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    Top 5 neuro signs never to ignore


    The compression or infarction of the normal pituitary gland may prevent the release of hormones leading to hypopituitarism. The majority of patients (73 percent) exhibit a deficiency of at least one hormone produced by the anterior.12 Panhypopituitarism, a deficiency of all anterior pituitary hormones, is a life-threatening endocrine emergency that may require urgent hormonal supplementation.

    Emergent imaging with a non-contrast CT head and neurosurgical consultation is indicated in patients with acute compressive symptoms or diminished mental status in pituitary apoplexy.3 The hyperdense signal from hemorrhage in acute apoplexy may be difficult to differentiate from other hyperdense lesions in the pituitary region such as a meningioma, Rathke cleft cysts, craniopharyngioma, and aneurysms. Magnetic resonance (MR) scan with and without contrast is useful in differentiating these lesions.12

    Neuro-surgical intervention may be necessary in patients with acute neurological symptoms, including neuro-ophthalmic symptoms. These patients require long-term follow-up for both visual and endocrinologic sequelae after pituitary apoplexy.3

    3. Acute painful ophthalmoplegia

    A 45-year-old male with uncontrolled diabetes mellitus presents to the emergency room with acute painful ophthalmoplegia and diabetic ketoacidosis (DKA). Mucormycosis, most commonly cerebro-rhino-orbital mucormycosis, is a rare but aggressive fungal infection that can affect immunocompromised or metabolically compromised patients but especially patients in DKA.3

    Diabetes mellitus is a common risk factor; however, 20 percent have no identifiable cause.13 Other common risk factors include immunosuppression, metabolic ketoacidosis, underlying neoplasm, acute renal failure, severe burns or trauma, and steroid therapy.14

    Rapid recognition of disease and treatment initiation improves the survival rate.14 Early symptoms include sinus tenderness, headaches, and blood-tinged or purulent rhinorrhea.3 Rapid angioinvasion and tissue infarction may produce a black necrotic eschar over the infected area, but this is a late and negative prognostic finding. Painful ophthalmoplegia, chemosis, diminished acuity, and proptosis can be present with orbital invasion.3,15

    Rhinocerebral mucormycosis has a high mortality rate, and thus it is imperative to rapidly recognize and treat the infection.

    Initial imaging with CT may be preferred over MRI because it is faster and provides better sinus, orbit, and bone detail.3

    Treatment involves correcting underlying systemic findings, such as DKA along with early aggressive surgical debridement and antifungal therapy with amphotericin B or posaconazole.3,16 In a study by Vehreschild et al, surgery and concomitant antifungal treatment with amphotericin B had the highest survival rate (70 percent) among 929 mucormycosis cases.16

    4. Acute painful anisocoria greater in the light

    A 65-year-old diabetic male presents with acute onset ophthalmoplegia and anisocoria. The pattern of ophthalmoplegia in a third nerve palsy involves the extraocular muscles mediating adduction, supraduction, and infraduction as well as the levator muscle, ciliary muscle, and iris sphincter.3,17


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