Cranial Nerve Examination Research Articles

Previously Undiagnosed Malignant Brain Tumor Discovered During Examination of a Patient Seeking Chiropractic Care

ObjectiveThis case report describes the diagnosis of a malignant brain tumor in a patient requesting chiropractic care for headaches after a motor vehicle accident. Clinical FeaturesA 30-year-old man presented with numbness and tingling in all extremities, lower extremity muscle weakness, and a recent increase in headaches with the loss of ability to concentrate. He was involved in a high-speed motor vehicle collision approximately 4 months before the onset of symptoms. Examination showed slow gait with a lack of arm swing, bilateral hip flexors and knee extensors were all graded as 4/5 on muscle testing, and cranial nerve examination was unremarkable with the exception of 2 beats of nystagmus on left lateral eye movement. Because of these findings and a family history of multiple sclerosis, the patient was referred for a brain magnetic resonance imaging scan. Intervention and OutcomeImaging showed a craniocervical junction mass centered at the floor of the fourth ventricle with obstruction of foramina and marked impingement on the medulla. A posterior fossa craniotomy and tumor removal procedure was performed by a neurosurgeon, followed by 34 sessions of radiation therapy. The final diagnosis was a grade II glioma with features of ependymoma. ConclusionsThis report describes the clinical presentation, examination, and medical management of a 30-year-old man presenting to a chiropractic practice with an unsuspected malignant brain tumor.

Staying Active

Staying Active

Standard Outcome Measures in Facial Paralysis: Getting on the Same Page.

Clinicians caring for patients with facial paralysis (FP) are universally interested in improving outcomes by developing and/or embracing treatment approaches that advance functional recovery, improve aesthetic outcome, and/or restore nonverbal communication ability. In facial plastic and reconstructive surgery, increasing emphasis on outcomes 1 has driven the development of myriad assays to measure the effects of therapy. Some assays have been statistically validated and tested for internal consistency, applying varying degrees of rigor, though many remain inadequately tested. Because of the high complexity and broad range of deficits that patients diagnosed with FP experience, agreement regarding standard outcomes measures has been particularly elusive. In the current era, agreement regarding these measures is critical to advancing care. Deep experience with the condition over the past several decades has permitted leaders to begin to agree on certain elements essential to progress in FP treatment. 2 Intake Patients with FP require meticulous standardized intake. 2 The process should include detailed medical history and physical examination, with full cranial nerve examination, including testing facial and corneal sensation, and motor function of the tongue and muscles of mastication. Requisite medical therapy, laboratory testing, consultations, and imaging investigations are applied as indicated. 3 Patients require standardized pho

A 75-year-old man with treatable progressive quadriparesis: question

A75-year-oldmanwas admitted to the department of neurology with a 1 year history of progressively worsening gait disturbance and painful paresthesia of all four limbs. His past medical history included hypertension and moderate hemophilia A. Physical examination revealed spastic quadriparesis with sphincter disorder andweakness of the lower limbswhenwalking for a fewmeters. No sensory level was clearly noted. Cranial nerve examination was normal. A clinical diagnosis of cervical myelopathy was made with imaging confirmation 6 months previously but a definite cause was not found. MRI of the spine showed extensive diffuse cervical cord swelling (Fig. 1). MRI of the brain was normal. The patient had not received any corticosteroid therapy prior to imaging.

Breast cancer presenting with intramedullary cervical spinal cord metastasis

A 45-year-old female patient was admitted to our hospital with complaints of weakness in her legs. There was no disturbance in sphincter function. Neurologic examination revealed generalized weakness and numbness in all four limbs. Examination of cranial nerves and tendon reflexes revealed normal functioning. Magnetic resonance imaging of the cervical spine demonstrated a 3 cm×0.9 cm×1.1 cmmass between the inferior two thirds of C2 and superior third of C3 (Figure). The mass was isointense on T1-weighted images, hyperintense on T2-weighted images, and homogeneously enhancing on post-contrast T1-weighted images. Sagittal T2-weighted images showed a pencil-shaped hyperintensity extending proximal to the lesion (Figure). The features were typical for intramedullary spinal cord metastasis (ISCM) [1]. An Ffluorodeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) scan showed a left breast lesion and multiple liver lesions. The patient underwent biopsy of the left breast mass and a liver mass. The breast mass was found to be a poorly differentiated, estrogen/progesterone (ER/ PR)-negative infiltrating ductal carcinoma, and an enlarged 1.6-cm left axillary lymph node biopsy revealed metastatic adenocarcinoma. The liver mass biopsy was reported to be an ER/PR-negative adenocarcinoma, consistent with metastatic breast cancer. The patient was started on dexamethasone, chemotherapy, and local external beam radiation therapy to the cervical spinal cord. After completion of the radiotherapy, there was improvement in the weakness and numbness of the extremities. The patient remained stable neurologically for 2 months after the diagnosis of breast cancer until death due to the liver metastases. Breast cancers can present with symptoms of the spinal cord metastasis. Intramedullary spinal cord metastasis of breast cancer is an extremely rare but severe condition that can cause neurologic deficits. Metastatic breast cancer should be considered when the typical features of ISCM are seen on spinal magnetic resonance imaging.

