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A case of CVA in the RVH ER…

A case of CVA in the RVH ER…. Chenjie Xia (PGY-3) AHD Interactive Case Wednesday, Feb. 23 rd , 2011. On call at the RVH…. RVH ER page at 9:30PM Code purple, please see stroke patient for admission…. Patient Background. ID: 74M, right handed RFC: stroke

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A case of CVA in the RVH ER…

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  1. A case of CVA in the RVH ER… Chenjie Xia (PGY-3) AHD Interactive Case Wednesday, Feb. 23rd, 2011

  2. On call at the RVH… • RVH ER page at 9:30PM • Code purple, please see stroke patient for admission…

  3. Patient Background • ID: 74M, right handed • RFC: stroke • Social history: Chinese origin, retired real estate agent, lives with wife

  4. Patient Background • PMHx: • HCC with cirrhosis • Dx since 2006, s/p radiofrequency ablation, RTX • Episodic encephalopathy • Esophageal varices • Diabetes • HTN • Left putamen lacunar infarct • Right sided parkinsonian Sx, now resolved • ASA discontinued due to bleed from esophageal varices • Gout • Right parotid tumour (biopsy 2008  pleomorphic adenoma)

  5. Patient Background • Meds • Allopurinol, MVI, Ca/Vit D, Mg, Remeron, HCTZ, Nadol, lactulose, Flagyl, lantus • Recently added: Celebrex, Dilaudid, Lyrica • All: • NKDA • Habits • Non-smoker, non-drinker

  6. History • Woke up this AM and notes new right facial weakness, i.e. right mouth droop

  7. What more do you want to know on history?

  8. More history • Isolated right facial droop, i.e. no arm or leg weakness, no sensory change, no speech difficulties • Feels lips “thickened” and right eyelid “stuck to eyeball” • Right ear deaf for many years, no change • No change in taste noted • No vertigo, no n/v

  9. More history • Right sided headache x few months • Increased pain in right parotid tumour x Nov. 2010. • Consulted multiple MDs (GP, ENT, neurologist) • Ultrasound shows stable right parotid mass? • Suboptimal pain control despite Celebrex, Dilaudid and Lyrica

  10. What is your differential at this point?

  11. Differential Diagnosis • Idiopathic facial nerve palsy (Bell’s palsy) • Facial nerve palsy from other causes (e.g. infectious, autoimmune, granulomatous, neoplastic, etc) • Stroke • Right brainstem (pons) • Left hemisphere

  12. On exam • Looks well, non toxic, head drooped (because “the light is bothering my right eye”) • BP 155/70, HR 62 (reg), RR 20, 100% (RA), 36.1oC • No carotid bruit, normal S1, S2

  13. What more do you want to know on exam? Be specific…

  14. More exam findings • No aphasia • Large, palpable, firm, tender right parotid mass • Pupils 21mm (bilat), VFs normal, EOMs (saccadic SP, otherwise normal) • Normal sensation (LT/PP) • Right facial droop (frontalis, orbicularis oculi, and orbicularis oris involved)

  15. How do you differentiate between UMN and LMN facial palsy?

  16. Can you name the main motor branches of the facial nerve?

  17. Muscles innervated by the Facial Nerve • The: Temporal branch • Zebra: Zygomatic branch • Bit: Buccal branch • My: Mandibular branch • Carrot: Cervical branch • (Stapedius and post. auricular branches)

  18. More Exam Findings • Taste: decreased on right hemi-tongue • Hearing: No lateralization on Weber, decreased air conduction on Rinne on the right • Palate, SCM, trap, tongue mvts normal • Rest of exam (tone, strength, reflexes, sensation, coordination, gait) unremarkable

  19. What is your top differential diagnosis at this point?

  20. Differential Diagnosis • Idiopathic facial nerve palsy (Bell’s palsy) • Facial nerve palsy from other causes (e.g. infectious, autoimmune, granulomatous, neoplastic, etc) • Stroke • Right brainstem (pons) • Left hemisphere

  21. Differential Diagnosis • Idiopathic facial nerve palsy (Bell’s palsy) • Facial nerve palsy from other causes (e.g. infectious, autoimmune, granulomatous, neoplastic, etc) • Stroke • Right brainstem (pons) • Left hemisphere

  22. Findings CT head: old left putamen lacune, nil acute

  23. Question • Does the decreased taste favor Bell’s palsy or facial nerve injury secondary to parotid lesion?

  24. Facial nerve enters parotid gland after it exits the stylomastoid foramen; fibers carrying taste and subserving lacrimation should NOT be affected. However, in malignant lesion, extension of lesion may very well invade nearby nerve branches

  25. Question • Can you name the 4 functional categories of the facial nerve and briefly describe what they do?

  26. Answer • 1) Branchial motor • Muscles of facial expression • Stapedius muscle • 2) Parasympathetic • Lacrimal glands • All salivary glands (e.g. submaxillary, submandibular) except parotid • 3) Visceral sensory (special) • Taste from anterior 2/3 of tongue • 4) General somatic sensory • Sensation from small region near external auditory meatus

  27. Question • With the help of the diagram, can you point out the nerves and ganglia involved in each of the functional categories?

  28. Facial nucleus Facial nerve exits at CPA Traverses internal auditory meatus Turns at genu Exits at stylomastoid foramen Passes through parotid gland Divides into branchial motor branches Branchial motor

  29. Facial nucleus Facial nerve exits at CPA Traverses internal auditory meatus Turns at genu Exits at stylomastoid foramen Passes through parotid gland Divides into branchial motor branches Branchial motor

  30. Superior salivatory nucleus GT petrosal nerve leaves genu Reach the sphenopalatine ganglion post-ganglionic fibers  lacrimal glands Parasympathetic (1)

  31. Superior salivatory nucleus GT petrosal nerve leaves genu Reach the sphenopalatine ganglion post-ganglionic fibers  lacrimal glands Parasympathetic (1)

  32. Superior salivatory nucleus Chorda tympani branches off before the stylomastoid foramen Goes through petrotympanic fissure Joins lingual nerve Submandibular ganglion postganglionic fibers  submandibular and sublingual glands Parasympathetic (2)

  33. Superior salivatory nucleus Chorda tympani branches off before the stylomastoid foramen Goes through petrotympanic fissure Joins lingual nerve Submandibular ganglion postganglionic fibers  submandibular and sublingual glands Parasympathetic (2)

  34. Sensory fibers carrying taste from anterior 2/3 of tongue Cell bodies in geniculate ganglion Synapse onto secondary neurons in the rostral nucleus solitarius Travel via CTT  VPM nucleus of thalamus  cortical taste area (inferior margin of postcentral gyrus, extends into parietal operculum and insula) Visceral sensory (Special)

  35. Sensory fibers carrying taste from anterior 2/3 of tongue Cell bodies in geniculate ganglion Synapse onto secondary neurons in the rostral nucleus solitarius Travel via CTT  VPM nucleus of thalamus  cortical taste area (inferior margin of postcentral gyrus, extends into parietal operculum and insula) Visceral sensory (Special)

  36. Region near external auditory meatus Synpase in spinal trigeminal nucleus General Somatic Sensory

  37. Region near external auditory meatus Synpase in spinal trigeminal nucleus General Somatic Sensory

  38. F/U Imaging • CT neck (compared to Nov 2010) • Significant increase in mass size compared to Nov. • Peripheral enhancement, central area of necrosis • Extension into deep lobe • Possibility of malignant transformation

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