dr ces material Flashcards
6th palsy with a Horner’s localizes to ______
6th palsy with a Horner’s localizes to the cavernous sinus
WHat are some expected signs/symptoms of cavernous sinus syndrome
-how is vision? EOMs?
- EOM palsies, either isolated or multiple, unilateral or bilateral
- severe headache
- numbness of V1 or V2
- vision NOT affected – the optic nerve lies above, not within, the sinus
what is a high flow cavernous sinus fistula
carotid-cavernous fistula: an artificial connection between a large artery and a small vein – a lot of blood and pressure overwhelms the system
what kind of symptoms do you expect with high flow cavernous sinus fistula?
dramatic, acute onset symptoms (CN 3, 4, 6 palsies) – orbital and ocular venous drainage has reversed blood flow
what type of pts do you expect to see high flow cavernous sinus fistula?
usually young men, following head trauma (can be immediate or delayed issue)
what is a low flow cavernous sinus fistula?
dural arteriovenous malformations: an abnormal connection between the arteries supplying the dura and the canverous sinuses (not the ICA, but another big-ish artery)
what type of pts do you expect to see low flow cavernous sinus fistula?
- could be congenital or acquired with insidious onset
- typically women >50yo or associated with HTN, pregnancy, or mild trauma
- often unilateral, might spontaneously resolve
what kind of ocular presentation do you see with cavernous sinus fistula?
• arterialized conjunctival vessels
• 3-10mm proptosis
• ophthalmoplegia or paresis, diplopia as a result
• audible bruit – can hear over closed lid using stethoscope
• anterior segment hypoxia: cells and flare
o increased IOP because of decreased venous outflow- gives corneal edema, rubeosis
o cataract if chronic
• if severe/really rare – venous stasis retinopathy
• venous dilation, dot-blot hemorrhages
• optic disc edema
how do you treat cavernous sinus fistula?
high flow refer to neurosurgeon, low flow often resolve
what kind of pt gets cavernous sinus thrombosis?
usually patient is immunocompromised
• if diabetic, assume mucor until proven otherwise
•could be from an infection elsewhere -> sinuses, dental abscess, ear infection, orbital cellulitis
what kind of signs/symptoms do you see with cavernous sinus thrombosis?
uni vs bilateral?
Often bilateral, retro-orbital pain, proptosis, chemosis, periorbital edema, multiple cranial neuropathies, headaches, nausea, fever, chills, tachycardia, seizues -> very specific signs with little variation
how do you treat cavernous sinus thrombosis?
- antibiotics or antifungals depending on assumed cause
- anticoagulation therapy
- corticosteroids – endocrine deficiencies especially
when should you get neuro imaging?
1) arterialized vessels
- suggestive of: carotid-cavernous fistula, dural-cavernous fistula, or cavernous sinus thrombosis (mucor in DM pts)
2) multiple cranial neuropathies
- suggestive of: carotid-cavernous fistula, cavernous sinus thrombosis, pituitary apoplexy (gives worst headache of life with or without loss of consciousness), Tolosa Hunt, Miller-Fischer variant of GBS
3) severe pain – because V1 is implicated
4) lid retraction but without lid lag (lid lag implies thyroid eye disease)
- Parinaud’s or Miller-Fischer
5) change in mental status
If you see acute orbital inflammatory syndrome in diabetics – raise suspicion of _____
what is the classic sign of this?
mucormycosis
(mucor is considered normal flora, but in an uncontrolled diabetic, high sugar environment allows overgrowth and overwhelms the immune system, rare if patient is not diabetic)
*classic sign: black nasal discharge secondary to gangrene
what is pituitary apoplexy?
what causes it?
bleeding into or impaired blood supply of the pituitary gland (usually from tumor)
may be precipitated by trauma, radiation, anticoagulation
