypothermia for anoxic brain injuries. It begins with the speaker's credentials and affiliations. The bulk of the document discusses advances in cooling patients using induced hypothermia after cardiac arrest or brain injuries. It provides details on the indications, contraindications, and methods for inducing hypothermia, both in the field and in-hospital. External cooling methods like ice packs and blankets as well as internal cooling methods using intravenous catheters are described.
Step up to bat and practice dictating complex cases a residents guide to effe...TriMed Media Group
Findings:
There is a normal appendix
visualized in the RLQ. The
small bowel appears normal
without evidence of
diverticulum.
The document provides guidelines for effective radiology reporting, noting that residency training focuses
Impression:
little on dictation skills. It highlights the importance of concise, clinically relevant reports that answer the
No evidence of Meckel
diverticulum. Normal exam.
clinical question. The guidelines emphasize organizing findings logically, providing a clear impression, and
focusing reports on the clinical history and diagnosis rather than just describing images.
This document presents 4 case studies to discuss barriers to correct diagnosis in neurology. Case 1 describes a woman misdiagnosed with back pain who later presented with spinal epidural abscesses. Case 2 involves a man diagnosed with labyrinthitis who later had a cerebellar infarct. Case 3 is about a woman discharged with headaches who returned with a cerebellar infarct. The document emphasizes considering alternative diagnoses and thorough neurological exams to avoid missed diagnoses.
Post dural puncture headache is a complication that can occur after a lumbar puncture or spinal anesthesia procedure. It is caused by leakage of cerebrospinal fluid through the puncture site in the dura mater, resulting in a decrease in intracranial pressure. Risk factors include being young, female, having a history of migraines or prior PDPH. Symptoms include frontal or occipital headache that worsens with upright position and improves with lying down. Treatment options range from bed rest, fluids and medications to more definitive treatments like epidural blood patch.
The document discusses the pathophysiology of post-dural puncture headache (PDPHA). There are two main mechanisms proposed for PDPHA - excessive loss of cerebrospinal fluid (CSF) leading to intracranial hypotension and traction on pain-sensitive structures, and loss of CSF causing compensatory intracranial venodilation per the Munro-Kellie doctrine. The rate of CSF leak through the dural puncture can exceed the rate of CSF production, especially with larger gauge needles. Factors like needle size, design, and bevel orientation can affect the amount of CSF lost. Reinserting the stylet may help reposition arachnoid tissue and reduce leaks.
Dnb pediatrics osce 2 for PGS in Southern Railway HospitalNibedita Mitra
DNB pediatrics Osce for Post graduates in southern Railway Head Quarter Hospital. This includes a video Station. Click on the picture to play the video
This document describes the case of a 21-month-old boy who presented to the emergency room with a Glasgow Coma Score of 3 after reportedly falling from a standing position on a kitchen chair. Imaging showed subdural hemorrhage, subarachnoid hemorrhage, hypoxic-ischemic encephalopathy, and retinal hemorrhages. The autopsy later revealed an impact site on the skull and fatal injury to the cervicomedullary junction, as well as traumatic spinal cord injury without radiographic abnormality from T5 to T12. Biomechanical analysis could not rule out nonaccidental injury but found the injuries were also consistent with an accidental fall as described.
This document describes the "Cool It" therapeutic hypothermia program implemented in Minnesota. The program expanded the use of therapeutic hypothermia (TH) to high-risk cardiac arrest patients beyond the inclusion criteria of previous studies. The "Cool It" program achieved faster cooling times, higher survival rates, and better neurological outcomes compared to previous studies. It demonstrated that TH can be effectively applied to broader cardiac arrest populations when cooling is initiated rapidly through organized protocols.
This document provides information about the Objective Structured Clinical Examination (OSCE) for postgraduate medical students. It discusses the following key points in 3 sentences:
The OSCE consists of 30 stations including 4-5 rest stations, for a total of 150 marks. Five of the stations are observed stations worth 50 marks, which is equivalent to one-third of the total OSCE marks. The document outlines the different types of stations in the OSCE, which are designed to assess candidates in various clinical skills and topics through question formats like questions/answers, clinical scenarios, matching, and interpreting photographs, charts or slides.
This document discusses imaging findings in cases of suspected non-accidental injury (NAI) in children. It notes that imaging alone cannot distinguish accidental from non-accidental injury or injuries from underlying medical conditions. It also summarizes traditional views of shaken baby syndrome (SBS) and battered child syndrome, but questions the quality of evidence and inconsistencies in diagnostic criteria. The document argues that most literature on SBS merits a low quality of evidence rating. It raises issues with relying solely on certain imaging findings like subdural hematomas and retinal hemorrhages to diagnose abuse versus other possible causes. Overall, the document advocates an evidence-based approach to diagnosing NAI versus other possibilities based on quality scientific evidence and standards
Молекулярная гетерогенность пузырчаток: парадигма буллезного эпидермолиза (Mo...Fund BELA / Фонд БЭЛА
Материалы с I Евразийской Конференции по редким заболеваниям и редким лекарствам и III Всероссийской Конференции по редким заболеваниям и редко применяемым медицинским технологиям
«Дорога жизни».
21-23 июня 2012 года в гостиничном комплексе «Измайлово»
The document provides an overview of dementia, including definitions of common terms like MCI, dementia, and amnesia. It discusses the classification of dementias and the most common causes, with Alzheimer's disease and vascular dementia accounting for about 70% of cases. Diagnosis involves taking a history, physical and neurological exam, and testing including imaging and lumbar puncture. Treatment depends on the underlying cause but may include medications to address behavioral issues, the pathophysiological process, or modifying vascular risk factors. The prognosis depends on factors like age, education level, and subtype of vascular dementia.
A 55-year-old man was found unconscious at home after ingesting kratom and alcohol. At the emergency department, he was comatose with low vital signs. Treatment with naloxone had no effect. He was given supportive care and woke up 10 hours later, admitting to ingesting kratom and whiskey. Kratom contains compounds that are opioid receptor agonists and can cause respiratory depression, especially in combination with other depressants like alcohol.
Syncope, or fainting, is a relatively common problem that is often misdiagnosed. It is caused by a temporary drop in blood pressure and loss of consciousness. The most common causes are neurally-mediated syncope, cardiac arrhythmias, and orthostatic hypotension. A thorough history, physical exam, and diagnostic tests like carotid sinus massage and tilt table testing can help identify the underlying cause. Treatment depends on the cause but may include lifestyle changes, medications, or pacemaker implantation in severe cases. Proper diagnosis and management of syncope is important as it can occasionally lead to injuries or accidents.
