LeeChuy, KatherineLee, Sidney Albert

Legaspi, Roberto JoseLerma, Daniel Joseph

Li, Henry WinstonLi, Kingbherly

Lichauco, RafaelLim, Imee Loren

Lim, Jason MorvenLim, John Harold

Lim, MaryLim, Phoebe RuthLim, Syndel Raina

Lipana, Kirk Andrew

51 y/o, Male

Chief complaint: Eight months of progressive visual loss and headache

OPHTHALMOLOGIC FINDINGS

Mild bilateral papilledema with some pallor of the right optic disc

Visual fields with enlarged blind spot

Concentric loss of the peripheral visual fields in both eyes (he could see only the center of the visual field with either eye)

Other Exams The remainder of his neurologic exam was normal.

LOCALIZATION AND DIFFERENTIAL DIAGNOSIS 1. Headache, papilledema and visual

field loss of this kind is seen in what syndrome?

2. What is the appropriate test to perform next?

APPROACH TO A NEUROLOGIC PROBLEM

Three Questions Asked:

1.Is there a neurologic problem?2.Where is the neurologic problem?3.What is the neurologic problem?

1. Is there a Neurologic Problem?

Focal Neurologic DeficitsCranial nerve deficit

Increase ICPHeadachePapilledemaVisual Loss

Meningeal Irritation

Causes of optic disc swellingOPHTHALMIC

ABNORMALITY UNDERLYING CAUSE VISUAL LOSSASSOCIATED SYMPTOMS PUPILS

Papilledema Increased intracranial pressure

None or transient blurring; constriction of visual fields and enlargement of blind spot; findings almost always binocular

Headache; signs of intracranial mass

Normal unless succeeded by optic atrophy

Anterior ischemic optic neuropathy (AION)

Infarction of disc and intraorbital optic nerve due to atherosclerosis or temporal arteritis

Acute visual loss, monocular (usually); may be an altitudinal defect

Headache with temporal arteritis

Afferent pupillary defect

Optic neuritis Inflammatory changes in disc and intraorbital part of optic nerve usually due to MS, sometimes to ADEM

Rapidly progressive visual loss; usually monocular

Tender globe, pain on ocular movement

Afferent pupillary defect

Hyaline bodies Congenital, familial Usually none; may be slowly progressive Enlargement of blind spot or arcuate inferior nasal defect

Usually none; rarely transient visual obscurations

Normal

2. Where is the Neurologic Problem Levelize

Optic nerve Subarachnoid space directly communicates

with sheaths of the optic nerve; increased CSF pressure leading to increased pressure in the optic nerve sheaths

Lateralize Advanced papilledema due to increased ICP

Almost always bilateral More pronounced on side with intracranial

tumor

Localize

3. What is the Neurologic Problem?

Insidious Onset (weeks to months) Mass lesions Degenerative Disease TB/ fungal meningitis

Imaging studies

Computed Tomography (CT) scan Magnetic Resonance Imaging (MRI) Magnetic Resonance Angiography

(MRA) MR spectroscopy Positron Emission Tomography (PET)

scan Cerebral angiography

Lumbar puncture

CSF analysis measure levels of protein and glucose Detect RBC, WBC, cancer cell Done only after a CT or MRI

Management for increased ICP Elevate head and body by 30

degrees to optimize venous drainage Reduce fever and control

hyperglycemia Maintain osmolarity at 305-315

mOsm/L Prevent seizures

Specific measures include: Hyperventilation Mannitol

1-2g/kg for severely increased pressure, followed by 50-300mg/kg q6

Corticosteroid Ventricular drainage Primary disorder should be treated

General approach on brain tumors: Craniotomy Stereotactic techniques Radiosurgery Shunts

Management of Meningitis

Fungal meningititis: long course of high dose antifungals,

such as amphotericin B and flucytosine TB meningitis:

Isoniazid, rifampicin, pyrazinamide and ethambutol for 2 months, followed by isoniazidanfrifampicin alone for a further ten months

Steroids are always used in the first six weeks of treatment

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