Leuprolide Injection Causing Pituitary Apoplexy: A Case Report

There is growing evidence to support occurrence of pituitary apoplexy following administration of gonadotropin releasing hormone (GnRH) agonists in patients with gonadotropin-secreting pituitary adenomas. We report a case of pituitary apoplexy after depot administration of the GnRH agonist leuprolide. The patient is a 78 year-old man with Gleeson 7, non-invasive prostate cancer who was treated with his first dose of leuprolide two days prior to presentation. He developed a severe headache four hours after leuprolide administration. Non-contrast Magnetic Resonance Imaging (MRI) brain showed a 1.2 cm T1 hyper intensity in the anterior pituitary, likely representing a hemorrhagic adenoma or cyst. 1 month later his repeat MRI of the brain showed resolution of the hemorrhage, as well as a 3 mm lesion within the pituitary thought to be a micro adenoma. What is unique in our case is the mild degree of symptoms manifested by intractable headaches with normal vision and cranial nerve examination, requiring no surgical intervention. There may be a correlation with the size of the adenoma and the severity of disease burden caused by the apoplexy.

Epic Fail! Poor Neuropsychiatric Documentation Practices in Emergency Psychiatric Patients

Background: There is a strong association between mental illness and poor physical health. However, research indicates that the standard of physical examinations performed on patients with psychiatric illnesses is sub-optimal, falling short of recommended/expected assessments. Objective: This study aimed to assess the completeness of the neurological and psychiatric examinations performed by emergency physicians in a level 1 trauma centre with a dedicated psychiatric emergency centre. Methods: A retrospective chart review of 50 consecutive emergency psychiatric patients was performed. Each of the 50 patients had been “medically cleared” and deemed stable for transfer to inpatient psychiatry. Results: The documented neurologic and psychiatric examinations were generally poor. Mood and affect were documented in less than 50% of cases. Suicidality was documented in less than 1/3 of the patients who presented with a chief complaint of suicidal ideation. Only one patient had a documented a mini-mental status examination. 16% of patients did not have their orientation status documented. More than half did not have a cranial nerve examination. Less than 25% had their gait or reflexes tested. 28% of patients had their strength tested and 12% had a sensory examination performed. Conclusions: Most psychiatric patients are not receiving a thorough neuropsychiatric physical examination by emergency providers, an alarming finding deserving more scrutiny. Additional research is needed to ascertain which components of the neurological and psychiatric examination are the highest yield and would have the greatest impact patient care outcomes and disposition. Interdisciplinary consensus must also be reached on what constitutes an adequate examination for patients with varying severity of neuropsychiatric presentations (e.g., suicidal ideation, altered mental status, frank psychosis).

Spinal muscular atrophy

Spinal muscular atrophy (SMA) is a genetic motor neuron disease characterized by progressive degeneration of motor neurons. Herein, a 12-year-old female child, born to healthy nonconsanguineous parents, was brought with the chief complaints of wasting and weakness of both lower limbs for 3 years. There was no family history of neurological illness. On examination, higher mental functions and cranial nerve examinations were normal. Typical worm-like fasciculations were seen in tongue and both lower limbs. Upper extremities were less affected. The child was able to feed herself. Respiratory muscles were not affected. A diagnosis of SMA-Type 3 (Kugelberg–Welander disease) was made on the basis of clinical presentation and subsequently, the diagnosis was genetically confirmed by molecular analysis of SMN gene. Electromyography showed spontaneous fibrillation at rest. Nerve conduction study was normal. No medical treatment was able to delay the progression. Supportive therapy includes orthopedic care and mild physiotherapy.

Acute Chorea Onset after Hot Food Consumption in a Patient with Moyamoya Disease.

Acute Chorea Onset after Hot Food Consumption in a Patient with Moyamoya Disease.

