Neuro-ophthalmology questions of the week: NOI15-Cavernous Sinus and Orbital Vascular Disorders 3

Questions:
12. What are the findings of thrombosis of the cavernous sinus?
13. What is the usual cause of cavernous sinus thrombosis?
14. What should be considered in a patient with apparent orbital cellulitis?
15. What are the major risks of thrombosis of the cavernous sinus?
16. What are 3 very serious complications of cavernous sinus thrombosis?
17. What is the mnemonic for the structures and their position in the cavernous sinus?

Neuro-ophthalmology questions of the week: NOI15-Cavernous Sinus and Orbital Vascular Disorders 2

Questions:
6. What are 10 ocular findings of carotid cavernous fistula?
7. Which of the cranial nerves is most commonly affected by a carotid cavernous fistula?
8. Can mechanical restriction of extraocular muscles occur in carotid cavernous fistula?
9. What diagnosis should be considered in an elderly woman with a mild headache, and elevated intraocular pressure?
10. What should be considered in all patients a bruit accompanying a chronically red eye?
11. When is treatment indicated for carotid cavernous fistulas?

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Neuro-ophthalmology questions of the week: NOI15-Cavernous Sinus and Orbital Vascular Disorders 1

Questions:
1. What signs and symptoms may develop from an aneurysm of the internal carotid artery within the cavernous sinus?
2. What are the characteristics of direct shunts between the internal carotid artery and the cavernous sinus?
3. What are the characteristics of indirect carotid cavernous or dural shunts?
4. Does a carotid cavernous fistula have unilateral or bilateral ocular symptoms?
5. Do carotid cavernous fistulas always have ocular symptoms?

Recommended Reading – Teaching NeuroImages: Ocular bruit in carotid-cavernous sinus fistula

Teaching NeuroImages: Ocular bruit in carotid-cavernous sinus fistula
Jeong-Yoon Choi, Seol-Hee Baek, Jin-Man Jung, Do-Young Kwon,
Moon Ho Park
Neurology. August 12, 2014; 83 (7) RESIDENT AND FELLOW SECTION

ARTICLE
A 57-year-old man who had a traffic accident 1 month previously presented with left ocular pain, double vision, and left eye proptosis with ptosis and conjunctival hemorrhage. Fundus showed dilated veins with no hemorrhages or disc edema. Left ocular motility showed complete external ophthalmoplegia (figure 1). There was prominent ocular bruit in his left eye (audio file on the Neurology® Web site at Neurology.org). MRI and magnetic resonance angiography showed a dilated left superior ophthalmic vein and an extravasation into cavernous sinus (figure 2). With chemosis, ophthalmoplegia, and retro-orbital pain, the auscultation of orbital bruit can make a correct and prompt diagnosis in the patient with carotid-cavernous sinus fistula.1


Figure 1 Physical examination
(A) Left eye with conjunctival injection and ptosis.

(B) Left eye proptosis.
(C) Fundus shows dilated veins with no hemorrhages or disc edema.
(D) Ocular motility shows complete external ophthalmoplegia in left eye and partial limitation of abduction in right eye.


Figure 2 Brain MRI and magnetic resonance angiography findings
(A) magnetic resonance angiography
(B) show a dilated left superior ophthalmic vein (black arrowhead) and a extravasation into cavernous sinus (white arrow).

Audio. Auscultation of ocular bruit.

(audio.mp3)
It was recorded using the JABES electronic stethoscope (GS tech., Korea) and WavePad Sound Editor (NCH software, Australia).

AUTHOR CONTRIBUTIONS Dr. Choi: participated in conceptualization of the manuscript, drafted the manuscript. Dr. Baek: participated in analysis of results and conceptualization of the manuscript. Dr. Jung: selected appropriate images and revised the manuscript for intellectual content. Dr. Kwon: participated in analysis of results and revised the manuscript for intellectual content. Dr. Park: drafted the manuscript and figure legend and revised the manuscript for intellectual content.

STUDY FUNDING
 
No targeted funding reported.
DISCLOSURE The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.
Footnotes
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Supplemental data at Neurology.org
Download teaching slides: Neurology.org
© 2014 American Academy of Neurology

REFERENCE 1. Ling JD, Chao D, Al Zubidi N, Lee AG. Big red flags in neuro-ophthalmology. Can J Ophthalmol2013;48:3–7.

