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    Top 5 neuro signs never to ignore

     

    Some authors have suggested high-dose IV steroids (e.g., methylprednisolone 1000 mg/day) for patients with visual loss or neurologic symptoms.3,6,9 In a retrospective study by Chan et al, the visual acuity of patients treated with high-dose IV steroids (1000 mg for three days) followed by oral steroids was significantly improved compared to those on oral steroids alone.6,9 No head-to-head IV vs. by mouth trial of steroids for GCA has performed, however.

    A temporal artery biopsy (TAB) remains the gold standard for the diagnosis of GCA.3,6 Although a floridly positive or completely negative TAB can be relatively straightforward, it is important to always read the entire body of the ocular pathology report.

    The finding of “no active lymphocytic infiltrate or no giant cells” can still be due to GCA because “healed or treated” GCA can produce findings. Focal disruption of the internal elastic lamina, areas of fibrosis, irregular intimal thickening, and lymphocytes in the adventitia may suggest healed arteritis.10 Immunohistochemistry stains for CD 68 positive macrophages might helpful in such cases to help establish the diagnosis of “healed or treated” GCA.

    2. Acute painful bitemporal hemianopsia

    A 22-year-old female presents at 4:45 pm on a Friday with a severe headache, 20/20 visual acuity OU but blurred vision, and a normal fundus exam. Visual field shows a bitemporal hemianopia.

    This is another uncommon but classic neuro-ophthalmic presentation of an emergent condition, pituitary apoplexy. Although typically the acute onset of severe headaches and painful vision loss (bitemporal hemianopsia) is common in apoplexy, some patients have less severe or absent headache, and the visual loss may be unilateral or bilateral and may or may not be the classic bitemporal hemianopic visual field loss.

    The incidence of pituitary adenoma is approximately seven per 100,000 per year.11 Typically, the slow growth of benign pituitary adenomas produces painless and progressive neuro-ophthalmic symptoms.

    In contrast, pituitary apoplexy often produces acute and painful visual loss.

    Acute hemorrhage or infarct of the pre-existing pituitary adenoma leads to compression of the surrounding anatomical structures (e.g., cavernous sinus or optic chiasm) and thus can produce the clinical findings of acute, severe headache, vision loss, ophthalmoplegia, altered consciousness, and hypopituitarism.3

    In one study of 62 patients with pituitary apoplexy by Semple et al, the average patient age was 51 years. The majority of patients (81 percent) had no previous history of pituitary tumor. The most common presenting symptom was headache (87 percent), followed by decreased vision (56 percent), visual field defects (34 percent), and cranial nerve palsies (45 percent).12

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    Optometry Times A/V