SNS Intern Course Case Scenarios

2014

Case # 7• 63 yr old left handed female presents with progressive

headache, left homonymous hemianopia and left hemiparesis.

• PMH: HTN, DM, breast cancer 12 years earlier with negative follow up

• ROS: no systemic complaints• Meds: Prozac, ASA, glucotrol, lasix

Physical Exam

Constitutional: Normal appearing, no evidence of systemic illnessNeurological: A&O x3, speech normal, memory decreasedCranial nerves: decrease vision left visual fieldMotor 4/5 leftSensory decreased leftDTRs increased on leftCerebellar normalGait normal, tandem off

Course• POD #1: Mild confusion, neurologically intact with

improved motor strength to 4+/5, some visual field deficit to the left.

• POD #5: Worsened confusion, with motor strength of 3/5 on the left

Case #8• 58 yr old female presents to your ED with sudden

headache followed by acute visual loss OU. • PMH is significant only for HTN, DM• On exam, the ED physician reports a patient in distress

with severe headache, mild meningismus, a non reactive right pupil with NLP, and left eye with light perception, finger counting.

Tests• Normal labs, except a prolactin level of 430, and low

cortisol• MRI in the Emergency Department shows an

abnormality

Course• Intraoperative findings: blood clot and likely adenoma.

Gross total resection. CSF leak intraop.

Course• POD #1: improved vision and headache, overnight urine

output increases to 400cc/hr• POD #2: Pt coughing excessively and intermittently

choking on fluid in nasopharynx

Case #9• 42 yr old right handed male presents to your hospital

with headaches, dysphasia and progressive right hemiparesis.

• PMH is significant for hypercholesterolemia• ROS: is negative for systemic complaints except chronic

cough.

Physical Examination• A&Ox3, speech hesitancy, memory intact• No meningismus• CN: intact• Motor 3/5 on the right, arm weaker than leg• Sensory, decreased on the right• DTR: increased on the right with + Babinski

Course• Day #1: Initial improvement in clinical condition• Day #3: Deterioration, with obtundation, rising fevers,

meningismus and WBC 22,000

Case #10

• 71 yr old female with a significant past medical history of HTN, DM, CRF

• The pt presents with acute right side weakness involving UE/LE

• ROS: several days of vomiting and diarrhea. No oral intake for several days.

Meds: ASA, Atrovent, Insulin, Cardizem

Physical Exam• AO x person, hospital, Mild aphasia • BP 94/50, Pulse 130• PERRL, EOMI • Face symmetric, tongue midline • LUE/LLE 4/5 • RUE/RLE 3/5

CT on Admission

MRI

CT Venogram

Repeat CT after 1 day

Course

• Negative hypercoagulable panel • CT chest/abd/pelvis – WNL

• Natural History

MRI x 6 months

Case #11• 71 y/o right handed man presents with sudden weakness

of left upper extremity, no headache, no speech loss, no pain.

• PMH: HTN and hypercholesterolemia• ROS: negative except for above• Meds: ASA, Lipitor

Physical Exam

Afebrile, BP 180/110, Pulse 70, RR 20Mental status and speech normalCranial nerves normalMotor: Left upper ext 3/5 in all muscle groupsSensory: mild left upper ext numbnessDTR and cerebellar: normal

MRI perfusion of brain

• Due to creatinine, the patient could not get a CTA or angiogram

• MRA shows a left carotid ICA stenosis of 90% with some ulcerated plaque.

• There is no tandem stenosis• No prior radiation to neck, no prior surgeries of the neck,

the bifurcation is C4-5

Course• Intraoperative monitoring shows ipsilateral hemispheric

decrease during the procedure

Case #12• 42-year-old male with 2-month with left shoulder and arm

pain

• Radiation of pain through his radial forearm to thumb and first finger

• Non-focal neurological exam with exception:– decreased (2/5) strength and reflex in the left bicep– decreased pinprick in the thumb and first finger

Course• POD #1: Arm pain is much better, mod swallowing

problems• POD#12: Arm pain returns, swallowing much worse.

Case #13• 18-year-old male s/p fall from a window, landing on his

head. At the scene, the patient is unable to move or feel his hands or legs and has severe neck pain. He can flex and extend his wrists, elbows and shoulders. He arrives on a backboard to your ED.

PMH/SH: noneROS: intoxicatedMeds: none

Physical Exam• Afebrile, BP 90/50, Pulse 45, RR 25• Laceration on occiput, neck immobilized but tender

posteriorly• Mental status is clear, but pt is intoxicated• Wrist flexion and extension 3/5, triceps, deltoids and

deltoids 5/5• Sensory C7 intact• DTRs areflexic• No rectal tone, no bulbocavernosus or abdominal

reflexes

Course• Pt does well with stabilization, pain is better. Pt transfers

to rehab.• At 3 month return visit, the patient has significant

extremity rigidity and pain, medically uncontrolled.

Case #14 • 34 yr old male with a 2 days history of progressive neck

pain, lower extremity numbness and worsening quadraparesis.

• No history of trauma, no headache• PMH: none• ROS: Recovered from recent viral illness, otherwise no

other complaints• Meds: Ibuprophen

Physical Exam• Obvious discomfort, pain with cervical ROM.• AVSS• Mental status and speech are normal• CN: Normal• Motor: deltoid 5/5. biceps, triceps, grasp and lower ext

are 3/5• Sensory: decreased in position sense and sharp pain• DTRs symmetric, rectal tone normal.

LABS• WBC: 12,000, elevated lymphocytes

Course• What is the treatment and natural history of this

disorder?