Migraine is a central nervous system disorder with a genetic basis. People with migraines have a hyperexcitable brain that is more sensitive to triggers. During migraine attacks, there is a wave of reduced blood flow called cortical spreading depression that starts in the occipital cortex and progresses forward. Repeated attacks can lead to changes in brain structures involved in pain processing like the periaqueductal gray, and an increased risk of white matter lesions. Preventive treatments aim to reduce central nervous system excitability underlying migraine while acute treatments target trigeminal pain pathways activated during attacks.
The document summarizes evidence from animal studies and human clinical trials on the use of therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy (HIE). Animal studies showed that prolonged hypothermia starting within 6 hours and continuing for at least 24 hours reduced brain injury. The Cool Cap study was a randomized controlled trial in humans that found selective head cooling plus mild systemic hypothermia for 72 hours starting within 6 hours of birth reduced death and disability in infants with moderate to severe HIE, excluding those with the most severe brain abnormalities on EEG. Other trials also found benefits with whole body cooling.
perioperative management Pacemaker Insertion In Congenital HeartAhmed Shalabi
This document describes the perioperative management of a 6-month-old boy undergoing permanent pacemaker implantation for congenital complete heart block. Key aspects of management included premedication with atropine and promethazine to prevent vagal stimulation, induction with ketamine to avoid negative chronotropic effects, and maintenance with non-depressant anesthetics like isoflurane. Intraoperative monitoring and defibrillator equipment were readily available due to the risk of arrhythmias. The pacemaker implantation procedure and postoperative course were uncomplicated with this careful anesthetic approach.
1) Therapeutic hypothermia after cardiac arrest and ischemic stroke has been shown to improve outcomes by reducing neurological injury through several mechanisms such as preventing blood-brain barrier disruption and reducing excitotoxic neurotransmitter release.
2) Two randomized controlled trials found that inducing mild hypothermia (32-34°C) for 24 hours in comatose cardiac arrest survivors improved survival and neurological outcomes with a number needed to treat of 6-7 to see benefit.
3) Methods to induce and maintain therapeutic hypothermia include surface cooling blankets, intravenous cold saline, endovascular cooling catheters, and cooling helmets. Careful rewarming is also important to avoid rebound injury.
1. Delirium is a disturbance of consciousness and cognition that commonly occurs in ICU patients. It is important to diagnose as it is associated with increased mortality, longer hospital stays, and long-term cognitive impairment.
2. Delirium is diagnosed using tools like the Confusion Assessment Method-ICU which assess inattention and altered mental status.
3. Delirium should be treated by addressing reversible causes, minimizing sedation, and using antipsychotics like haloperidol or dexmedetomidine. Early mobility can also help prevent delirium and shorten ICU stays.
Therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathyMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
This document provides an overview of seizure disorders including basics, epidemiology, risk factors, pathophysiology, diagnosis, treatment, and prognosis. Some key points:
- Seizures are caused by excessive firing of neurons resulting in impaired brain function. Common causes include brain tumors, head injuries, infections, genetic factors.
- Around 200,000 new cases of epilepsy are diagnosed in the US each year, most commonly in children under 15 and older adults over 65.
- Diagnosis involves differentiating epileptic from non-epileptic seizures based on eyewitness accounts and EEG/MRI testing. Initial lab work checks for metabolic causes.
- Treatment primarily involves anti-epileptic medications chosen based
ACTEP2014: Therapeutic hypothermia for ACTEP 2014taem
This document discusses therapeutic hypothermia after cardiac arrest and suggests starting it in the emergency department. It defines therapeutic hypothermia and reviews studies showing improved neurological outcomes when mild hypothermia is induced after cardiac arrest. The benefits of therapeutic hypothermia are explained. Methods for inducing hypothermia in the emergency department are presented, including cold intravenous fluids and surface cooling techniques. The document recommends inducing therapeutic hypothermia for comatose cardiac arrest patients with initial rhythms of ventricular fibrillation or pulseless ventricular tachycardia.
This patient presented with transient monocular vision loss and was found to have an irregular heartbeat, flushed face, and purpuric skin lesions. Investigations revealed atrial fibrillation and a mid-diastolic heart murmur. The most likely diagnosis is infective endocarditis given the clinical findings and heart abnormalities on examination.
Isolated Cerebellar Stroke Masquerades as DepressionZahiruddin Othman
Two case reports illustrate how isolated cerebellar stroke can masquerade as depression. In both cases, patients presented with vertigo and were initially misdiagnosed with depression due to seeming uncooperative behavior. Further examination revealed neurological deficits and imaging showed infarcts in the cerebellum. Cerebellar stroke can cause severe vertigo, nausea, and inability to walk that mimic depressive symptoms. However, the acute onset and lack of mood changes suggest an organic cause. Physicians must consider cerebellar stroke and fully examine for neurological signs when vertigo is present to avoid misdiagnosing potentially life-threatening conditions as psychiatric disorders.
- An 8-year-old boy presented with developmental delay, seizures, mandibular prognathism, strabismus, and unusual facial expressions. Exams found unsteady gait but normal muscle tone and reflexes.
- Genetic testing identified the genetic basis as Angelman syndrome.
Neuro-ophthalmic Diagnoses You Don't Want To Miss !neurophq8
The presentation will discuss common life-threatening of vision-threatening neuro-ophthalmic emergencies.
Target: Ophthalmologists/Neurologists/Family Physicians/Internists/Emergency Physicians.
Dnb pediatrics osce 2 for PGS in Southern Railway HospitalNibedita Mitra
DNB pediatrics Osce for Post graduates in southern Railway Head Quarter Hospital. This includes a video Station. Click on the picture to play the video
This document describes the case of a 21-month-old boy who presented to the emergency room with a Glasgow Coma Score of 3 after reportedly falling from a standing position on a kitchen chair. Imaging showed subdural hemorrhage, subarachnoid hemorrhage, hypoxic-ischemic encephalopathy, and retinal hemorrhages. The autopsy later revealed an impact site on the skull and fatal injury to the cervicomedullary junction, as well as traumatic spinal cord injury without radiographic abnormality from T5 to T12. Biomechanical analysis could not rule out nonaccidental injury but found the injuries were also consistent with an accidental fall as described.
