Cool case: quick one

[Nerdoscience]

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I'll give you your imaging after exam. In other words, you could get it with exam alone. But I'm gonna ask you for specific things you examine and how just to be a pain in the S3-S5 dermatomes.

 

[neglect]

Occasional "tension Headaches" lifelong, but none out of the ordinary lately. No weakness or numbness, vision changes, or seizures. It's only in his right ear. No history of heart trouble, but has "borderline high blood pressure" according to his doc, controlled without meds. No kidney trouble. Cholesterol was mildly elevated, but he started taking fish oil, and now it's good. No drug use. Only meds are the fish oil and occasionally a few aspirin for HA.

No "whooshing" on exam. What specifically would you do to test the CNs?

Based on the history he has an abnormality of his vessels, especially if this really follows his heartbeat. Could be dissection, but no pain, but CN: pupils, ptosis.

Mass lesion pressing on a vessel: All CN 8 needs to get checked. Throw in corneal's for neurosis' sake. Look into the ear.

I think AVM is the best idea.

 

[neglect]

double post.

 

[danielmd06]

I hate showing my inexperience.

It definitely sounds vascular in origin, though I would also be curious about a possible paraganglioma or glomus tumor. The top of my differential would include AVM or AVF. Curious that the whooshing is constant but not present in the ED/clinic.

History: Is the sound dependent on head or neck position? Can it be recreated with a full ROM of the neck? Any history of dizziness?

Physical: Any subtle bumps or masses in the neck, behind the ear, or along the occipital base on the ipsilateral side? Any arcane vascular stigmata on the patient's skin?

 

[Wheezy]

I'm going to be naughty... Include carotid cavernous fistula in the diagnosis (my gut feeling tells me, I"m too tired to think "i don't do this with patients")

 

[Nerdoscience]

Checked CN I with coffee beans. Intact. CN II with fundoscope, confrontation, "count the fingers" visual fields, swinging flashlight. Intact. CN III,IV,VI with observation of no ptosis, lateral, sup. lat, and inf lat gazes bilaterally. Intact. CN V by touching face with cotton whisp has broken swab tip in all three areas, and clenching jaw. Intact. CN VII by holding eyelids shut against resistance and smiling. Intact. Skipping CN VIII (lower down). CN IX, X, XII by opening mouth wide (seeing palate), and sticking out tongue. Intact. CN XI by shrug against resistance bilat. Intact.


CN VIII Rinne test NL on L. Abnl on R -- After fork is moved from mastoid to ear, he cannot hear the tone. Webber test Abnl -- sounds louder on R. He's got too much cerumen to get a good look at his TMs on either side, but not so much that you would expect it to affect his hearing.

To answer other questions that have been asked -- not dependent on head position, but if it's really loud around him, he can't hear it. No skin findings. No neck masses. To clarify -- he can hear the sound whenever it's quiet, but YOU can't.

So, what else would you like to do?

 

[danielmd06]

If the Rinne test is abnormal on the right, then that indicates conductive hearing loss on the right. A Weber test should lateralize to the deaf ear in conductive hearing loss, which would properly be the right ear.

Causes of conductive hearing loss would include cerumen impaction, otitis externa, otitis media, neoplasms, exostoses, and tympanic membrane perforation.

How does he respond to a Whisper test? I would irrigate the ears to view the tympanic membranes, also.

An audiogram and an MRI would be appropriate to order.

 

[neurodoc]

If the Rinne test is abnormal on the right, then that indicates conductive hearing loss on the right. A Weber test should lateralize to the deaf ear in conductive hearing loss, which would properly be the right ear.

Causes of conductive hearing loss would include cerumen impaction, otitis externa, otitis media, neoplasms, exostoses, and tympanic membrane perforation.

How does he respond to a Whisper test? I would irrigate the ears to view the tympanic membranes, also.

An audiogram and an MRI would be appropriate to order.

Weber to the R and Rinne (AC>BC) to the L indicates conductive hearing loss on the right side. This could be due to many things, but most of them are peripheral and "not important" neurologically.

This patient needs an MRI and probably an MRA. Get the studies and let us know the results.