 

Neuro-ophthalmology Questions of the Week: Pupil – Abnormal Miosis

Questions:
1. What are the signs of Horner Syndrome?
2. What signs and symptoms and signs can be associated with Horner syndrome?
3. Which eye drops can be used to establish the diagnosis of Horner syndrome?
4. What is the mechanism of action of cocaine when used to test Horner syndrome?
5. What is observed when testing for Horner syndrome with cocaine?
6. What is the mechanism of action of the apraclonidine when used to test Horner syndrome?
7. What is observed when testing for Horner syndrome with apraclonidine?
8. Which eye drop is used to localize which order neuron is involved in Horner syndrome?
9. What is the mechanism of hydroxyamphetamine when used to test Horner syndrome?
10. What is observed when hydroxyamphetamine is used to test Horner syndrome?
11. What is the classic cause of a first-order neuron Horner syndrome?
12. What does the combination of an ipsilateral Horner syndrome (first-order) and contralateral superior oblique palsy (fourth nerve palsy) suggest?
13. What does the combination of an ipsilateral Horner syndrome and (third-order) and an abducens paresis suggest?
14. What should the presumed cause of an acute painful Horner syndrome?
15. If the localization of a Horner syndrome is unknown what imaging tests should be done?
16. In a young child with an isolated Horner syndrome a workup should be done for what condition?
17. What imaging test should be done in a child with a Horner syndrome without a surgical history to explain it?

Neuro-ophthalmology Questions of the Week: Pupils – Examination, Anatomy & Physiology

Questions:
1. When examining the pupils, what should you record?
2. Does a RAPD cause anisocoria?
3. If a patient is suspected of having optic neuropathy (regardless of the cause) has no RAPD does that rule-out this diagnosis?
4. If a patient has a severe bilateral optic neuropathy will the pupils respond to near stimuli?
5. Which order neuron is involved when the Horner syndrome is caused by a tumor in the apex of a lung?
6. Why do patients with a third-order Horner syndrome usually do not have anhidrosis?
7. What is neurotransmitter is released at the neuromuscular junction of the iris sphincter to result in pupillary constriction?
8. What is neurotransmitter is released at the neuromuscular junction of the iris sphincter to result in pupillary dilation?
9. Why do lesions of the geniculate nucleus, the optic radiations, or the visual cortex not affect pupillary size or pupillary reactivity?
10. What is the course of the parasympathetic fibers for pupillary constriction from the Edinger-Westphal nucleus to the ciliary ganglion?
11. What is the ratio of postganglionic parasympathetic fibers that innervate the ciliary muscle to those that innervate the pupillary sphincter muscle?

Neuro-ophthalmology Questions of the Week: Hallucinations and Illusions 2

Questions:
1. What is the classic tetrad of narcolepsy?
2. What is palinopsia?
3. What is polyopia?
4. 
What is the Alice in Wonderland syndrome?
5. 
What is visual allesthesia?
6. 
What is the Riddoch Phenomenon?
7. 
What is Blindsight?
8. 
What is Residual Vision?
9. 
What 6 conditions are associated oscillopsia?
10. What is the Anton Syndrome?

Neuro-ophthalmology Questions of the Week: Hallucinations and Illusions 1

Neuro-ophthalmology Question of the Week: Hallucinations and Illusions 1

Questions:
1. What is the difference between a hallucination and an illusion?
2. Are isolated visual hallucinations common in psychiatric disorders?
3. What is the Pulfrich effect?
4. What is the Charles Bonnet syndrome?
5. Which dementias may be associated with paranoid hallucinations and illusions?
6. What is the duration of migraine with visual aura episodes?
7. What is the duration of visual phenomenon of occipital seizures?
8. What is peduncular hallucinosis and where is its lesion?

Neuro-ophthalmology Questions of the Week: Specific Disorders of Higher Cortical Function

Questions:
1. What is the Balint syndrome and where is its lesion?
2. What is the Gerstmann syndrome and where is its lesion?
3. What is hemineglect and where is its lesion?
4. What are the symptoms of posterior cortical atrophy and where is its lesion?
5. What are the visual symptoms of Alzheimer disease and when in the course of the disease are they likely to occur?
6. What visual symptoms may occur in Creutzfeldt–Jakob disease?

Neuro-ophthalmology Questions of the Week: Terms – Disorders of Higher Cortical Function

Questions:
1. What are the names and functions of the 2 visual higher cortical function processing streams?
2. What are the findings in a patient with alexia without agraphia?
3. Where is the lesion in alexia without agraphia?
4. What is prosopagnosia?
5. What is visual object agnosia?
6. What is optic aphasia?
7. What is topographagnosia?
8. What is akinetopsia?
9. What is simultagnosia?
10. What is ocular apraxia?