Ambulatory Report – Cranial Neuropathies – 11.16.16

Thank you to Emily Harrington from Neuro for presenting a fantastic case of a 51 yo F h/o DM, HTN, HL, and migraines p/w 3 weeks of progressive eye pain and double vision.  
  • Pearls dropped!
    • When neuro asks for the Oligoclonal Bands & IgG Index —> that’s pretty much like the ESR of the CSF 
      • it tells you if there’s something that’s neuroinflammatory going on, like demyelinating & paraneoplastic processes)
      • Remember when you order IgG of the CSF, be sure to get an IgG of the serum within 24
    • Per Anna Parks, Tracy Minichiello says it’s ok to check APLS labs INPATIENT when you have a young patient with arterial thromboses
      • otherwise, it’s very difficult to interpret APLS labs when you have an admitted patient)
    • CNs and the Brainstem
      • Midbrain – 3, 4
      • Pons – 5, 6, 7, 8
      • Medulla – 9, 10, 11, 12
  • Differential for a CN 3/4/6 Palsy
    • Cavernous sinus – mass, thrombosis, carotid-cavernous fistula, aneurysm, inflammation
    • Mass adjacent to cavernous sinus – pituitary adenoma, sphenoid meningioma, aneurysm, craniopharmyngioma, orbital tumor
    • CSF process in subarachnoid space – infection, carcinomatous meningitis, TB, sarcoid
    • Inflammatory – idiopathic orbital inflammation (orbital pseudotumor), sarcoidosis, rheumatoid arthritis, vasculititis(GPA, GCA), infliltrativethryoid, IgG4
    • Peripheral – neuromuscular junction- myasthenia, Lambert-Eaton; demyelinating Miller-Fisher
  • Pain vs non-painful CN neuropathies involving eye:
    • eye pain -> think inflammation/infection (vasculitic, optic neuritis, orbital/retro-orbital infection or mass)
    • no eye pain -> ischemic cranial neuropathy (DM, thyroid), mass, tumor or aneurysm, stroke, peripheral cranial nerve process (GBS/Miller Fisher), neuromuscular junction (botulism, MG)
  • Pupil involvement vs sparing CNIII neuropathy (pupillary fibers on outside of CNIII)
    • dilated pupil -> think complete cavernous sinus involvement, compression externally- aneurysm or mass
    • normal pupil -> think ischemic (affects fibers inside nerve) like DM or thyroid, incomplete cavernous sinus
    • dilated minimally non-reactive pupil -> think botulism, severe optic neuritis

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