ABC of Spinal cord trauma

Spinal cord trauma is potentially the most devastating consequence of injury to the spine. This well-established, practical guide provides a detailed overview from the scene of the accident to rehabilitation and discharge from hospital care. This latest edition has been substantially rewritten to include the most recent developments in practical management of patients with potential spine injury and risk-minimisation techniques. There is also a new chapter on spinal cord injury in developing countries.

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Ramsay Hunt Syndrome(clinical)

CAUSES:
Classic Ramsay Hunt syndrome is ascribed to infection of the geniculate ganglion by herpesvirus 3 (varicella-zoster virus [VZV]).



HISTORY:
*Patients usually present with paroxysmal pain deep within the ear. The pain often radiates outward into the pinna of the ear and may be associated with a more constant, diffuse, and dull background pain.

*The onset of pain usually precedes the rash by several hours and even days.

*Classic Ramsay Hunt syndrome can be associated with the following:
-Vesicular rash of the ear or mouth (as many as 83% of cases),The rash might precede the onset of facial paresis/palsy.
-Ipsilateral lower motor neuron facial paresis/palsy (CN VII)
-Vertigo and ipsilateral hearing loss (CN VII)
-Tinnitus,Otalgia,Headaches,DysarthriaGait,ataxia.
-Fever,Cervical adenopathy.

*Facial weakness usually reaches maximum severity by one week after the onset of symptoms.

*Other cranial neuropathies might be present and may involve cranial nerves (CNs) VIII, IX, X, V, and VI.

*Ipsilateral hearing loss has been reported in as many as 50% of cases.

*Blisters of the skin of the ear canal, auricle, or both may become secondarily infected, causing cellulitis.


EXAMINATION:

.The primary physical findings in classic Ramsay Hunt syndrome include peripheral facial nerve paresis with associated rash or herpetic blisters in the distribution of the nervus intermedius.
.The location of the accompanying rash varies from patient to patient, as does the area innervated by the nervus intermedius. It may include the following:
1.Anterior two thirds of the tongue
2.Soft palate
3.External auditory canal
4.Pinna
.The patient may have associated ipsilateral hearing loss and balance problems.
.A thorough physical examination must be performed, including neuro-otologic and audiometric assessment.

Brain herniation Sites

Brain herniation refers to displacement of a portion of the brain from its normal position through openings in the inelastic dura secondary to.............

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Cranial Nerve 9 Dysfunction Pic

Cranial Nerve 9 Dysfunction: Patient has suffered stroke, causing loss of function of left CN 9 (Glossopharyngeal nerve). As a result, uvula is pulled towards the normally functioning (ie right) side.

Researchers on a Completely fearless woman, Do you belive !!

It has been known since the 1930s that when a certain part of monkeys’ brains were removed, the animals became fearless. Now similar effects are being seen in humans according to a study in the journal Current Biology. Justin Feinstein, the study’s lead author and a clinical neuropsychologist at the University of Iowa said, “There’s not very many humans with this sort of brain damage… Luckily for us, we had access to a patient, SM, and we studied her different fear behaviours and we read her personal diaries.”

SM due to a rare condition called lipoid proteinosis does not have her amygdala. The amygdala is an almond-shaped structure that studies have shown plays a role in processing fear and other emotions, though experts say its exact role is unclear. Her condition is termed Urbach-Wiethe disease. This has made her fearless to all normally fear evoking stimuli like snakes, spiders etc. This has also made her put her life at risk a few times. Now the team is trying to coach the patient to behave in a more cautious manner.


Dr. Jon Shaw, professor of psychiatry at the University of Miami School of Medicine said, “It’s very striking that she has only a rational response, not a physiological one… The body is not prepared for a physiological response because the amygdala has been taken out of the loop.” Ruben Gur, professor in the Departments of Psychiatry, Radiology & Neurology at the University of Pennsylvania School of Medicine in Philadelphia was said, “If you look at past neuroimaging studies, there is clear evidence that the amygdala is extremely sensitive to fearful stimuli.”

Researchers believe that her condition may offer clues for therapy of people with excessive fear like war veterans. This condition is known as post-traumatic stress disorder or PTSD. Feinstein said, “We may be able to dampen the effects of the amygdale… We can do that through psychotherapy and possibly through medication.”

