1. SNS Intern Course Case Scenarios 2014

2. Case # 7 63 yr old left handed female presents with progressive headache, left homonymous hemianopia and left hemiparesis. PMH: HTN, DM, breast cancer 12 years earlier with negative follow up ROS: no systemic complaints Meds: Prozac, ASA, glucotrol, lasix

3. Physical Exam Constitutional: Normal appearing, no evidence of systemic illness Neurological: A&O x3, speech normal, memory decreased Cranial nerves: decrease vision left visual field Motor 4/5 left Sensory decreased left DTRs increased on left Cerebellar normal Gait normal, tandem off

5. Course POD #1: Mild confusion, neurologically intact with improved motor strength to 4+/5, some visual field deficit to the left. POD #5: Worsened confusion, with motor strength of 3/5 on the left

7. Case #8 58 yr old female presents to your ED with sudden headache followed by acute visual loss OU. PMH is significant only for HTN, DM On exam, the ED physician reports a patient in distress with severe headache, mild meningismus, a non reactive right pupil with NLP, and left eye with light perception, finger counting.

8. Tests Normal labs, except a prolactin level of 430, and low cortisol MRI in the Emergency Department shows an abnormality

11. Course Intraoperative findings: blood clot and likely adenoma. Gross total resection. CSF leak intraop.

12. Course POD #1: improved vision and headache, overnight urine output increases to 400cc/hr POD #2: Pt coughing excessively and intermittently choking on fluid in nasopharynx

13. Case #9 42 yr old right handed male presents to your hospital with headaches, dysphasia and progressive right hemiparesis. PMH is significant for hypercholesterolemia ROS: is negative for systemic complaints except chronic cough.

14. Physical Examination A&Ox3, speech hesitancy, memory intact No meningismus CN: intact Motor 3/5 on the right, arm weaker than leg Sensory, decreased on the right DTR: increased on the right with + Babinski

17. Course Day #1: Initial improvement in clinical condition Day #3: Deterioration, with obtundation, rising fevers, meningismus and WBC 22,000

18. Case #10 71 yr old female with a significant past medical history of HTN, DM, CRF The pt presents with acute right side weakness involving UE/LE ROS: several days of vomiting and diarrhea. No oral intake for several days. Meds: ASA, Atrovent, Insulin, Cardizem

19. Physical Exam AO x person, hospital, Mild aphasia BP 94/50, Pulse 130 PERRL, EOMI Face symmetric, tongue midline LUE/LLE 4/5 RUE/RLE 3/5

20. CT on Admission

21. MRI

22. CT Venogram

23. Repeat CT after 1 day

24. Course Negative hypercoagulable panel CT chest/abd/pelvis – WNL Natural History

25. MRI x 6 months

26. Case #11 71 y/o right handed man presents with sudden weakness of left upper extremity, no headache, no speech loss, no pain. PMH: HTN and hypercholesterolemia ROS: negative except for above Meds: ASA, Lipitor

27. Physical Exam Afebrile, BP 180/110, Pulse 70, RR 20 Mental status and speech normal Cranial nerves normal Motor: Left upper ext 3/5 in all muscle groups Sensory: mild left upper ext numbness DTR and cerebellar: normal

28. MRI perfusion of brain

29. Due to creatinine, the patient could not get a CTA or angiogram

31. MRA shows a left carotid ICA stenosis of 90% with some ulcerated plaque. There is no tandem stenosis No prior radiation to neck, no prior surgeries of the neck, the bifurcation is C4-5

32. Course Intraoperative monitoring shows ipsilateral hemispheric decrease during the procedure

33. Case #12 42-year-old male with 2-month with left shoulder and arm pain Radiation of pain through his radial forearm to thumb and first finger Non-focal neurological exam with exception: – decreased (2/5) strength and reflex in the left bicep – decreased pinprick in the thumb and first finger

35. Course POD #1: Arm pain is much better, mod swallowing problems POD#12: Arm pain returns, swallowing much worse.

36. Case #13 18-year-old male s/p fall from a window, landing on his head. At the scene, the patient is unable to move or feel his hands or legs and has severe neck pain. He can flex and extend his wrists, elbows and shoulders. He arrives on a backboard to your ED. PMH/SH: none ROS: intoxicated Meds: none

37. Physical Exam Afebrile, BP 90/50, Pulse 45, RR 25 Laceration on occiput, neck immobilized but tender posteriorly Mental status is clear, but pt is intoxicated Wrist flexion and extension 3/5, triceps, deltoids and deltoids 5/5 Sensory C7 intact DTRs areflexic No rectal tone, no bulbocavernosus or abdominal reflexes

42. Course Pt does well with stabilization, pain is better. Pt transfers to rehab. At 3 month return visit, the patient has significant extremity rigidity and pain, medically uncontrolled.

43. Case #14 34 yr old male with a 2 days history of progressive neck pain, lower extremity numbness and worsening quadraparesis. No history of trauma, no headache PMH: none ROS: Recovered from recent viral illness, otherwise no other complaints Meds: Ibuprophen

44. Physical Exam Obvious discomfort, pain with cervical ROM. AVSS Mental status and speech are normal CN: Normal Motor: deltoid 5/5. biceps, triceps, grasp and lower ext are 3/5 Sensory: decreased in position sense and sharp pain DTRs symmetric, rectal tone normal.

46. LABS WBC: 12,000, elevated lymphocytes

47. Course What is the treatment and natural history of this disorder?