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Case of the Month

Welcome to CNS Case of the Month Section.
The purpose of this Web area is to provide a forum for discussion and debate regarding the management of both ordinary and extraordinary cases. There are no right or wrong answers, but rather, there are various opinions on what should be the "standard of care." The answers given will be collected anonymously, and be presented in a graphical format at the end of each month. We will then see the spectrum of thought regarding the management of these patients.

We are always open to suggestions, and if you have a case or questions that you would like to have presented, please submit them to: info@1cns.org

Brian L. Hoh, MD
University of Florida
Ashok R. Asthagiri, MD
Associate Professor
Department of Neurological Surgery
University of Virginia
Maryam Rahman, MD MS
Assistant Professor
Department of Neurosurgery
University of Florida
Alexander A. Khalessi MD, MS
University of California San Diego
Wilson Z. Ray, MD
Assistant Professor in Neurosurgery
Department of Neurological Surgery
Washington University School of Medicine
Edward R. Smith, MD
Director, Pediatric Cerebrovascular Surgery
Department of Neurosurgery
Children's Hospital Boston / Harvard Medical School
Sameer Sheth, MD, PhD
Assistant Professor of Neurosurgery
Columbia University Medical Center
New York Presbyterian Hospital
 
September 2014: Sudden Onset Visual Disturbance

HPI

  • 24-year-old female presents with sudden onset of decreased vision. Denies headaches or other neurologic symptoms.
  • PMH – neg
  • PsurgHx – neg
  • Meds – none
  • PE
  • AF VSS
  • Neurologically intact except for L homonymous hemianopia

Figure 1: T2
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Figure 2: T1+contrast
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Figure 3: T1+contrast
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Figure 4: Diffusion
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Figure 5: ADC
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1. Which is highest on your differential based on the history and imaging?
    a. Stroke
    b. Astrocytoma
    c. Infection
    d. Demyelinating disease
    e. Hemorrhage
2. What further testing would you recommend?
    a. Spine MRI
    b. PET scan
    c. Lumbar puncture
    d. HIV test
    e. CTA
3. What treatment would you offer?
    a. Resection
    b. Steroids
    c. Radiation
    d. IVIG
    e. Antiplatelet drugs
4. Which of the following describes you?
    a.   Resident/fellow
    b.   Private practice
    c.   Academics
5. I practice in one of the following locations.
    a.   I practice in one of the following states: WA, OR, CA, AK, HI
    b.   I practice in one of the following states: AZ, ID, NV, MT, WY, CO, NM, UT
    c.   I practice in one of the following states: ND, SD, NE, KS, OK, MN, IA, MO, WI, IL MI, IN, OH
    d.   I practice in one of the following states: TX, AR, AL, LA, KY, TN, MS, WV, NC, SC, GA, FL
    e.   I practice in one of the following states: ME, VT, NH, MA, RI, CT, NJ, NY, PA, DE, MD, DC, VA
    f.   I practice in Mexico or Canada
    g.   I practice in South America
    h.   I practice in Europe
    i.   I practice in Asia
    j.   I practice in Australia/Pacific Rim
    k.   I practice in Africa
6. Comments
   

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Pubmed References
  • Filippi et al. Association between pathological and MRI findings in MS. Lancet Neurol, 2012.

  • Thompson et al. Pharmacological management of symptoms in MS. Lancet Neurol, 2010.