Not all are convinced. Elizabeth Phelps, professor of psychology and neural science at New York University said, “You have to interpret case studies with caution since there’s been contradictory work done.” She pointed out that there is one study that found an unusual emotional response in monkeys whose brains were experimentally damaged, but only during specific stages of development. She explained there was another patient HM who had part of his brain, including the amygdala, removed to treat severe epilepsy. His main problem, according to experts, was his memory loss.

The Confusion Assessment Model (CAM)

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Diplopia in a Patient with HIV Infection

A 25-year-old man with human immunodeficiency virus (HIV) infection who was receiving highly active antiretroviral therapy presented with a 1-week history of diplopia and headache. The CD4 count was 218 cells per cubic millimeter, and the viral load was 50,000 copies per milliliter.
The neurologic examination revealed an inability to abduct the right eye with horizontal gaze, a finding that was consistent with an isolated right abducens nerve palsy (rightward gaze, Panel A; leftward gaze, Panel B). The examination of other cranial nerves was normal. The remainder of the motor and sensory examination was within normal limits.
The patient reported having had low back pain and constipation for the previous week. There was no history of bowel or bladder incontinence. A gadolinium-enhanced magnetic resonance image of the brain showed a minimally enhancing mass filling and expanding the right cavernous sinus (Panel C, arrow). Lumbar-spine imaging showed a mass with similar radiographic characteristics involving the ventral epidural compartment.
Biopsy of the spinal lesion revealed diffuse large-B-cell lymphoma. A chemotherapeutic regimen of cyclophosphamide, doxorubicin, vincristine, and prednisolone, along with the monoclonal antibody rituximab (R-CHOP), was started. Progressive leg weakness from spinal involvement developed, and the patient had a poor response to corticosteroids and radiation therapy and died 3 months later.

Diagnostic Algorithm for Evaluation of Acute Myelopathies and Myelitis.

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How is Neuroblastoma Clinically Presentating ?

Neuroblastoma is a childhood cancer that is diagnosed at a median age of about 17 months. Tumors can arise anywhere along the sympathetic nervous system, with the majority occurring in the adrenal medulla. Primary tumors in the neck or upper chest can cause Horner's syndrome (ptosis, miosis, and anhidrosis)............

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Minimally Invasive Surgery Corrects Urinary Incontinence

A DMC patient with urinary stress incontinence regains control with less-invasive surgery at DMC Sinai-Grace, performed by DMC Ob/Gyn specialist Dr. Korial Atty. ~ Detroit Medical Center.

6th Cranial Nerve Palsy

Left 6th Cranial Nerve Palsy: Left eye unable to move laterally beyond midline. In this case, nerve ..............

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Blepharospasm

Blepharospasm is an abnormal tic, spasm, or twitch of the eyelid. It is sometimes referred to as Benign Essential Blepharospasm. Focal dystonia is another phrase for this condition, which involves a involuntary muscle contraction around the eyes. The cause can be fatigue, irritant or caffeine. The symptoms can last for a few days, but commonly disappear without treatment. Severe cases can be chronic.

Besides the tic, symptoms of blepharospasm are eye dryness, excessive blinking, twitching, sensitivity to the sun and bright lights. Blepharospasm occurs spontaneously with no indicators. Patients who experience blepharospasm usually have a history of dry eyes and photo sensitivity. Other syndromes such as Meige’s syndrome have been associated with blepharospasm. Drugs used to treat Parkinson’s disease have also been known to cause blepharospasm. Rarely, blepharospasms can be caused by concussions.

causes of coma, mnemonic

There are several medical causes of coma. One of the easiest ways to remember these causes is to use the mnemonic AEIOU TIPS:

* A - alcohol (overdose / withdraw / Wernicke's encephalopathy)
* E - epilepsy or exposure (heat stroke, hypothermia) or electrolytes
* I - insulin (diabetic emergency - high/low sugar)
* O - overdose or oxygen deficiency
* U - uremia (metabolic) or underdose
* T - trauma (head injury) or toxicology
* I - infection / inflammation
* P - psychosis or poisoning
* S - stroke / SAH / shock / syncope

Babinski Response

Babinski Response: Note upgoing great toe upon stimulation of lateral foot in patient with
upper motor neuron lesion.