Nick

 

[Nerdoscience]

I would irrigate the ears to view the tympanic membranes, also.

So, you clean out his ears, and the L TM looks NL. The R TM is unusual -- it has a purplish spot on it that takes up about 1/4 the area of the visible TM.

While you are examining him, he complains of a pain that is developing in the area of his right mastoid process. You look there, and there is nothing visible from the outside. No other symptoms, and no change in CN exam.

Do you have a diagnosis? Do you want any other exam? And yes, I will give you the imaging when I'm done being annoying.

 

[danielmd06]

So, you clean out his ears, and the L TM looks NL. The R TM is unusual -- it has a purplish spot on it that takes up about 1/4 the area of the visible TM.

While you are examining him, he complains of a pain that is developing in the area of his right mastoid process. You look there, and there is nothing visible from the outside. No other symptoms, and no change in CN exam.

Does the purple spot blanch on pneumatic otoscopy? Otherwise I would go for imaging at this point.

It sounds like a glomus tumor case that I saw on a Neurosurgery rotation as a third year MS.

 

[Nerdoscience]

You got it. Temporal bone CT and IAC MRI with contrast both show a mass that tracks up the IAC to the TM, overlying but only minimally compressing CN VII and VIII. When you puff in the ear, the spot does blanch, and pushing on the carotid (minimally) reduces the pulsation, all of which support the diagnosis of glomus cell tumor. These tumors are highly vascularized, and are actually the most common tumor of the middle ear, despite being a relatively uncommon cause of pulsatile tinnitus.

This guy developed a peripheral Bell's type facial palsy before treatment was started, but did quite well after radiation and resection.

 

[danielmd06]

Still hoping for more cases! They can certainly be typical ones, too.

I'd like to hear anything.

 

[neglect]

32 yo man with terrible headache on the right side. Non-throbbing. Onset two days prior after gradual onset, no change since. Has had about 5 headaches in his life previously, all due to alcohol hangovers. No associated migranous features. Exam is normal. Labs are normal. Sed rate wasn't back, but will prove to be normal. Head CT shows a thickening of the tentorium ipsilaterally to the headache. Without a picture, that's the best I can do. Radiology read is normal, when you bring it to their attention, they say MRI and possible SDH. This guy doesn't have a SDH. Any other considerations?

 

[neglect]

32 yo man with terrible headache on the right side. Non-throbbing. Onset two days prior after gradual onset, no change since. Has had about 5 headaches in his life previously, all due to alcohol hangovers. No associated migranous features. Exam is normal. Labs are normal. Sed rate wasn't back, but will prove to be normal. Head CT shows a thickening of the tentorium ipsilaterally to the headache. Without a picture, that's the best I can do. Radiology read is normal, when you bring it to their attention, they say MRI and possible SDH. This guy doesn't have a SDH. Any other considerations?

 

[Methyldopa]

32 yo man with terrible headache on the right side. Non-throbbing. Onset two days prior after gradual onset, no change since. Has had about 5 headaches in his life previously, all due to alcohol hangovers. No associated migranous features. Exam is normal. Labs are normal. Sed rate wasn't back, but will prove to be normal. Head CT shows a thickening of the tentorium ipsilaterally to the headache. Without a picture, that's the best I can do. Radiology read is normal, when you bring it to their attention, they say MRI and possible SDH. This guy doesn't have a SDH. Any other considerations?

My guess at the Dx: Idiopathic hypertrophic cranial pachymeningitis

 

[neurodoc]

My guess at the Dx: Idiopathic hypertrophic cranial pachymeningitis

M-dopa, You is da Man! Yeah, focal pachymeninitis seems to fit the picture. I wouldn't be so quick to call it "idiopathic" before ruling out specific causes. The one case I saw more than 10 years ago turned out to be syphilitic. Besides syphilis, you need to consider sarcoid, TB, and fungal meningitis. Also rheumatic disease, especially Bechet's. I think the next step would be LP and of course get an HIV test. Great case, neglect. Keep us updated.🙂

Nick

 

[neglect]

M-dopa, You is da Man! Yeah, focal pachymeninitis seems to fit the picture. I wouldn't be so quick to call it "idiopathic" before ruling out specific causes. The one case I saw more than 10 years ago turned out to be syphilitic. Besides syphilis, you need to consider sarcoid, TB, and fungal meningitis. Also rheumatic disease, especially Bechet's. I think the next step would be LP and of course get an HIV test. Great case, neglect. Keep us updated.🙂

Nick

This makes me think I didn't consider things fully.

