a case of cva in the rvh er… chenjie xia (pgy-3) ahd interactive case wednesday, feb. 23 rd, 2011

A case of CVA in the RVH ER…

Chenjie Xia (PGY-3)

AHD Interactive Case

Wednesday, Feb. 23rd, 2011

On call at the RVH…

• RVH ER page at 9:30PM

• Code purple, please see stroke patient for admission…

Patient Background

• ID: 74M, right handed

• RFC: stroke

• Social history: Chinese origin, retired real estate agent, lives with wife

Patient Background

• PMHx:– HCC with cirrhosis

• Dx since 2006, s/p radiofrequency ablation, RTX• Episodic encephalopathy• Esophageal varices

– Diabetes– HTN– Left putamen lacunar infarct

• Right sided parkinsonian Sx, now resolved• ASA discontinued due to bleed from esophageal varices

– Gout– Right parotid tumour (biopsy 2008 pleomorphic

adenoma)

Patient Background

• Meds– Allopurinol, MVI, Ca/Vit D, Mg, Remeron,

HCTZ, Nadol, lactulose, Flagyl, lantus– Recently added: Celebrex, Dilaudid, Lyrica

• All:– NKDA

• Habits– Non-smoker, non-drinker

History

• Woke up this AM and notes new right facial weakness, i.e. right mouth droop

What more do you want to know on history?

More history

• Isolated right facial droop, i.e. no arm or leg weakness, no sensory change, no speech difficulties

• Feels lips “thickened” and right eyelid “stuck to eyeball”

• Right ear deaf for many years, no change

• No change in taste noted

• No vertigo, no n/v

More history

• Right sided headache x few months• Increased pain in right parotid tumour x

Nov. 2010.• Consulted multiple MDs (GP, ENT,

neurologist)• Ultrasound shows stable right parotid

mass?• Suboptimal pain control despite Celebrex,

Dilaudid and Lyrica

What is your differential at this point?

Differential Diagnosis

• Idiopathic facial nerve palsy (Bell’s palsy)

• Facial nerve palsy from other causes (e.g. infectious, autoimmune, granulomatous, neoplastic, etc)

• Stroke– Right brainstem (pons)– Left hemisphere

On exam

• Looks well, non toxic, head drooped (because “the light is bothering my right eye”)

• BP 155/70, HR 62 (reg), RR 20, 100% (RA), 36.1oC

• No carotid bruit, normal S1, S2

What more do you want to know on exam?

Be specific…

More exam findings

• No aphasia

• Large, palpable, firm, tender right parotid mass

• Pupils 21mm (bilat), VFs normal, EOMs (saccadic SP, otherwise normal)

• Normal sensation (LT/PP)

• Right facial droop (frontalis, orbicularis oculi, and orbicularis oris involved)

How do you differentiate between UMN and LMN facial palsy?

Can you name the main motor branches of the facial nerve?

Muscles innervated by the Facial Nerve

• The: Temporal branch

• Zebra: Zygomatic branch

• Bit: Buccal branch

• My: Mandibular branch

• Carrot: Cervical branch

• (Stapedius and post. auricular branches)

More Exam Findings

• Taste: decreased on right hemi-tongue

• Hearing: No lateralization on Weber, decreased air conduction on Rinne on the right

• Palate, SCM, trap, tongue mvts normal

• Rest of exam (tone, strength, reflexes, sensation, coordination, gait) unremarkable

What is your top differential diagnosis at this point?

Differential Diagnosis

• Idiopathic facial nerve palsy (Bell’s palsy)

• Facial nerve palsy from other causes (e.g. infectious, autoimmune, granulomatous, neoplastic, etc)

• Stroke– Right brainstem (pons)– Left hemisphere

Differential Diagnosis

• Idiopathic facial nerve palsy (Bell’s palsy)

• Facial nerve palsy from other causes (e.g. infectious, autoimmune, granulomatous, neoplastic, etc)

• Stroke– Right brainstem (pons)– Left hemisphere

Findings

CT head: old left putamen lacune, nil acute

Question

• Does the decreased taste favor Bell’s palsy or facial nerve injury secondary to parotid lesion?

Facial nerve enters parotid gland after it exits the stylomastoid foramen; fibers carrying taste and subserving lacrimation should NOT be affected.

However, in malignant lesion, extension of lesion may very well invade nearby nerve branches

Question

• Can you name the 4 functional categories of the facial nerve and briefly describe what they do?

Answer

• 1) Branchial motor– Muscles of facial expression – Stapedius muscle

• 2) Parasympathetic– Lacrimal glands– All salivary glands (e.g. submaxillary, submandibular) except

parotid

• 3) Visceral sensory (special)– Taste from anterior 2/3 of tongue

• 4) General somatic sensory– Sensation from small region near external auditory meatus

Question

• With the help of the diagram, can you point out the nerves and ganglia involved in each of the functional categories?

Branchial motor

• Facial nucleus• Facial nerve exits at CPA• Traverses internal

auditory meatus• Turns at genu• Exits at stylomastoid

foramen• Passes through parotid

gland• Divides into branchial

motor branches

Branchial motor

• Facial nucleus• Facial nerve exits at CPA• Traverses internal

auditory meatus• Turns at genu• Exits at stylomastoid

foramen• Passes through parotid

gland• Divides into branchial

motor branches

Parasympathetic (1)

• Superior salivatory nucleus

• GT petrosal nerve leaves genu

• Reach the sphenopalatine ganglion

• post-ganglionic fibers lacrimal glands

Parasympathetic (1)

• Superior salivatory nucleus

• GT petrosal nerve leaves genu

• Reach the sphenopalatine ganglion

• post-ganglionic fibers lacrimal glands

Parasympathetic (2)

• Superior salivatory nucleus

• Chorda tympani branches off before the stylomastoid foramen

• Goes through petrotympanic fissure

• Joins lingual nerve • Submandibular ganglion• postganglionic fibers

submandibular and sublingual glands

Parasympathetic (2)

• Superior salivatory nucleus

• Chorda tympani branches off before the stylomastoid foramen

• Goes through petrotympanic fissure

• Joins lingual nerve • Submandibular ganglion• postganglionic fibers

submandibular and sublingual glands

Visceral sensory (Special)• Sensory fibers carrying taste

from anterior 2/3 of tongue• Cell bodies in geniculate

ganglion• Synapse onto secondary

neurons in the rostral nucleus solitarius

• Travel via CTT VPM nucleus of thalamus cortical taste area (inferior margin of postcentral gyrus, extends into parietal operculum and insula)

Visceral sensory (Special)• Sensory fibers carrying taste

from anterior 2/3 of tongue• Cell bodies in geniculate

ganglion• Synapse onto secondary

neurons in the rostral nucleus solitarius

• Travel via CTT VPM nucleus of thalamus cortical taste area (inferior margin of postcentral gyrus, extends into parietal operculum and insula)

General Somatic Sensory

• Region near external auditory meatus

• Synpase in spinal trigeminal nucleus

General Somatic Sensory

• Region near external auditory meatus

• Synpase in spinal trigeminal nucleus

F/U Imaging

• CT neck (compared to Nov 2010)– Significant increase in mass size compared to

Nov. – Peripheral enhancement, central area of

necrosis– Extension into deep lobe– Possibility of malignant transformation