This document describes the "Cool It" therapeutic hypothermia program implemented in Minnesota. The program expanded the use of therapeutic hypothermia (TH) to high-risk cardiac arrest patients beyond the inclusion criteria of previous studies. The "Cool It" program achieved faster cooling times, higher survival rates, and better neurological outcomes compared to previous studies. It demonstrated that TH can be effectively applied to broader cardiac arrest populations when cooling is initiated rapidly through organized protocols.
This document provides information about the Objective Structured Clinical Examination (OSCE) for postgraduate medical students. It discusses the following key points in 3 sentences:
The OSCE consists of 30 stations including 4-5 rest stations, for a total of 150 marks. Five of the stations are observed stations worth 50 marks, which is equivalent to one-third of the total OSCE marks. The document outlines the different types of stations in the OSCE, which are designed to assess candidates in various clinical skills and topics through question formats like questions/answers, clinical scenarios, matching, and interpreting photographs, charts or slides.
This document discusses imaging findings in cases of suspected non-accidental injury (NAI) in children. It notes that imaging alone cannot distinguish accidental from non-accidental injury or injuries from underlying medical conditions. It also summarizes traditional views of shaken baby syndrome (SBS) and battered child syndrome, but questions the quality of evidence and inconsistencies in diagnostic criteria. The document argues that most literature on SBS merits a low quality of evidence rating. It raises issues with relying solely on certain imaging findings like subdural hematomas and retinal hemorrhages to diagnose abuse versus other possible causes. Overall, the document advocates an evidence-based approach to diagnosing NAI versus other possibilities based on quality scientific evidence and standards
Молекулярная гетерогенность пузырчаток: парадигма буллезного эпидермолиза (Mo...Fund BELA / Фонд БЭЛА
Материалы с I Евразийской Конференции по редким заболеваниям и редким лекарствам и III Всероссийской Конференции по редким заболеваниям и редко применяемым медицинским технологиям
«Дорога жизни».
21-23 июня 2012 года в гостиничном комплексе «Измайлово»
The document provides an overview of dementia, including definitions of common terms like MCI, dementia, and amnesia. It discusses the classification of dementias and the most common causes, with Alzheimer's disease and vascular dementia accounting for about 70% of cases. Diagnosis involves taking a history, physical and neurological exam, and testing including imaging and lumbar puncture. Treatment depends on the underlying cause but may include medications to address behavioral issues, the pathophysiological process, or modifying vascular risk factors. The prognosis depends on factors like age, education level, and subtype of vascular dementia.
A 55-year-old man was found unconscious at home after ingesting kratom and alcohol. At the emergency department, he was comatose with low vital signs. Treatment with naloxone had no effect. He was given supportive care and woke up 10 hours later, admitting to ingesting kratom and whiskey. Kratom contains compounds that are opioid receptor agonists and can cause respiratory depression, especially in combination with other depressants like alcohol.
Syncope, or fainting, is a relatively common problem that is often misdiagnosed. It is caused by a temporary drop in blood pressure and loss of consciousness. The most common causes are neurally-mediated syncope, cardiac arrhythmias, and orthostatic hypotension. A thorough history, physical exam, and diagnostic tests like carotid sinus massage and tilt table testing can help identify the underlying cause. Treatment depends on the cause but may include lifestyle changes, medications, or pacemaker implantation in severe cases. Proper diagnosis and management of syncope is important as it can occasionally lead to injuries or accidents.
Migraine is a central nervous system disorder with a genetic basis. People with migraines have a hyperexcitable brain that is more sensitive to triggers. During migraine attacks, there is a wave of reduced blood flow called cortical spreading depression that starts in the occipital cortex and progresses forward. Repeated attacks can lead to changes in brain structures involved in pain processing like the periaqueductal gray, and an increased risk of white matter lesions. Preventive treatments aim to reduce central nervous system excitability underlying migraine while acute treatments target trigeminal pain pathways activated during attacks.
The document summarizes evidence from animal studies and human clinical trials on the use of therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy (HIE). Animal studies showed that prolonged hypothermia starting within 6 hours and continuing for at least 24 hours reduced brain injury. The Cool Cap study was a randomized controlled trial in humans that found selective head cooling plus mild systemic hypothermia for 72 hours starting within 6 hours of birth reduced death and disability in infants with moderate to severe HIE, excluding those with the most severe brain abnormalities on EEG. Other trials also found benefits with whole body cooling.
perioperative management Pacemaker Insertion In Congenital HeartAhmed Shalabi
This document describes the perioperative management of a 6-month-old boy undergoing permanent pacemaker implantation for congenital complete heart block. Key aspects of management included premedication with atropine and promethazine to prevent vagal stimulation, induction with ketamine to avoid negative chronotropic effects, and maintenance with non-depressant anesthetics like isoflurane. Intraoperative monitoring and defibrillator equipment were readily available due to the risk of arrhythmias. The pacemaker implantation procedure and postoperative course were uncomplicated with this careful anesthetic approach.
1) Therapeutic hypothermia after cardiac arrest and ischemic stroke has been shown to improve outcomes by reducing neurological injury through several mechanisms such as preventing blood-brain barrier disruption and reducing excitotoxic neurotransmitter release.
2) Two randomized controlled trials found that inducing mild hypothermia (32-34°C) for 24 hours in comatose cardiac arrest survivors improved survival and neurological outcomes with a number needed to treat of 6-7 to see benefit.
3) Methods to induce and maintain therapeutic hypothermia include surface cooling blankets, intravenous cold saline, endovascular cooling catheters, and cooling helmets. Careful rewarming is also important to avoid rebound injury.
1. Delirium is a disturbance of consciousness and cognition that commonly occurs in ICU patients. It is important to diagnose as it is associated with increased mortality, longer hospital stays, and long-term cognitive impairment.
2. Delirium is diagnosed using tools like the Confusion Assessment Method-ICU which assess inattention and altered mental status.
3. Delirium should be treated by addressing reversible causes, minimizing sedation, and using antipsychotics like haloperidol or dexmedetomidine. Early mobility can also help prevent delirium and shorten ICU stays.
Therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathyMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
This document provides an overview of seizure disorders including basics, epidemiology, risk factors, pathophysiology, diagnosis, treatment, and prognosis. Some key points:
- Seizures are caused by excessive firing of neurons resulting in impaired brain function. Common causes include brain tumors, head injuries, infections, genetic factors.
