Neurology-Main神经内科-1-10

Hematology_OncologyMain1-10Q1A65-yesr-oldmsncomestotheemergencydepartmentduetosudden-onsetpainlessvisionlossirttherighteyethatbeganseveralhoursago.Thepatientsays,IFltwaslikeashadedroppingovermyeye.Hehadasimilarepisode3monthsagothatresolvedspontaneouslyafterseveralminutes.Hehasneverseenflashinglightsorfloatersinhiseyes.Thepatient'smedicalhistoryincludeshypertensionandhyperlipidemia.Temperatureis37.1C(98.8F),bloodpressureis150/90mmHg:pulseis72/minandregular,andrespirationsare14/min,Visualacuityis20/20ontheleftand20/200ontheright.Funduscopyfindingsoftherighteyeareshownbelow.Whichofthefollowingisthemostlikelycauseofthispatient'ssymptoms?A.ArterialembolicocclusionB.MalignanthypertensionC.RetinaldetachmentD.VenousthromboticocclusionE.VitreoushemorrhageA1Correctanswer:AThispatientwithacutepainlessmonocularvisionlossthatpersistsforseveralnourslikelyhasacentralretinalarteryocclusion(CRAO),whichmostcommonlybeginsasanemtiolizedplaquefromtheipsllateralcarotidartefy;acardioembolicsourceegduetoatrialfibrillation?isalsopossibleMostpatientsdevelopsignificantpermanentvisualdeficitsFunduscopycanrevealawhitenedretina(duetoedema)and.finthemacula,thecentralfoveaappearsredfromunderlyingchoroid(cherryredspot).Patientsusuallyhaveadefectintheafferentpupilreflex.CRAOrsanophthalmologicemergency,andattemptsatrecoveringvision(eg.anteriorchamberparacentesis,ocularmassage,revascularization)shoufdbeconsidered.WorkupaisoincEudesnoninvasiveimagingofthecarotidstoevafu^teforstenosis.AttieroscErotictreatment(eg,aspirin,statin)and,incasesofcardioembolicphenomenon,long-tennanticoagulation(eg,warfarin)areofteninitiated,(ChoiceB)Patientswithhypertensiveretinopathytypicallydonothaveacutevisionloss.Onfunduscopy.thereisfocalspasmofarteriolesTfollowedbyprogressivesclerosisandnarrowing.Dependingontheseverity,arteriovenousnicking,copperorsilverwiring,exudates,and/orhemorrhagesmaybepresent.(ChoiceC)Patientswithadetachedretinatypicallyhavelightflashes,floaters,oracurtailacrosstheirvisualfield(usuallystartingfromtheperipheryratherthandroppingverticallyasinthispatient}thatIsnot廿ansient.FunduscopicfindingscanIncludeawrinkledordetachedretina.(ChoiceD)Painless,sudden(sometimessubacute)visionloss{orhazeicanbeseenircentralretinalvr-mocclusion,Ijke^yfromvenousthrombosis,ttcanprogresstoanischemicformthatcanbepainfulFunduscopyusuallyreveatsdilatedandtortuousveins由adingtoscaderedanddtffusehemorrhages(“bloodandthunder),disks入ellirg.and/orcottonwoolspots.(ChoiceE)Patientswithvitreoushemorrhage(egduetoretinaltear,vrtreousdetach巾enthavefloaters.D丨abet丨cretinopathyisacommoncause.Ontunduscopyrahemontiageisusuallyseen,butitmayalsobedifficulttovisualizethefundusduetoobscureddetailsfromhemorrhage.Educationalobjective:CentralrettnatarteryocclusionisamonocularpainlessacutevisionlossmostcommonlycausedbyanembollzedatheroscleroticplaquefromtheIpsilateralcarotidartery.Q2A69-year-oldmancomestotheemergencydepartmentduetosevereoccipitalheadache,nausea,andvomitingforthelast3hours.Hehasneverhadaheadachelikethisbeforeandhasotherwisebeeningoodphysicalcondition.Thepatientwastoldseveralyearsagothathehashighbloodpressure,buthehasnotbeentakinganymedicationsorseenanyhealthcareproviders.Hehassmokedhalfapackofcigarettesdailyfor40yearsanddrinks1or2cansofbeereveryevening.Bothofhisparentsdiedofnaturalcauses.Bloodpressureis160/90mmHgandpulseis86/minandregular.HisnoncontrastheadCTscanisshownintheimagebelow.Whichofthefollowingphysicalexaminationfindingsismostlikelytobeseeninthispatient?A.HomonymoushemianopiaB.LeftheminegiectC.LefthemiplegiaD.LefthemisensorylossE.PinpointpupilsF.RighteyevisionlossG.RighthemiataxiaM,RighthemiplegiaI.RighthemisensorylossA2Correctanswer:GThispatienthasdevelopedaspontaneousIntraparenchymaihemorrhageintherightcerebellarhemisphere(redarrow)likelyrelatediopoorlycontrolledhypertension.Themostcommonsitesforhypertensivehemorrhageindescendingorderincludethebasalganglia(putamen)：cerebellarnuclei,thalamus,pons：andcerebralcortex.Patientswithintraparenchymaihemorrhageusuallypresentwithgradualonsetofsymptoms(minutestoafewhours)incontrasttobrainembolismorsubarachnoidhemorrhage：inwhichsymptomsareabrupt.Typicalfeaturesofcerebellarhemorrhageincludeoccipitalheadache(mayradiatetoneck/shoulders),neckstiffness(duetoextensionofbloodintothe4thventricle),nausea/vomiting,andnystagmus.PatientsmayalsohaveIpsllateralhemlataxlaofthetrunk(cerebellarvermis)and/orlimbs(cerebellarhemispheres)asthecorticopontocerebellarfibersdecussatetwice.Hemiparesisandsensorylossareusuallyabsentbutextensionofthebleedtothebrainstemcancauseera门ialneuropathies(eg:ipsilateralfacialnervepalsy).Furtherhematomaexpansionmayleadtobrainstemcompressionresultinginstupor,coma,andultimatelydeath.EarlydiagnosiswithnoncontrastheadCTscaniscrucialasemergencydecompressionmaybelife-saving,especiallyifthehemorrhageis3cm.(ChoiceA)Anyunilateralvisualpathwaylesionbeyondtheopticchiasm(eg,optictract,lateralgeniculatebody：opticradiations,primaryvisualcortex)cancausecontralateralhomonymoushemianopia.丁his丨sfrequentlyseenwithintracerebralhemorrh