Left facial numbness

1. Left facial numbness Ann Schmidt Oct 2005

2. Patient Presentation • 54 yo female • Left facial swelling, left leg swelling and left arm weakness • Headache

3. Past Medical History • Hypothyroidism • Hx of panic attacks • Postmenopausal • Surgeries - hysterectomy

4. Family history • Father with carcinoid, hypertension and dementia • Mother died of brain aneurysm, also had breast cancer

5. Social history • Owns a large business • Recent family stress • Loss of a friend to breast cancer

6. Exam • 148/94 Pulse 76 temp 97 resp 16 • No sign. Findings • Diag Panic attack

7. Future visits • 7/20 • Review of Urgent care visit. Question of panic attack vs. other etiology. • Set up MRI TIA?

8. Future visits • 7/29 patient presents to the ER with new drooping of left eye lid, numbness of her face No headache, fever or neck pain. Exam noted slight ptosis of right eyelid. • CT scan ordered • Diagnosis Bells palsy Start on Prednisone and Val acyclovir.

9. Future visits • 7/30 Clinic visit – review ER note and MRI.

10. Future visits • 7/30 Clinic visit- review clinic note and MRI • Order MRI/MRA

11. Future visits • MRA results • Neurosurgery consult • CT angio completed

12. Intracranial Aneurysms

13. Intracranial Aneurysms • Goals of this talk include • Review the prevalence of aneurysms • Review the etiology/ pathogenesis of aneurysms • Discuss the treatment of unruptured aneurysms.

14. Intracranial Aneurysms IA • Prevalence • Incidence • Pathogenesis • Heritable connective tissue disorders, autosomal dominant – Ehlers Danlos Syndrome, Neurofibromatosis, Marfans syndrome, Polycystic kidney • Familial

15. Familial aggregation • 1954 Chambers • 1995 reported in J Neurosurgery “Familial aneurismal subarchnoid hemorrhage : a community based study” • Did family members of patients with ruptured aneurysms have an increase risk of developing a SAH

16. Familial trends • 1970-1989 81 patients had SAH • Families contacted and fhx obtained • 76 had complete fhx • 15 had a 1st or 2nd degree relative with SAH • The number observed with a 1st degree was 11 – expected was 2.6 • 4 fold increase risk among 1st degree relatives

17. Study results • Risk may be highest among siblings in the index patient • Earlier age, may be smaller and recur. • Affected siblings are often the same decade of life.

18. Diagnosis • Clinical Presentation • Anterior communicating artery – 34% • Middle cerebral artery- 20% • Posterior communicating artery- 23% • Internal carotid artery 4% • Asymptomatic IC • Most aneurysms never rupture

20. Natural History of Aneurysms • The International Study of Unruptured Intracranial Aneurysms Investigators • In a group of 1449 patients the rate of rupture per year was eleven times higher if the patient had a history of previous rupture • Surgery did not decrease M and M if lesion was less than 10 mm and no previous history of rupture.

21. Neurology 1999 Johnston,Gress • Which unruptured cerebral aneurysms should be treated? A cost utility analysis • For aneurysms >10 mm those producing symptoms by compressing neighboring nerves and brain structures or in patients with a history of SAH from a different aneurysm treatment was cost effective.

22. Task force of the Stroke CouncilAHA 2000 • Recommendations • The treatment for small intracaverous ICA is not generally indicated. • Symptomatic intradural aneurysms of all sizes should be considered for treatment. • Coexisting or remaining aneurysms of all sizes in patients with SAH due to another treated aneurysm carry a higher risk for further hemorrhage. • <10 mm observe, >10 mm consider treatment

23. Management • Aneurysms <10 mm annual rupture .05-2% • Presence of smoking, Fhx Polycystic kidney disease or lupus elevates risk. • Considerable mortality/morbidity with treatment – 3.8%- 15.7% • Quality of life living with an aneurysm