- Around 200,000 new cases of epilepsy are diagnosed in the US each year, most commonly in children under 15 and older adults over 65.
- Diagnosis involves differentiating epileptic from non-epileptic seizures based on eyewitness accounts and EEG/MRI testing. Initial lab work checks for metabolic causes.
- Treatment primarily involves anti-epileptic medications chosen based
ACTEP2014: Therapeutic hypothermia for ACTEP 2014taem
This document discusses therapeutic hypothermia after cardiac arrest and suggests starting it in the emergency department. It defines therapeutic hypothermia and reviews studies showing improved neurological outcomes when mild hypothermia is induced after cardiac arrest. The benefits of therapeutic hypothermia are explained. Methods for inducing hypothermia in the emergency department are presented, including cold intravenous fluids and surface cooling techniques. The document recommends inducing therapeutic hypothermia for comatose cardiac arrest patients with initial rhythms of ventricular fibrillation or pulseless ventricular tachycardia.
This patient presented with transient monocular vision loss and was found to have an irregular heartbeat, flushed face, and purpuric skin lesions. Investigations revealed atrial fibrillation and a mid-diastolic heart murmur. The most likely diagnosis is infective endocarditis given the clinical findings and heart abnormalities on examination.
Isolated Cerebellar Stroke Masquerades as DepressionZahiruddin Othman
Two case reports illustrate how isolated cerebellar stroke can masquerade as depression. In both cases, patients presented with vertigo and were initially misdiagnosed with depression due to seeming uncooperative behavior. Further examination revealed neurological deficits and imaging showed infarcts in the cerebellum. Cerebellar stroke can cause severe vertigo, nausea, and inability to walk that mimic depressive symptoms. However, the acute onset and lack of mood changes suggest an organic cause. Physicians must consider cerebellar stroke and fully examine for neurological signs when vertigo is present to avoid misdiagnosing potentially life-threatening conditions as psychiatric disorders.
- An 8-year-old boy presented with developmental delay, seizures, mandibular prognathism, strabismus, and unusual facial expressions. Exams found unsteady gait but normal muscle tone and reflexes.
- Genetic testing identified the genetic basis as Angelman syndrome.
Neuro-ophthalmic Diagnoses You Don't Want To Miss !neurophq8
The presentation will discuss common life-threatening of vision-threatening neuro-ophthalmic emergencies.
Target: Ophthalmologists/Neurologists/Family Physicians/Internists/Emergency Physicians.
This document summarizes key aspects of coma and brain stem death. It discusses the neurological structures involved in consciousness and what is required to induce coma. Coma is defined as unarousable unresponsiveness, distinguished from an alert state. Assessing a comatose patient involves obtaining history, performing a general and neurological exam including the Glasgow Coma Scale, and considering appropriate investigations and management. Brain death is defined as the irreversible loss of all brain functions including the brainstem, determined by coma, absence of brainstem reflexes, and apnea on testing.
Why seizure not just epilepsy as it used to?SolidaSakhan
The document discusses the differences between syncope and seizures. Syncope is a transient loss of consciousness due to low blood flow to the brain that results in a brief loss of muscle tone, while seizures involve abnormal electrical activity in the brain. Key differences include triggers, motor activity during the episode, and recovery time. A thorough history and physical exam are important for differentiating the two, and tests like EEG, imaging, and cardiac monitoring may also provide useful information. Misdiagnosis can have negative health and psychosocial consequences.
A 68-year-old woman presented with shortness of breath, flank pain, fever, and weakness. She had a diffuse rash and a history of diabetes. Examination found pallor, cyanosis, tachycardia, and hypotension. Tests showed metabolic acidosis and renal failure. A diagnosis of Waterhouse-Friderichsen syndrome was made due to shock unresponsive to vasopressors, rash, disseminated intravascular coagulation, and Pseudomonas aeruginosa bacteremia from a leg ulcer. The syndrome results from bilateral adrenal hemorrhage during fulminant meningococcal or other severe infections.
This document discusses the pathophysiology and management of epilepsy. It defines epilepsy as a neurological condition characterized by recurrent seizures that occur unpredictably. The causes of epilepsy can be genetic, acquired like head trauma, or of unknown origin. Seizures occur due to an imbalance between inhibitory and excitatory neurotransmitters in the brain. Treatment involves both non-pharmacological options like surgery and ketogenic diets as well as pharmacological treatment with anti-epileptic drugs that work by various mechanisms such as enhancing GABA activity or blocking sodium channels. The document provides details on the classification, mechanisms, and use of various anti-epileptic drug classes.
This patient, a 65-year-old male, presented with 6 months of gradually worsening gait difficulties and incoordination. Over the past 4 months, he developed forgetfulness, hallucinations, and sensorium changes. Exams found rigidity, myoclonic jerks, and a non-reactive semi-conscious state. Imaging and tests were suggestive of Creutzfeldt-Jakob disease (CJD), a prion disease characterized by spongiform changes in the brain. A definitive diagnosis requires brain biopsy or autopsy.
This patient, a 65-year-old male, presented with 6 months of difficulty walking and 4 months of forgetfulness and hallucinations. Examination found he was semiconscious with rigidity and myoclonic jerks. Imaging and tests were consistent with a prion disease like Creutzfeldt-Jakob disease (CJD). A lumbar puncture found elevated proteins. He was diagnosed with a rapidly progressive neurodegenerative condition likely CJD.
Лікувальна гіпотермія новонароджених із гіпоксично-ішемічною енцефалопатієюMCH-org-ua
1) Therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy has been shown to reduce mortality and morbidity when initiated before 6 hours of life.
2) Studies have found hypothermia reduces brain injury as seen on MRI and lowers rates of cerebral palsy, cognitive impairment, and death when compared to normothermia.
3) While mid-term outcomes up to age 7 show benefits of hypothermia, long-term follow up is still needed to fully understand impacts on neurocognitive, behavioral, and social development into childhood. Combining hypothermia with neuroprotective drugs is a promising area for further research.
1) Consciousness is defined as awareness of oneself and one's environment, while unconsciousness is a lack of awareness or responsiveness.
2) Causes of unconsciousness include structural brain lesions, metabolic abnormalities, and psychogenic factors.
3) Assessment of an unconscious patient involves evaluating their Glasgow Coma Scale score, respiration, pupils, brainstem reflexes, and ordering diagnostic tests.
4) Initial management of an unconscious patient focuses on ABCs - airway, breathing, and circulation to optimize oxygen and glucose delivery to the brain while minimizing increased intracranial pressure.
