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Anisocoria

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121. Horner Syndrome (Overview)

and life-threatening disorder. Careful direction of the history to rule out such life-threatening disorders is vital. Given that malignancy is a prominent feature of recently diagnosed preganglionic Horner syndrome, patients may avoid an unnecessary extensive workup for carcinoma if the lesion can be shown to be old or long-standing. To prove that a lesion is long-standing, inspect old photographs of the patient that might show ptosis or anisocoria. If the affected iris is blue and the other is brown (...) of the sympathetic interruption, because of the absence of endogenous norepinephrine in the synapse. For optimal accuracy, test results should be evaluated 30 minutes or longer after cocaine is administered. The maximal response is seen 40-60 minutes after instillation of the drops. Postcocaine anisocoria greater than 0.8 mm is sufficient to diagnose Horner syndrome. The disadvantages of the topical cocaine test are as follows: The drops are difficult to obtain because they must be made at a compounding pharmacy

2014 eMedicine.com

122. Epilepsia Partialis Continua (Treatment)

%) - Tetraparesis (4%), hemiparesis (23.3%), monoparesis (13.3%), oculomotor paresis (0.7%), facial paresis (10%), hypoglossal paresis (1.9%), soft palate paresis (0-3%) Sensory deficit (21%) - Hemihypoesthesia and hemianesthesia (9.7%), monohypoesthesia and monoanesthesia (4.4%), deep sensation (3.6%), stereognosis (3.3%) Anisocoria (1%) Conjugate deviation of eyes (1%) Homonymous hemianopsia (5%) Aphasia (14%) - Motor (8.3%), sensory (2.5%), amnestic (2.6%) Apraxia (1%) Alexia (2%) Neurological symptoms

2014 eMedicine.com

123. Epidural Hematoma (Treatment)

, Polat G, Gurel I. Posterior fossa epidural hematomas: observations on a series of 73 cases. Neurosurg Rev . 1999. 22(1):34-40. . Cohen JE, Montero A, Israel ZH. Prognosis and clinical relevance of anisocoria-craniotomy latency for epidural hematoma in comatose patients. J Trauma . 1996 Jul. 41(1):120-2. . de Andrade AF, Figueiredo EG, Caldas JG, Paiva WS, De Amorim RL, Puglia P, et al. Intracranial vascular lesions associated with small epidural hematomas. Neurosurgery . 2008 Feb. 62(2):416-20

2014 eMedicine.com

124. Oculomotor Nerve Palsy (Follow-up)

palsies. Ann Neurol . 1983 Dec. 14 (6):696-7. . Raja IA. Aneurysm-induced third nerve palsy. J Neurosurg . 1972 May. 36 (5):548-51. . BOTTERELL EH, LLOYD LA, HOFFMAN HJ. Oculomotor palsy due to supraclinoid internal carotid artery berry aneurysm. A long-term study of the results of surgical treatments on the recovery of third-nerve function. Am J Ophthalmol . 1962 Oct. 54:609-16. . Dhume KU, Paul KE. Incidence of pupillary involvement, course of anisocoria and ophthalmoplegia in diabetic oculomotor

2014 eMedicine.com

125. Neurosyphilis (Follow-up)

proprioception, loss of vibratory sense, otosclerosis, vertigo, sensory ataxia, chorioretinitis) - 48% Pupillary changes (anisocoria, Argyll Robertson pupils, skew deviation) - 43% Cranial neuropathy - 36% Dementia, mania, or paranoia - 35% Romberg sign - 24% Charcot joint - 13% