Neurologist
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Anterior ischemic optic neuropathy (AION) is the most common cause of acute optic neuropathy after age 50, but may also occur in younger patients. The diagnosis is clinical and includes painless visual loss associated with a relative afferent pupillary defect and disc edema. In almost all cases, there is an underlying crowded optic nerve with a small cup-to-disc ratio. ⋯ A coagulation workup should also be considered in younger patients. It is essential to rule out giant cell arteritis in all patients over the age of 50 with ischemic optic neuropathies. Posterior ischemic neuropathy (in which the optic nerve is normal acutely) is rare and should be considered a diagnosis of exclusion.
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Review Case Reports
The clinical utility of high resolution magnetic resonance imaging in the diagnosis of giant cell arteritis: a critically appraised topic.
Giant cell arteritis (GCA) is a relatively common form of systemic vasculitis, known for its predisposition to affect extracranial branches of the carotid artery and associated potential for causing visual loss and stroke. Neurologists need to be vigilant for this disorder, diagnose it early, and institute effective corticosteroid therapy. The differential diagnosis can be broad. Unfortunately, all clinical and laboratory features of GCA are limited by either low sensitivity or low specificity. Temporal artery biopsy remains the gold standard, but it has its own limitations. Noninvasive imaging techniques, like magnetic resonance imaging (MRI), may be capable of detecting the occurrence of GCA. ⋯ The specificity and positive LR of high resolution MRI are sufficiently high that a positive MRI combined with other clinical and laboratory data consistent with GCA may be useful in diagnosing GCA. Given the relatively low sensitivity of the test, a negative MRI would not be sufficient to rule out the diagnosis of GCA.
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Extracranial and intracranial internal carotid artery (ICA) dissections following sports-related activities have been reported as a result of blunt traumatic injuries. The incidence of carotid artery dissection in sports is not known. Failure of physicians to suspect a dissection in the context of a minor injury or to obtain a history from the patient can lead to permanent neurologic deficits. ⋯ Pathogenesis of sports-related ICA dissections may be multifactorial. Structural aberrations in the arterial walls and defective connective tissue components are assumed in some patients. Several genes have been shown to be candidates for the connective tissue aberrations. Since sports-related ICA dissection can occur extracranially or intracranially, the combined use of proper diagnostic techniques that provides information on the extracranial and intracranial vessels is recommended. Although the mechanisms and treatment modalities for intracranial and extracranial dissections might be different, the initial steps of evaluation and stabilization should be standardized for both. There is no randomized controlled study for the best treatment or management of ICA dissection.
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Ischemic stroke and transient ischemic attack can be difficult to diagnose clinically, and both acute and preventive therapies carry some risk. Serum biomarkers could increase diagnostic certainty by helping to distinguish cerebral ischemia from common mimics such as focal seizure, complicated migraine, and psychogenic spells. Biomarkers could also identify patients at high risk for future vascular events, which would aid in management decisions. ⋯ Large series examining many candidate molecules will be needed to find valid biomarkers, and this should be followed by use in future intervention trials to prove their utility.
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Case Reports Comparative Study
Establishing a diagnosis of benign paroxysmal positional vertigo through the dix-hallpike and side-lying maneuvers: a critically appraised topic.
Many patients consult neurologists because of vertigo. Benign paroxysmal positional vertigo (BBPV) is one of the most common types of vertigo. Although the clinical presentation of this common condition is straightforward, the diagnosis and diagnostic maneuvers can be challenging. ⋯ The Dix-Hallpike test is the standard from which the diagnosis of posterior semicircular canal BPPV is made. Hence evaluations of its diagnostic test properties and utility are challenging. For patients unable to move into the Dix-Hallpike test positions, alternative tests such as the side-lying test can be attempted. These modifications, however, are rarely necessary.