1. A 27-year-old female presented with sudden loss of language over 2 days. She had a history of left parietal lobe trauma and hematoma requiring craniectomy at age 19. CT showed a new left parietal lobe lesion.
2. The diagnosis is aphasic status epilepticus, likely caused by the new left parietal lobe lesion seen on CT.
3. Status epilepticus is a medical emergency requiring prompt treatment to stop seizures and prevent complications. The goals of management are to maintain vital functions, stop seizures, identify and treat the underlying cause, and manage any sequelae.
The document discusses two conditions: paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS). PNH is a complement-mediated hemolytic anemia treated with the drug eculizumab, a C5a inhibitor. aHUS is a complement-mediated thrombotic microangiopathy that can cause stroke, heart attack, and kidney failure, and is also treated with eculizumab. The document asks the reader to identify PNH, aHUS, and the mode of action of eculizumab.
Neurologic Emergencies - Dr. Michael Oubrebcooper876
A 39-year-old woman presented with right facial weakness and blurry right eye vision. On examination, she had right facial droop and inability to fully raise her right eyebrow or wrinkle her forehead. She was diagnosed with Bell's palsy. Steroids are recommended for treatment as they improve recovery rates. The addition of antivirals may provide additional benefit for severe cases.
The document contains several clinical cases presented as short paragraphs with multiple choice questions. It discusses cases involving a man with hives, a woman who underwent fundoplication surgery, a man with gout and kidney disease, a man with hemoptysis and kidney problems, a man with ulcerative colitis, a woman with asthma, a woman with sudden vision loss, a man with HIV and brain lesions, a man with sepsis and kidney injury, and a pregnant woman with lupus and hypertension. Each case is followed by a question testing the reader's knowledge of diagnosis or treatment.
This document contains several clinical case summaries presented as questions with multiple choice answers. The cases cover topics including a patient presenting with hives, a post-surgery complication, a patient with joint swelling and chronic gout, and a pregnant patient with SLE and high blood pressure. For each case, the correct answer is provided to identify the underlying mechanism, appropriate treatment, most likely diagnosis, or best next test.
The brain eater (Creutzfeldt Jakob Disease)Lex Luthor
Creutzfeldt-Jakob disease (CJD) is a rapidly progressive neurodegenerative brain disorder caused by prions. Symptoms include dementia, muscle stiffness, and myoclonus. It is always fatal, with death usually occurring within 1 year of symptom onset. While there is no cure, management focuses on symptom relief. CJD can occur sporadically, through infection or genetic mutation, and was first described in the early 1920s.
Creutzfeldt-Jakob disease (CJD) is a rapidly progressive neurodegenerative brain disorder caused by prions. Symptoms include dementia, muscle stiffness, and myoclonus. It is always fatal, with death usually occurring within 1 year of symptom onset. There are several forms including sporadic, variant, and familial CJD. No effective treatments exist, so management focuses on symptom relief.
Este documento resume la varicela, causada por el virus varicela-zóster. Describe que el 90-95% de las personas la adquieren en la niñez y se transmite por vía aérea o contacto. Tras una incubación de 14-16 días, aparecen lesiones dérmicas (máculas, pápulas y vesículas) que siguen un curso centrípeto. Las complicaciones más comunes son infecciones bacterianas secundarias, neumonía y encefalitis. El tratamiento incluye control de síntomas y
El sarampión es una enfermedad viral altamente contagiosa causada por un virus paramixovirus que se transmite por vía aérea. Se caracteriza por tres fases: una fase prodrómica con fiebre y síntomas respiratorios, una fase exantemática con erupción cutánea y una fase de convalecencia con descamación. Puede causar complicaciones graves como neumonía, encefalitis y diarrea. El tratamiento incluye vitamina A para reducir la gravedad y mortalidad.
El documento proporciona información sobre varias enfermedades infecciosas, incluido su agente causal, síntomas, periodo de incubación y contagio. Describe las características del eritema infeccioso, la exantema súbita, el síndrome mano-pie-boca, el síndrome de Gianotti-Crosti y la rubeola, así como los diferentes tipos de exantemas. También correlaciona diferentes enfermedades con sus respectivos periodos de incubación.
El documento proporciona información sobre quemaduras. Las quemaduras afectan principalmente a niños pequeños y las quemaduras severas ocurren más comúnmente en niños menores de 5 años. En México, la mayoría de las quemaduras son causadas por fuego o escaldadura. El documento describe los grados de quemadura, el tratamiento, y los criterios para referencia a un centro especializado.
Este documento describe la parotiditis, una virosis glandular altamente contagiosa que causa la inflamación de las glándulas salivales, especialmente las parótidas. Afecta principalmente a niños entre 5 y 15 años e incide más en invierno y primavera. Se transmite por contacto directo con la saliva de personas infectadas. Sus síntomas incluyen fiebre, dolor e hinchazón de las glándulas parótidas que puede durar hasta dos semanas. El diagnóstico se confirma mediante pruebas serológic
La adolescente presentó cuadro de meningitis bacteriana aguda con alteración del estado de conciencia y signos meníngeos negativos. El líquido cefalorraquídeo mostró niveles elevados de proteínas y glucosa disminuida, lo que es compatible con una etiología bacteriana. Se requiere tratamiento antibiótico empírico de amplio espectro y monitorización estrecha dado el riesgo de complicaciones asociadas a la gravedad del cuadro clínico.
Este documento describe la leucemia, en particular la leucemia linfoblástica aguda. Define la leucemia como una enfermedad caracterizada por la proliferación no controlada de células precursoras linfoides en la médula ósea. Explica la epidemiología, etiología, síntomas, diagnóstico y tratamiento de la leucemia linfoblástica aguda, que es el tipo más común de leucemia en niños. También resume brevemente la leucemia mieloide aguda.
La influenza es una infección viral aguda de las vías respiratorias causada principalmente por los virus de la influenza A y B. Los síntomas son similares a un resfriado común pero más graves e incluyen fiebre, tos, dolor de garganta y cuerpo. Los grupos de alto riesgo incluyen ancianos, niños pequeños, embarazadas y personas con enfermedades crónicas. El tratamiento se enfoca en aliviar los síntomas y la terapia antiviral puede prevenir complicaciones en grupos de alto riesgo. La vacuna
La faringoamigdalitis es más frecuente en niños menores de 3 años, siendo causada principalmente por bacterias como el estreptococo hemolítico del grupo A o virus. Presenta signos como dolor faríngeo, fiebre y exudado amigdalar. Su tratamiento incluye antibióticos como penicilina o eritromicina para prevenir complicaciones como la fiebre reumática. Las otitis medias también son comunes en niños pequeños y su tratamiento es con antibióticos como amoxicilina.