Berry aneurysm

A berry aneurysm refers to an intracranial aneurysm with a characteristic shape which accounts for the vast majority of intracranial aneurysms as well as non-traumatic subarachnoid haemorrhages. They occur at branch points, usually of sizable vessels, but sometimes at the origin of small perforators which may not be seen on imaging.

This photo on the right is Photo of a Norwegian blueberry.

Pathology

The aneurysmal pouch is composed of thickened hyalinised        intima with the muscular wall & internal elastic lamina being absent.

Comments required on a radiology report:

* size : ideally 3 axis maximum size meansurements
* neck : maximal width of the neck of the aneurysm
* shape and lobulations
* orientation : the direction in which the aneurysm points is often important in both endovascular and surgical planning

This small berry aneurysm projecting inferiorly from the ACOM had pushed into the optic chiasm causing a bitemporal hemianopia, similar to that seen in pituitary lesions.

SAH angiogram

Treatment of Heat-Related Illnesses

Algorithm for the treatment of heat-related illnesses. (CNS = central nervous system; ABCs = airway, breathing, and circulation; EMS = emergency medical services.)

Cranial Nerve Examination

Ramsay Hunt Syndrome

What is it? Ramsay Hunt syndrome is defined as an acute peripheral facial neuropathy associated with erythematous vesicular rash of the skin of the ear canal, auricle (also termed herpes zoster oticus,Hunt's Syndrome ), and/or mucous membrane of the oropharynx.
This syndrome is also known as geniculate neuralgia or nervus intermedius neuralgia. Ramsay Hunt syndrome can also occur in the absence of a skin rash, condition known as zoster sine herpete.

Pathophysiology:

Ramsay Hunt syndrome is defined as VZV infection of the head and neck that involves the facial nerve, often the seventh cranial nerve (CN VII). Other cranial nerves might be also involved, including CN VIII, IX, V, and VI (in order of frequency). This infection gives rise to vesiculation and ulceration of the external ear and ipsilateral anterior two thirds of the tongue and soft palate, as well as ipsilateral facial neuropathy (in CN VII), radiculoneuropathy, or geniculate ganglionopathy.

VZV infection causes 2 distinct clinical syndromes. Primary infection, also known as varicella or chickenpox, is a common pediatric erythematous disease characterized by a highly contagious generalized vesicular rash. The annual incidence of varicella infection has significantly declined after the introduction of mass vaccination programs in most countries of the world. After chickenpox, VZV remain latent in neurons of cranial nerve and dorsal root ganglia. Subsequent reactivation of latent VZV can result in localized vesicular rash, known as herpes zoster. VZV infection or reactivation involving the geniculate ganglion of CN VII within the temporal bone is the main pathophysiological mechanism of Ramsay Hunt syndrome.

Mortality/Morbidity:

Ramsay Hunt syndrome is not usually associated with mortality. It is a self-limiting disease; the primary morbidity results from facial weakness. Unlike Bell palsy, this syndrome has a complete recovery rate of less than 50%.

CN 3 Palsy (Oculomotor nerve Palsy)

Right CN3 Palsy: Patient's right eye is deviated laterally, there is ptosis of the lid, and the right pupil (the 2nd picture) is more dilated than the left.
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Drugs administered in Status Epilepticus

A 21 year old is brought to your clinic in status epilepticus. What drug should be administered initially?

• A) Lorazepam
• B) Phenytoin
• C) Phenobarbital
• D) Pentobarbital
• E) Fosphenytoin

Answer and Discussion
The answer is A. Lorazepam should be administered intravenously and approximately 1 minute allowed to assess its effect. Diazepam or midazolam may be substituted if lorazepam is not available. If seizures continue at this point, additional doses of lorazepam should be infused and a second intravenous catheter placed in order to begin a concomitant phenytoin (or fosphenytoin) loading infusion. Even if seizures terminate after the initial lorazepam dose, therapy with phenytoin or fosphenytoin is generally indicated to prevent the recurrence of seizures.