Download - A case of CVA in the RVH ER… Chenjie Xia (PGY-3) AHD Interactive Case Wednesday, Feb. 23 rd, 2011
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A case of CVA in the RVH ER…
Chenjie Xia (PGY-3)
AHD Interactive Case
Wednesday, Feb. 23rd, 2011
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On call at the RVH…
• RVH ER page at 9:30PM
• Code purple, please see stroke patient for admission…
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Patient Background
• ID: 74M, right handed
• RFC: stroke
• Social history: Chinese origin, retired real estate agent, lives with wife
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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)
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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
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History
• Woke up this AM and notes new right facial weakness, i.e. right mouth droop
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What more do you want to know on history?
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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
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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
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What is your differential at this point?
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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
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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
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What more do you want to know on exam?
Be specific…
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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)
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How do you differentiate between UMN and LMN facial palsy?
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Can you name the main motor branches of the facial nerve?
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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)
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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
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What is your top differential diagnosis at this point?
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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
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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
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Findings
CT head: old left putamen lacune, nil acute
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Question
• Does the decreased taste favor Bell’s palsy or facial nerve injury secondary to parotid lesion?
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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
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Question
• Can you name the 4 functional categories of the facial nerve and briefly describe what they do?
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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
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Question
• With the help of the diagram, can you point out the nerves and ganglia involved in each of the functional categories?
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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
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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
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Parasympathetic (1)
• Superior salivatory nucleus
• GT petrosal nerve leaves genu
• Reach the sphenopalatine ganglion
• post-ganglionic fibers lacrimal glands
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Parasympathetic (1)
• Superior salivatory nucleus
• GT petrosal nerve leaves genu
• Reach the sphenopalatine ganglion
• post-ganglionic fibers lacrimal glands
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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
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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
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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)
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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)
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General Somatic Sensory
• Region near external auditory meatus
• Synpase in spinal trigeminal nucleus
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General Somatic Sensory
• Region near external auditory meatus
• Synpase in spinal trigeminal nucleus
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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
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