Este documento describe las neumonías, definiéndolas como un proceso inflamatorio e infeccioso del parénquima pulmonar causado por varios microorganismos. Explica que existen neumonías adquiridas en la comunidad y clasificadas como típicas o atípicas. Finalmente, cubre factores de riesgo, etiología, diagnóstico, tratamiento y más detalles sobre las neumonías.
Este documento proporciona información sobre la hepatitis A. Resume que la hepatitis A es una infección viral aguda transmitida oral-fecalmente, con un periodo de incubación promedio de 30 días. Los síntomas incluyen ictericia, fiebre, dolor abdominal y elevación de las enzimas hepáticas. La infección es muy común en México en niños menores de un año. No causa secuelas crónicas.
Este documento describe la escarlatina, una enfermedad estreptocócica que causa faringoamigdalitis, exantema, fiebre y descamación. Se presenta típicamente en niños de 3 a 15 años en invierno y primavera. El agente causal es el estreptococo beta hemolítico del grupo A. El cuadro clínico incluye fiebre alta, exantema en la piel y enantema (manchas) en la boca. El tratamiento de elección es la penicilina.
Este documento describe las características de las mordeduras de serpientes venenosas en México. Existen dos especies venenosas principales, la familia Viperidae, responsable del 90% de los accidentes ofídicos, y la familia Elapidae. La gravedad del envenenamiento se clasifica dependiendo del grado de edema y los síntomas pueden incluir dolor, hinchazón, náuseas y vómitos. El tratamiento incluye la administración de antiveneno según la gravedad del caso y la monitorización de parámetros como
Este documento describe las picaduras de arañas como un problema importante de salud pública, enfocándose en las arañas Latrodectus (viuda negra) y Loxosceles (araña violinista) encontradas en México. Explica sus características, síntomas de las picaduras y tratamientos recomendados que incluyen analgésicos, antivenenos y esteroides para prevenir daños mayores.
Este documento describe la intoxicación por veneno de alacrán en México. Explica que la costa del Pacífico y el centro-oeste de México son zonas alacranógenas, con más de 200,000 accidentes por picadura de alacrán cada año. Detalla los síntomas de intoxicaciones leves, moderadas y severas, así como el tratamiento específico requerido en cada caso.
Este documento resume varios casos clínicos de parasitosis comunes en México, incluyendo información sobre el agente causal, ciclo de vida, síntomas, diagnóstico y tratamiento. Se describen casos de necatoriasis, triquinosis, giardiasis, enterobiasis, himenolepiasis, trichuriasis, teniasis, ascariasis, estrongiloidosis y amibiasis. Para cada caso, se identifica el parásito responsable, sus características, y los métodos para diagnosticar y tratar la infección.
Este documento describe la diarrea en niños de 2 meses a 5 años. Define diarrea aguda, crónica y prolongada. Explica los factores de riesgo para diarrea persistente y deshidratación. Detalla las principales causas bacterianas y virales de diarrea como rotavirus, E. coli, Shigella, Salmonella y Campylobacter. Incluye información sobre diagnóstico, tratamiento y prevención, resaltando la importancia de la hidratación y la promoción de la salud a través de buena higiene.
La paciente es una mujer de 44 años que presenta síntomas de mareo, astenia y adinamia progresivos. Las pruebas de laboratorio muestran linfopenia, anemia y resultados repetidamente reactivos para VIH. El diagnóstico es infección por VIH manifestando un síndrome agudo. Durante la hospitalización se diagnostica una infección oportunista, posiblemente neumocystis, la cual mejora con el tratamiento recibido.
Este documento resume información sobre tres enfermedades infecciosas: paludismo, tuberculosis y dengue. Describe la epidemiología, etiología, manifestaciones clínicas, complicaciones y tratamiento del paludismo, causado por parásitos del género Plasmodium y transmitido por mosquitos. También resume brevemente la tuberculosis, enfermedad causada por bacterias del complejo Mycobacterium tuberculosis, y su transmisión. No incluye detalles sobre dengue.
Este documento resume dos tipos de vasculitis: la arteritis de células gigantes y la arteritis de Takayasu. La arteritis de células gigantes involucra las arterias carótidas y causa cefalea, disminución de pulsos y pérdida de visión. Se diagnostica con biopsia y se trata con corticoesteroides. La arteritis de Takayasu afecta la aorta y sus ramas principales y causa disminución de pulsos, soplos y claudicación. Su diagnóstico incluye arteriografía
1. 02/03/2013
CLINICAL PRESENTATION A 41 year old man with sudden onset
headache and diplopia.
Background:
Dr. Juan Carlos Díaz Torre A 41-year-old man presents to the ED with an acute
DR. JCDT
DR. JCDT
severe headache, associated diplopia, photophobia,
Pediatra Neonatólogo nausea, vomiting and fever. The patient also has mild
dr_diaz_torre@hotmail.com gynecomastia.
(779) 100 . 40 . 26 HINT: The neurologic findings on this patient's physical
examination aid in establishing the etiology of his
1 headache. 2
He denies experiencing any associated seizures,
A 41-year-old man presents to the emergency focal weaknesses, previous similar episodes,
department (ED) complaining of a severe frontal frequent headaches, or previous visual disturbances.
headache that began suddenly and awakened him from
sleep. The headache is associated with nausea, He does not have any prior significant medical
DR. JCDT
DR. JCDT
vomiting, and subjective fevers. problems, and his only medication is occasional
sildenafil.
He also complains of new-onset diplopia and
photophobia, but denies any decrease in visual acuity. He drinks socially, does not smoke, and denies
recreational drug use.
3 4
On physical examination, the patient is ill-appearing
but alert and in no apparent distress. His vital signs
reveal a temperature of 103.1°F (39.5°C), a blood
pressure of 155/95 mm Hg, and a pulse of 110 bpm.
The ocular examination demonstrates ptosis of the right
eye (see Figure 1), which is deviated inferolaterally and
DR. JCDT
DR. JCDT
has a dilated and unreactive pupil (see Figure 2).