The history I hid: he had an idiopathic DVT in the past. The thickened tentorium was just deep to the skull.

Anyone want to order another imaging study? How soon would you order it?

Anyway, he did well in the hospital.

 

[neurodoc]

This makes me think I didn't consider things fully.

The history I hid: he had an idiopathic DVT in the past. The thickened tentorium was just deep to the skull.

Anyone want to order another imaging study? How soon would you order it?

Anyway, he did well in the hospital.

OK, now I am thinking of a venous thrombosis involving the transverse sinuses. How about MRA or just go to regular cerebral angio?

Nick

 

[neglect]

OK, now I am thinking of a venous thrombosis involving the transverse sinuses. How about MRA or just go to regular cerebral angio?

Nick

The MRI showed the clot, and MRV showed no flow. Did well on heparin then coumadin.

 

[danielmd06]

Out of curiosity, which transverse sinus was occluded?

 

[neglect]

Out of curiosity, which transverse sinus was occluded?

Which one do you think?

 

[danielmd06]

The left transverse sinus is more commonly involved in a thrombosis.

I was interested in hearing if it was the right transverse that was affected in this instance...as you probably guessed. 😉

 

[neglect]

Pregnant woman in her 29th week, in the ER because she cannot move her left shoulder. She has some deep gnawing pain in that shoulder, deltoid is 2/5, bi is 4/5, rest of arm is spared. No bicep reflex. No other medical problems.

What would you do?

 

[Nerdoscience]

So, thinking L C5 isolated lesion?

 

[Methyldopa]

My big guess: cervical radiculopathy or brachial plexus neuritis.

Couple of questions: sudden onset? Pain in neck? Sensory deficits? Recent Trauma? Any signs of inflammation in shoulder joint? Full Range of Motion?

 

[neurodoc]

Pregnant woman in her 29th week, in the ER because she cannot move her left shoulder. She has some deep gnawing pain in that shoulder, deltoid is 2/5, bi is 4/5, rest of arm is spared. No bicep reflex. No other medical problems.

What would you do?

Sounds like an upper plexopathy. I presume that there is no trauma to account for it, so it would be some sort of "idiopathic" plexitis, aka, Parsonage-Turner Syndrome. I've seen this in women AFTER delivery, i.e. "post-partum plexopathy," but never before delivery, but maybe that's the case here.

Of course the pregnancy could be a red herring, i.e. you need to look for other potential causes. Thoracic Outlet Syndrome usually affects the ulnar distribution and lower plexus, which doesn't sound like your case. The main rule-outs are sarcoid and other granulomatous disease, gestational diabetes with diabetic amyotrophy, and c5-6 radiculopathy.

Next step? EMG/NCS, neuroimaging of the C-spine, and LP.

BTW, I don't mean to be a curmudgeon, but "bicep" is not a real word. This is a common mistake, due to the erroneous assumption that "biceps" is a plural noun whose singular is "bicep." "Biceps" is singular. Ther pural, if you want to use it, would be "bicipetes." 🙂

 

[neurodoc]

or "bicipites." Various spellings are possible.

 

[Methyldopa]

Next step? EMG/NCS, neuroimaging of the C-spine, and LP.

BTW, I don't mean to be a curmudgeon, but "bicep" is not a real word. This is a common mistake, due to the erroneous assumption that "biceps" is a plural noun whose singular is "bicep." "Biceps" is singular. Ther pural, if you want to use it, would be "bicipetes." 🙂

How useful is EMG if you're thinking plexitis? Will it show you anything?

You already know which nerves are involved. And you know there is no bicipetes reflexetes!😀

 

[Nerdoscience]

or "bicipites." Various spellings are possible.

I love this about the Neuro forum. I was thinking that, but decided not to post it. And then someone else did! Only here...