Severe Pure Acute Motor Axonal Neuropathy

Acute motor axonal neuropathy (AMAN) is a subtype of Guillain-Barre syndrome. Characteristic electrophysiological features of AMAN are reduced amplitude or absence of muscle action potentials. Our patient described progressive weakness in his leg and was not able to independently walk; he had a feeling weakness in his arms within 24 h after the onset of symptoms. He was diagnosed with AMAN according to the clinical and electrophysiological features. He could independently walk after two years following intensive physical therapy and monitoring. Neurologists and physiatrist should conduct long term monitoring and rehabilitation for patients with AMAN because neurological deficits may persist for a long time. AMAN was first reported to occur in patients having peripheral axonal dysfunction without demyelinating findings in the electroneuromyograph (ENMG) and is seen mostly during summers in the rural areas of China. Some cases were reported from some countries out of Asia, such as Mexico, in spite of the absence of seasonal predisposition. AMAN is characterized by acute motor paralysis, loss of reflexes or hyporeflexia, and peripheral axonal involve- ment without demyelinating findings in ENMG. In a study the median age of patients with AMAN in China was found to be 10 years (3). In this study, it was aimed to present an 8-year-old patient with AMAN and who had muscle weakness in the lower extremity at the beginning and then developed tetraplegia as a result of pure motor involvement without sensory involvement in a short time. The patient was treated with intravenous immunoglobulin (IVIG) therapy. CASE REPORT An 8-year-old male patient presented to our outpatient clinic with complaints of incapability of walking and moving his hands and arms. The patient who had not experienced such a complaint before complained about loss of strength that had suddenly occurred in his right leg a week ago. He stated that the weakness spread to the other leg and arms within the first 24 h after the onset of the symptoms. He told that he did not have any pain at the onset of symptoms but that he began to feel pain as the weakness progressed. The investigation of his medical history revealed no previous infection, surgical intervention, or vaccination. Moreover, he did not have a history of fever, vomiting, and diarrhea before the illness; no serious pathological history was found in his family and relatives. The patient was conscious, and he was completely oriented and cooperative. His systemic examination results were normal. The eyes were at the midline and moving to every direction. The patient could count fingers at 6 m. His pupils were isocoric; direct and indirect light reflexes were positive, and the examination of the fundus was normal. No pathological changes were detected on cranial nerve examination.

What makes a good children’s doctor? Exploring the child perspective in the OSCE setting

Background: Patient feedback is increasingly important in clinical practice, and this should include children’s views. 28 children aged 8–10 years participating in a large-scale OSCE underwent cranial nerve examination by student candidates. They scored each out of 10 for the question: ‘If you had to see a doctor again, how happy would you be to see this one?’ An age-adapted qualitative focus group methodology was used to explore why they scored some students more highly than others.Results: Children’s scores for the 256 medical students ranged from 2 to 10 (median 9; mean 8.46). 76% of scores were above 8. ‘Good' doctor attributes included: ‘friendly’, ‘funny’, ‘knowledgeable’, ‘confident’; ‘bad’ doctor attributes were: ‘making mistakes’, ‘not paying attention’, ‘forgot everything’, ‘serious’. Children’s reasons for specific scores are further explored.Discussion and conclusion: Scores were positively skewed, in line with most patient/simulated patient feedback, and children discriminated between candidates. It should not be assumed that clinician examiners can accurately represent the views of child patients who may value different qualities in doctors. Children participating in our study had clear views of what they want from a doctor: a consultative approach with clear and kind explanation of the process of examination.

In this issue – July 2015

In this issue – July 2015

The equine guttural pouch: Clinically relevant anatomy and basic treatment options for trauma

The equine guttural pouch: Clinically relevant anatomy and basic treatment options for trauma

Stumbling towards a diagnosis

A previously well 24-year-old man presented with 4 days of increasing gait disturbance and clumsiness with tingling sensations in his forearms. He could still walk without the help of others...

Hemichorea-Hemiballism as the First Presentation of Type 2 Diabetes

Hemichorea-hemiballism (HCHB) is a hyperkinetic disorder characterized by continuous, nonpatterned, proximal, involuntary movements on one side of the body, resulting from involvement of the contralateral basal ganglia and particularly the striatum. We report here an interesting case of sudden onset HCHB associated with nonketotic hyperglycemia, with complete remission of symptoms after control of blood glucose. HCHB as the first presentation of type 2 diabetes has been described rarely. This case report reinforces that, especially in elderly patients with newly diagnosed HCHB, nonketotic hyperglycemia should be recognized promptly. Early diagnosis and treatment of hyperglycemia yield an excellent prognosis. A 61-year-old man presented after 2 days’ duration of sudden-onset involuntary movements of the left side, first involving the upper limb and 6 hours later involving the homolateral lower limb. There was no history of stroke or preceding trauma. He was conscious and alert, with normal higher mental functions and cranial nerve examination. He had periodic choreiform and ballistic movements of the left upper and lower extremities that could not be suppressed voluntarily but that ceased during sleep. Initial biochemistry revealed a random blood glucose of 527 mg/dL, a normal venous pH (7.37), and negative blood ketones (0.5 mmol/L). A diagnosis was made of diabetic nonketotic hyperosmolar state causing HCHB. The patient’s A1C was …

Aphasia in multilingual individuals: the importance of bedside premorbid language proficiency assessment.