The visual field examination demonstrates bitemporal
hemianopsia. Funduscopic examination shows normal
venous pulsation and mild bilateral temporal disc pallor.
5 6
1
2. 02/03/2013
Laboratory investigations reveal a hemoglobin
The cranial nerves are otherwise without deficit. The concentration of 13 g/dL (130 g/L); a white blood cell
neck is supple and without meningismus. Examination (WBC) count of 16.0 × 103/µL (16.0 × 109/L), with 75%
of the chest reveals mild bilateral gynecomastia, without neutrophils; and a platelet count of 340 × 103/µL (340 ×
nipple discharge. The lungs are clear to auscultation. 109/L). The electrolyte, blood urea nitrogen (BUN),
Cardiac auscultation reveals a normal S1 and S2 and no creatinine, and glucose examinations are all within
murmurs, rubs, or gallops.
DR. JCDT
DR. JCDT
normal limits.
The abdomen is soft and nontender, and no Cerebrospinal fluid (CSF) specimens show 420,000 red
organomegaly is detected. Bilateral upper and lower blood ceels (RBC)/μL, 20,000 WBC/μL, a normal glucose
extremity strength is 5/5, with normal deep tendon and of 85 mg/dL (4.72 mmol/L), and an elevated protein
plantar reflexes. The patient's sensation is intact to light concentration of 230 mg/dL (2.3 g/L). The CSF Gram
touch and pinprick throughout, and the gait is normal. 7 stain is negative for bacteria. 8
A computed tomography (CT) scan of the What is the most likely diagnosis?
brain is performed, followed immediately by
magnetic resonance imaging (MRI); (see - Subarachnoid hemorrhage
Figure 3).
- Cerebellar infarction
DR. JCDT
DR. JCDT
- Pituitary tumor apoplexy
- Cavernous sinus thrombosis
9 10
Discussion
Your Colleagues Responded:
The noncontrast CT scan of the brain showed a 2-cm
- Subarachnoid hemorrhage 13% sellar mass, with suprasellar extension. There was
impingement on the optic chiasm and the
- Cerebellar infarction 3% hypothalamus, with upward displacement. There was
increased density on the right side of the mass, which
DR. JCDT
DR. JCDT
- Pituitary tumor apoplexy **** 61% was suggestive of hemorrhage.
- Cavernous sinus thrombosis 22% The sagittal and coronal T1 and T2 MRI scans
demonstrated a large soft-tissue mass in the pituitary
fossa, with areas of intermediate- and high-intensity
11 signal suggestive of hemorrhage (see Figure 3). 12
2
3. 02/03/2013
Coronal gadolinium-enhanced T1 images
revealed that the mass had a heterogeneous These findings are consistent with pituitary
pattern of faint peripheral enhancement apoplexy as a result of hemorrhage with or
(Figure 4). without infarction, likely into a pituitary adenoma.
There was evidence of mass effect on the right Tests for evaluating the hormonal status of the
DR. JCDT
DR. JCDT
cavernous sinus, which was most evident in patient revealed panhypopituitarism. Prior to the
the coronal T1- and T2 images. acute apoplectic episode, the patient had findings
suggestive of central hypogonadism, probably as a
component of his hypopituitarism caused by
pituitary macroadenoma (diminished libido and
13
bilateral gynecomastia). 14
His neurologic finding (right-sided ptosis with a
fixed and dilated pupil pointing downward and
outward) was consistent with a right-sided 3rd The word "apoplexy" stems from a Greek term
nerve palsy caused by extension of hemorrhage meaning to "have a stroke".
into the right cavernous sinus.
Neurologic symptoms and signs are secondary to
DR. JCDT
DR. JCDT
Pituitary tumor apoplexy is defined as displacement of the optic nerve and impingement
hemorrhage or infarction of a pituitary gland of the 3rd, 4th, and 6th cranial nerves.
associated with the presence of a preexisting
pituitary adenoma. It manifests as a sudden, Hormonal dysfunction results from destruction of
severe headache, and it is sometimes associated the anterior pituitary gland.
with neurologic and hormonal dysfunction.
15 16
Pituitary tumor apoplexy is a rare disorder with an Pituitary tumor apoplexy is only rarely associated
annual incidence of about 1.2 per million. Men are with a healthy gland; however, approximately 50%
affected twice as often as women, and all age of patients who present with pituitary tumor
DR. JCDT
DR. JCDT
groups can be affected, with the majority of apoplexy are not diagnosed with a pituitary lesion
patients in the 5th or 6th decades of life. It is prior to their presentation. All types of pituitary
estimated to occur in 1.5-27.7% of cases of tumors carry the same risk for apoplexy.
pituitary adenoma.
17 18
3
4. 02/03/2013
The most common symptom of pituitary tumor The increase in intrasellar pressure results in many
apoplexy is headache. Almost all patients of the symptoms and signs of pituitary tumor
describe a sudden, severe retro-orbital or apoplexy.
bifrontal headache, which is associated with
vomiting in two-thirds of cases. Laterally, the increased pressure causes
compression of the structures in the cavernous
DR. JCDT
DR. JCDT
The headache and vomiting result from the sinus, namely the 3rd, 4th, and 6th cranial nerves,
sudden increase in intrasellar pressure either with the 3rd being most commonly affected as a
caused by the hemorrhage or secondary to result of its vulnerable position (parallel to the
meningeal irritation from blood or tumor lateral wall of the pituitary gland). The 6th cranial
products that leak into the CSF. nerve is the least commonly involved because of its
most lateral location within the sinus.
19 20
Ophthalmoplegia (caused by 3rd, 4th, and 6th
nerve palsies or any combination thereof) is
present in around 80% of patients presenting with Blood leaking into the subarachnoid space may
pituitary tumor apoplexy. result in chemical meningitis with fever,
meningismus, and photophobia. Fever in patients
Also located within the cavernous sinus is the with apoplexy may also be explained by alteration in
trigeminal nerve; its involvement may cause facial thermal regulation caused by hypothalamic
DR. JCDT
DR. JCDT
pain or sensory loss. Carotid siphon compression involvement by the hemorrhage or by adrenal
may present as hemiplegia. Superiorly, the insufficiency associated with hypopituitarism.
increased pressure compresses the optic chiasm,
optic tract, or optic nerve, leading to decreased Hemorrhage may extend into the brain parenchyma
visual acuity or visual field defects (classically, causing cortical irritation and provoking seizures.
bitemporal hemianopsia). 21 22
The elevated intrasellar pressure also accounts for
the endocrine abnormalities found in cases of Although not common, patients with pituitary tumor
pituitary tumor apoplexy. This pressure increase apoplexy may have diabetes insipidus at presentation.
results in compression of the pituitary tissue, The true etiology of diabetes insipidus in this setting
compromising its vascular supply and leading to is unknown, but it may result from the increased
DR. JCDT
DR. JCDT
hypopituitarism. pressure on the pituitary infundibulum, which
impedes the antidiuretic hormone from passing from
Adrenal insufficiency is the most clinically significant the hypothalamus to the posterior lobe of the
result of hypopituitarism, contributing significantly pituitary.
to the mortality of patients with pituitary tumor
apoplexy if not promptly recognized and treated.
