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HEADACHE AND PROGRESSIVE VISUAL LOSS Case Conference I Department of Neurology

LeeChuy , Katherine Lee, Sidney Albert Legaspi , Roberto Jose Lerma , Daniel Joseph Li, Henry Winston Li, Kingbherly Lichauco , Rafael Lim, Imee Loren Lim, Jason Morven Lim, John Harold Lim, Mary Lim, Phoebe Ruth Lim, Syndel Raina Lipana , Kirk Andrew.

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HEADACHE AND PROGRESSIVE VISUAL LOSS Case Conference I Department of Neurology

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  1. LeeChuy, Katherine Lee, Sidney Albert Legaspi, Roberto Jose Lerma, Daniel Joseph Li, Henry Winston Li, Kingbherly Lichauco, Rafael Lim, Imee Loren Lim, Jason Morven Lim, John Harold Lim, Mary Lim, Phoebe Ruth Lim, SyndelRaina Lipana, Kirk Andrew HEADACHE AND PROGRESSIVE VISUAL LOSSCase Conference IDepartment of Neurology

  2. 51 y/o, Male • Chief complaint: Eight months of progressive visual loss and headache

  3. OPHTHALMOLOGIC FINDINGS • Mild bilateral papilledema with some pallor of the right optic disc • Visual fields with enlarged blind spot • Concentric loss of the peripheral visual fields in both eyes (he could see only the center of the visual field with either eye)

  4. Other Exams • The remainder of his neurologic exam was normal.

  5. LOCALIZATION AND DIFFERENTIAL DIAGNOSIS • 1. Headache, papilledema and visual field loss of this kind is seen in what syndrome? • 2. What is the appropriate test to perform next?

  6. APPROACH TO A NEUROLOGIC PROBLEM Three Questions Asked: • Is there a neurologic problem? • Where is the neurologic problem? • What is the neurologic problem?

  7. 1. Is there a Neurologic Problem? • Focal Neurologic Deficits • Cranial nerve deficit • Increase ICP • Headache • Papilledema • Visual Loss • Meningeal Irritation

  8. Causes of optic disc swelling

  9. 2. Where is the Neurologic Problem • Levelize • Optic nerve • Subarachnoid space directly communicates with sheaths of the optic nerve; increased CSF pressure leading to increased pressure in the optic nerve sheaths • Lateralize • Advanced papilledema due to increased ICP • Almost always bilateral • More pronounced on side with intracranial tumor • Localize

  10. 3. What is the Neurologic Problem? • Insidious Onset (weeks to months) • Mass lesions • Degenerative Disease • TB/ fungal meningitis

  11. Diagnostic tests

  12. Imaging studies • Computed Tomography (CT) scan • Magnetic Resonance Imaging (MRI) • Magnetic Resonance Angiography (MRA) • MR spectroscopy • Positron Emission Tomography (PET) scan • Cerebral angiography

  13. Lumbar puncture • CSF analysis • measure levels of protein and glucose • Detect RBC, WBC, cancer cell • Done only after a CT or MRI

  14. Management for increased ICP • Elevate head and body by 30 degrees to optimize venous drainage • Reduce fever and control hyperglycemia • Maintain osmolarity at 305-315 mOsm/L • Prevent seizures

  15. Specific measures include: • Hyperventilation • Mannitol • 1-2g/kg for severely increased pressure, followed by 50-300mg/kg q6 • Corticosteroid • Ventricular drainage • Primary disorder should be treated

  16. General approach on brain tumors: • Craniotomy • Stereotactic techniques • Radiosurgery • Shunts

  17. Management of Meningitis • Fungal meningititis: • long course of high dose antifungals, such as amphotericin B and flucytosine • TB meningitis: • Isoniazid, rifampicin, pyrazinamide and ethambutol for 2 months, followed by isoniazidanfrifampicin alone for a further ten months • Steroids are always used in the first six weeks of treatment

  18. THANK YOU FOR LISTENING! HAVE A GOOD DAY

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