 

[neurodoc]

How useful is EMG if you're thinking plexitis? Will it show you anything?

You already know which nerves are involved. And you know there is no bicipetes reflexetes!😀

EMG would be very useful. It would show whether or not there is axonopathy involving specific nerve branches. It would help you to decide which parts of the brachial plexus, if any, are affected. EMG combined with NCS are pretty informative in PNS lesions. I'm surprised you would not be aware of this.

Nick

 

[Methyldopa]

Double Post!

 

[Methyldopa]

I'm surprised you would not be aware of this.

Nick

Truth be told, I'm still a prelim and so my neuro knowledge is lacking! Actually I was basing my statement on what an attending once told me. We had one case of brachial plexitis and the attending said it would be useless to get an EMG. He probably meant specifically with the case in hand rather than in general.

 

[neglect]

Still waiting. The MRI is pending of the plexus first, hold up by insurance. I don't think she has a C5 lesion, but the MRI actually images the roots very well, which in this case is all I'm interested in. I'll do an EMG in a month if there's no improvement. I also held off on treatment. Called her and she's doing fine, getting a bit better.

BTW, about a month ago I saw in second opinion a similar woman who had an EMG showing denervation in multiple upper roots (not done by me). Her MRI was stone cold normal about 3 months after onset. She was left with a bit of pain and little else.

 

[neurodoc]

... We had one case of brachial plexitis and the attending said it would be useless to get an EMG. He probably meant specifically with the case in hand rather than in general.

Your attending may have meant something like that, if the case was otherwise so clear from the clinical presentation, and especially if it was improving, but in general NCS/EMG is essential for the work up of plexopathy, not only for anatomic localization, but also for prognosis.

I did a fellowship in Clinical Electrophysiology and a large part of my practice is in peripheral neurology. I think I'm pretty good at clinical diagnosis, but I also believe in backing up my clinical impression with electrophysiologic data. There are some neurologists out there with minimal training in electrophysiology and who don't seem to think that EMG/NCS/EP studies are helpful. I think many of them are misguided. 🙂

Nick

 

[neurodoc]

waiting. The MRI is pending of the plexus first, hold up by insurance. I don't think she has a C5 lesion...

Based on your exam (weakness of deltoid and biceps only, no other muscles affected), I would also doubt a C5 lesion. With a C5 lesion I'd also expect some involvement of the pec major, brachioradialis, and possibly the ECR.

This really sounds like some autoimmune partial upper plexitis or even a C5 radiculitis, especially with its getting better. I've seen this post-partum, but never pre-partum. It may be worth going all out to locate a lesion and writing up the case. Consider a thorough EMG/NCS study, high-field (3+ Tesla) MRI w/gad (the root or part of the plexus may light up), and LP. Of course someone will need to pay for it, and her insurer seems to be balking...and she IS getting better, so it will be a very hard sell.

One of the "nice things" about residency training in academic/governmental teaching hospitals is the ability to waste other people's money in the pursuit of answers to cases like this one. 😉

 

[neglect]

Based on your exam (weakness of deltoid and biceps only, no other muscles affected), I would also doubt a C5 lesion. With a C5 lesion I'd also expect some involvement of the pec major, brachioradialis, and possibly the ECR.

This really sounds like some autoimmune partial upper plexitis or even a C5 radiculitis, especially with its getting better. I've seen this post-partum, but never pre-partum. It may be worth going all out to locate a lesion and writing up the case. Consider a thorough EMG/NCS study, high-field (3+ Tesla) MRI w/gad (the root or part of the plexus may light up), and LP. Of course someone will need to pay for it, and her insurer seems to be balking...and she IS getting better, so it will be a very hard sell.

One of the "nice things" about residency training in academic/governmental teaching hospitals is the ability to waste other people's money in the pursuit of answers to cases like this one. 😉

Everything was ready to go, but the patient didn't follow up, is better now, and it'll probably be negative anyway by now. To think I was a few inches away from admitting her. We'll never know. Bad move, imho, because when it occurs again, then...

OK, new topic: how far have you pushed tPA into the discomfort zone? You go first.