23 24
4
5. 02/03/2013
Pituitary tumor apoplexy following childbirth
A precipitating factor is identified in 50% of cases of associated with significant postpartum hemorrhage
pituitary tumor apoplexy. Predisposing factors include in nontumorous glands is termed "Sheehan
dopamine agonist treatment, head trauma, pituitary syndrome".
irradiation, pregnancy, coronary artery bypass
grafting, surgical operations, and anticoagulation. The hypertrophy of the pituitary gland that occurs in
normal pregnancy combined with the arterial spasm
DR. JCDT
DR. JCDT
Endocrine stimulation tests are also associated with of the pituitary's blood supply (caused by bleeding
pituitary tumor apoplexy. It is postulated that and hypotension) both contribute to the
hormones used in these tests may increase blood flow development of Sheehan syndrome; however the
in pituitary adenomas, provoking bleeding in friable clinical presentation of pituitary apoplexy in these
vessels. cases is usually less dramatic, with a more gradual
25 development of signs and symptoms of 26
hypopituitarism.
Once recognized, effective treatment of pituitary
tumor apoplexy requires prompt administration of
The diagnosis of pituitary tumor apoplexy is best high-dose corticosteroids. Steroids should be
established by MRI; however, this is usually preceded administered in supraphysiologic doses to not only
by a rapid diagnostic CT scan to screen for intracranial replace endogenous hormone deficiency during a
hemorrhage. MRI is superior to CT scanning for stressful condition, but also to take advantage of its
evaluating the pituitary gland and possibly visualizing
DR. JCDT
DR. JCDT
anti-inflammatory effect by decreasing swelling on
hemorrhage not seen by CT. parasellar structures.
In one study, the detection rate of pituitary tumor The definitive treatment for pituitary tumor
apoplexy by CT scanning was 21%, whereas the apoplexy is emergent surgical decompression.
detection rate was 100% with MRI. Transsphenoidal resection is the most common
27 approach in this situation. 28
In cases where there is significant extension of With prompt recognition, timely surgery, and proper
hemorrhage into the brain parenchyma beyond the medical management, the majority of patients with
diaphragma sella, an intracranial approach may be pituitary tumor apoplexy improve. Ophthalmoplegia
preferred. In a minority of cases, conservative medical is usually the first symptom to resolve. Less readily
therapy is an acceptable alternative; examples of this restored is the optic nerve defect resulting in
include patients who are poor surgical candidates and decreased visual acuity and restricted visual fields.
DR. JCDT
DR. JCDT
selected patients who present with isolated
meningismus or ophthalmoplegia and show More than half of patients, however, will have
significant improvement with steroid administration. permanent hormone deficiencies resulting from
pituitary injury and will require hormone
Medical management includes monitoring of replacement.
endocrine, neurologic, and ophthalmologic function 29 30
combined with hormone replacement.
.
5
6. 02/03/2013
One study showed that maintenance steroid,
thyroid hormone, and testosterone replacement An endocrinology evaluation was completed, and
was essential postoperatively in 82%, 89%, and 64% the patient was confirmed to have hypopituitarism.
of patients, respectively. Two weeks following surgery, his ophthalmoplegia
and visual field deficits had completely resolved.
Following immediate administration of high dose
DR. JCDT
DR. JCDT
corticosteroids, the patient in this case underwent Pharmacologic management of the patient's
an emergent transsphenoidal resection. An infarcted hypopituitarism included replacement therapy with
adenoma was identified, with extensive areas of corticosteroids, levothyroxine, and testosterone.
hemorrhage and necrosis consistent with apoplexy.
Resolution of the headache and improvement of
visual and extraocular function were noted 24 hours 31 32
after surgery.
A patient presents to the ED with a rapid onset of
headache accompanied by diplopia, photophobia,
and decreased visual acuity, raising concern for a
number of potentially serious conditions. Which of
Your colleagues responded:
the following diagnostic tests is most likely to assist
in confirming pituitary tumor apoplexy as the
- Lumbar puncture 1%
diagnosis?
DR. JCDT
DR. JCDT
- MRI of the brain **** 89 %
- CT of the brain 10 %
- Lumbar puncture
- Carotid ultrasonography 0%
- MRI of the brain
- Dilated retinal examination 0%
- CT of the brain
- Carotid ultrasonography
- Dilated retinal examination 33 34
The patient you are examining is confirmed to have
pituitary tumor apoplexy. Which of the following
The diagnosis of pituitary tumor apoplexy is best
choices, if they were part of this patient's history, is a
established by MRI. Although this may be
potentially responsible precipitating factor for this
preceded by a CT scan to screen for intracranial
occurrence?
hemorrhage.
DR. JCDT
DR. JCDT
- Coronary artery bypass graft
Lumbar puncture may reveal xanthochromia
- Head trauma
and/or red blood cells, but this may also be seen in
- Endocrine stimulation tests
subarachnoid hemorrhage resulting from a
- Dopamine agonist treatment
ruptured aneurysm.
- All of the above
35 36
6
7. 02/03/2013
Your colleagues responded:
- Coronary artery bypass graft 1%
- Head trauma 5% Gracias por su atención
- Endocrine stimulation tests 7%
- Dopamine agonist treatment 4%
DR. JCDT
DR. JCDT
- All of the above **** 83 % Dr. Juan Carlos Díaz Torre
Pediatra Neonatólogo
Predisposing factors for pituitary apoplexy include
bromocriptine treatment, head trauma, pituitary dr_diaz_torre@hotmail.com
irradiation, pregnancy, coronary artery bypass (779) 100 . 40 . 26
grafting, surgical operations, anticoagulation, and 37 38
endocrine stimulation tests.
7