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    Top 5 neuro signs never to ignore

     

    Pain (e.g., headache, eye pain, face pain, or neck pain) is the most common presenting symptom of a Horner syndrome from a carotid artery dissection but may be absent or variable in severity. The incidence is approximately 2.6 per 100,000 in the United States, and it can occur spontaneously or secondary to trauma.3,22 Most patients experience a positive clinical outcome with resolution or recanalization in 80 percent.23

    Apraclonidine is a direct acting, non-selective alpha-agonist (predominantly alpha-2 activity) commonly used in diagnosing the HS. As a result of denervation hypersensitivity after a HS, a positive apraclonidine test will reverse the anisocoria due to dilation from up-regulation of the post-synaptic alpha-1 effect in the eye with the HS and the normal alpha-2 effect in the fellow eye (which produces slight pupillary constriction). This test has a high sensitivity and specificity.3,22,24

    In the acute ER setting, a CT-CTA of the head and neck to thoracic level (T2) is the preferred initial study, and we do not generally recommend waiting for confirmation with topical apraclonidine.

    References

    1. Hellmann DB. Temporal arteritis: a cough, toothache, and tongue infarction. JAMA. 2002 Jun 12;287(22):2996-3000.

    2. Smetana GW, Shmerling RH. Does this patient have temporal arteritis? JAMA. 2002 Jan 2;287(1):92-101.

    3. Smith SV, Amram AL, Rodarte EM, Lee AG. Neuro-Ophthalmology Cases for the Neurologist. Neurol Clin. 2016 Aug;34(3):611-29.

    4. Paraskevas KI, Boumpas DT, Vrentzos GE, Mikhailidis DP. Oral and ocular/orbital manifestations of temporal arteritis: a disease with deceptive clinical symptoms and devastating consequences. Clin Rheumatol. 2007 Jul;26(7):1044-1048.

    5. Hayreh SS, Podhajsky PA, Raman R, Zimmerman B. Giant cell arteritis: validity and reliability of various diagnostic criteria. Am J Ophthalmol. 1997 Mar;123(3):285-296.

    6. Fraser JA, Weyand CM, Newman NJ, Biousse V. The treatment of giant cell arteritis. Rev Neurol Dis. 2008 Summer;5(3):140-152.

    7. Mazlumzadeh M, Hunder GG, Easley KA, Calamia KT, Matteson EL, Griffing WL, Younge BR, Weyand CM, Goronzy JJ. Treatment of giant cell arteritis using induction therapy with high-dose glucocorticoids: a double-blind, placebo-controlled, randomized prospective clinical trial. Arthritis Rheum. 2006 Oct;54(10):3310-3318.

    8. Hayreh SS, Zimmerman B. Management of giant cell arteritis. Our 27-year clinical study: new light on old controversies. Ophthalmologica. 2003 Jul-Aug;217(4):239-259.

    9. Chan CC, Paine M, O'Day J. Steroid management in giant cell arteritis. Br J Ophthalmol. 2001 Sep;85(9):1061-4.

    10. Lee YC, Padera RF, Noss EH, Fossel AH, Bienfang D, Liang MH, Docken WP. Clinical course and management of a consecutive series of patients with “healed temporal arteritis.” J Rheumatol. 2012 Feb;39(2):295-302.

    11. McDowell BD, Wallace RB, Carnahan RM, Chrischilles EA, Lynch CF, Schlechte JA. Demographic differences in incidence for pituitary adenoma. Pituitary. 2011 Mar;14(1):23-30.

    12. Semple PL, Webb MK, de Villiers JC, Laws ER, Jr. Pituitary apoplexy. Neurosurgery. 2005;56(1):65-72; discussion 72-63.

    13. Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, Sein M, Sein T, Chiou CC, Chu JH, Kontoyiannis DP, Walsh TJ. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis. 2005 Sep 1;41(5):634-53.

    14. Jiang N, Zhao G, Yang S, Lin J, Hu L, Che C, Wang Q, Xu Q. A retrospective analysis of eleven cases of invasive rhino-orbito-cerebral mucormycosis presented with orbital apex syndrome initially. BMC Ophthalmol. 2016 Jan 12;16:10.

    15. Ribes JA, Vanover-Sams CL, Baker DJ. Zygomycetes in human disease. Clinical microbiology reviews. 2000 Apr;13(2):236-301.

    16. Vehreschild JJ, Birtel A, Vehreschild MJ, Liss B, Farowski F, Kochanek M, Sieniawski M, Steinbach A, Wahlers K, Fätkenheuer G, Cornely OA. Mucormycosis treated with posaconazole: review of 96 case reports. Crit Rev Microbiol. 2013 Aug;39(3):310-24.

    17. Bruce BB, Biousse V, Newman NJ. Third nerve palsies. Semin Neurol. 2007 Jul;27(3):257-68.

    18. Lee AG, Hayman LA, Brazis PW. The evaluation of isolated third nerve palsy revisited: an update on the evolving role of magnetic resonance, computed tomography, and catheter angiography. Surv Ophthalmol. 2002 Mar-Apr;47(2):137-57.

    19. Jeong HW, Seo JH, Kim ST, Jung CK, Suh SI. Clinical practice guideline for the management of intracranial aneurysms. Neurointervention. 2014 Sep;9(2):63-71.

    20. Vaphiades MS, Cure J, Kline L. Management of intracranial aneurysm causing a third cranial nerve palsy: MRA, CTA or DSA? Semin Ophthalmol. 2008 May-Jun;23(3):143-50.

    21. Vaphiades MS, Roberson GH. Imaging of Oculomotor (Third) Cranial Nerve Palsy. Neurol Clin. 2017 Feb;35(1):101-113

    22. Moodley AA, Spooner RB. Apraclonidine in the diagnosis of Horner's syndrome. S Afr Med J. 2007 Jul;97(7):506-7.

    23. Pelkonen O, Tikkakoski T, Leinonen S, Pyhtinen J, Lepojarvi M, Sotaniemi K. Extracranial internal carotid and vertebral artery dissections: angiographic spectrum, course and prognosis. Neuroradiology. 2003 Feb;45(2):71-7.

    24. Abrams DA, Robin AL, Pollack IP, deFaller JM, DeSantis L. The safety and efficacy of topical 1% ALO 2145 (p-aminoclonidine hydrochloride) in normal volunteers. Arch Ophthalmol. 1987 Sep;105(9):1205-7.

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