This case has me stumped, does this look familiar to anyone?

[UCLA2002]

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A 56-year-old woman has had 6 weeks of left facial numbness and intermittent left-sided headaches. The numbness has gradually increased, ultimately involving both her face and her tongue on the left. She also notices horizontal diplopia, more pronounced when she looks at distant than at near objects.

On examination there is decreased sensation to pinprick, temperature, and touch over her left face and anterior scalp as far back as the vertex; the sensory loss spares the pinna of her ear, the angle of her jaw, her posterior scalp, and her neck but includes her nasal mucous membranes, inner cheek, anterior tongue, and gums. The afferent limb of the corneal reflex is absent on the left; neither eye blinks when her left cornea is touched, but both eyes blink when her right cornea is touched. As she opens her mouth, her jaw deviates to the left, and when she bites down forcibly, the masseter and temporalis muscles are les firmly contracted on the left. There is limited abduction of her left eye. Eye movements are otherwise full, and her pupils are equal and reactive. Findings on her neurological examination, including other cranial nerves, are otherwise normal.

It seems that it involves the trigeminal nerve (V1, V2, and V3) as well as CN VI. Is this supposed to be an obvious diagnosis or could it just be a lesion that is involved with CN V and VI? Any ideas? Thanks.

 

[sanityonleave]

A 56-year-old woman has had 6 weeks of left facial numbness and intermittent left-sided headaches. The numbness has gradually increased, ultimately involving both her face and her tongue on the left. She also notices horizontal diplopia, more pronounced when she looks at distant than at near objects.

On examination there is decreased sensation to pinprick, temperature, and touch over her left face and anterior scalp as far back as the vertex; the sensory loss spares the pinna of her ear, the angle of her jaw, her posterior scalp, and her neck but includes her nasal mucous membranes, inner cheek, anterior tongue, and gums. The afferent limb of the corneal reflex is absent on the left; neither eye blinks when her left cornea is touched, but both eyes blink when her right cornea is touched. As she opens her mouth, her jaw deviates to the left, and when she bites down forcibly, the masseter and temporalis muscles are les firmly contracted on the left. There is limited abduction of her left eye. Eye movements are otherwise full, and her pupils are equal and reactive. Findings on her neurological examination, including other cranial nerves, are otherwise normal.

It seems that it involves the trigeminal nerve (V1, V2, and V3) as well as CN VI. Is this supposed to be an obvious diagnosis or could it just be a lesion that is involved with CN V and VI? Any ideas? Thanks.

We're just starting neuro, so I can't give an exact answer -- but wouldn't a small pontine lesion be able to produce these symptoms? The motor nucleus of CNV and CNVI are right next to each other, and the sensory nucleus of CNV passes in close proximity as it extends all the way from the midbrain down through the medulla.

I apologize if that doesn't make sense (again, just starting to study the same material).

Here's a paper that seems to investigate a stroke like this -- it looks like it's a possibility?
http://stroke.ahajournals.org/content/28/4/809.full

EDIT: A little google research shows that it doesn't seem very common that you could have a pontine infarct small enough to have these specific sensory deficits but an otherwise normal exam. Also, re-reading your post the time course seems to suggest a progressive lesion -- maybe a tumor? That could also explain the relatively small distribution. Not sure -- definitely a tough case.

 

[shadowfox87]

View attachment Diagnosis Meme.jpg

 

[UCLA2002]

Here you go....

 

[Rendar5]

Headache + CN6 palsy seems to suggest something causing increased intracranial pressure, e.g. tumor/bleed/IIH.

Of course that thing you posted likes to go on and on about all the features of a complete CN5 palsy, and misdirects you from the salient points of the case.

Just so I can assist you with your homework help request even more, when it comes to neuro, the basic differential is always the same for pre-clinical years: ischemic stroke, hemorrhagic stroke, tumor, MS, complex migraine, +/-seizure

 

[sanityonleave]

Headache + CN6 palsy seems to suggest something causing increased intracranial pressure, e.g. tumor/bleed/IIH.

Of course that thing you posted likes to go on and on about all the features of a complete CN5 palsy, and misdirects you from the salient points of the case.

Just so I can assist you with your homework help request even more, when it comes to neuro, the basic differential is always the same for pre-clinical years: ischemic stroke, hemorrhagic stroke, tumor, MS, complex migraine, +/-seizure

What explains the CN5 palsy, though? Neuroanatomy > me.

If only she was a he, it could be metastatic prostate cancer... http://www.nature.com/eye/journal/v16/n6/full/6700210a.html case #4. That said, looks like there are several areas where local pathology could explain the constellation of sx.

 

[Rendar5]

What explains the CN5 palsy, though? Neuroanatomy > me.

If only she was a he, it could be metastatic prostate cancer... http://www.nature.com/eye/journal/v16/n6/full/6700210a.html case #4. That said, looks like there are several areas where local pathology could explain the constellation of sx.

You're trapping yourself by trying to get the exact diagnosis that requires a biopsy when you're simply at the H&P stage. You're not supposed to arrive at the exact answer. You're supposed to arrive at a list of possible answers. CN6 palsy can be simply produced by generalized intracranial pressure, so if you see that, think space-occupying lesion (again, blood, tumor, IIH, etc.) In this case, you only need to localize CN5 and see where isolated lesions may effect it before it splits up into its motor/sensory pathways. If you're looking for a very focal lesion (infarct, MS), then you look for where CN5 and 6 lay adjacent to each other, from the nucleus to anywhere before CN5 splits.