Aphasia in multilingual individuals: the importance of bedside premorbid language proficiency assessment.

Cranial Nerve Examination for Neurogenic Dysphagia Patients

This cross-sectional study aimed to validate a cranial nerve assessment for swallowing against fiber optic-endoscopic examination of swallowing (FEES) in a group of neurological patients. A specific cranial nerve evaluation was designed, comprising semi-qualitative evaluations of the main five cranial nerves involved in swallowing. Eighty-five participants were consecutively recruited with the following inclusion criteria were: a) neurological diagnosis; b) ability to respond to simple verbal command; c) absence of citrus allergy and age<18 years. All participants first underwent cranial nerve examination (the “I&I” test), followed by a FEES conducted by a blinded otolaryngologist who completed the penetration aspiration scale (PAS) and the functional oral intake scale (FOIS). The results showed that I&I test had a high sensitivity (0.89) and specificity (0.93) for identify dysphagia in persons with neurologic disorders, with an area under ROC curve of 0.97. Significant differences were found from the comparison between I&I test scores and the three severity levels of PAS. In conclusion, the I&I test is a useful scale to detect the major deficits affecting the cranial nerves in patients with swallowing disorders. In addition, it allows defining the pathophysiological dysphagia symptoms, which are fundamental for planning the customized rehabilitation interventions.

An epidemiological study of traumatic brain injury cases in a trauma centre of New Delhi (India).

Background:Trauma is one of the leading causes of death and disability in Indian population.Aim:To correlate various variables like epidemiology, clinical status, severity of TBI & associated co-morbid conditions and its outcome.Settings and Design:This study involved retrospective collection, prospective management and follow up of 796 cases of TBI admitted to the neurosurgery department of a tertiary care hospital in New Delhi during one year study duration.Materials and Methods:All the relevant variables recorded and analyzed with Glasgow Outcome Scale (GOS) in 6 months into 3 groups i.e. group 1 (GOS-1/Dead), group 2 (GOS-2&3/Bad) and group 3- (GOS-3&4/good).Statistical Analysis:Compiled data collected, analyzed and difference between two proportions was analyzed using Chi Square test.Results:This study included 791 cases with 569 (72%) males and 222 (28%) females with average age of 24 years. Fall from height was the main cause of TBI (56%) followed by road traffic injury (RTI) (36%). Majority (61%) patients reached the hospital within 6 hours of injury out of which 27% patients were unconscious. As per Glasgow coma scale mild, moderate & severe grade of TBI was seen in 62%, 22% &16% cases respectively. Radiological examination of other body parts revealed injuries in 11% cases. Only 11% cases required surgical management, rest was managed conservatively. Good outcome noted in 80% cases and 20% cases expired. Average duration of hospital stay was 5 days. According to multivariate analysis, the factors which correlated with poor prognosis are presence of radiological injuries to other body parts, GCS, abnormal cranial nerve examination, abnormal plantar and abnormal pupillary reflex. (P < 0.05)Conclusion:TBI predominantly affects young male population and most of these are preventable. Early transportation to the hospital and first aid results in good outcome. Mortality increases with the severity of TBI and associated injuries therefore multimodality approach in polytrauma is essential.

Gyral Calcification in an Adult Masquerading as Subarachnoid Hemorrhage

An 85-year-old female with a medical history significant for coronary artery disease, status post pacemaker placement, and a prior stroke presented to an outside emergency department (ED) with complaints of lethargy, diaphoresis, dysarthria, and an episode of transient loss of consciousness at her nursing home. There was no history of trauma and she was not on any anticoagulants. A computed tomography (CT) scan was performed and read by the ED physician as subarachnoid hemorrhage (SAH) in the left sylvian fissure, and the patient was emergently transferred to our hospital for further management with a tentative diagnosis of SAH. Upon arrival to our intensive care unit, she was following commands, oriented to self, dysarthric but with fluent speech. Cranial nerve examination was within normal limits except for the presence of rightsided upper motor neuron–type facial nerve palsy. Careful evaluation of the CT scan showed the presence of a serpentine hyperdensity along the left perisylvian cortex consistent with dystrophic calcification from prior ischemic insult rather than an SAH, along with chronic microvascular ischemic changes, old lacunar infarcts, and age-appropriate cerebral parenchymal volume loss (Figure 1). CT angiography performed as part of a

Progressive bilateral facial weakness

A 72-year-old man presented with sudden onset of right-sided facial muscle weakness and slurred speech and a 3-day history of fevers, myalgia and sore throat. There was no hyperacusis, change...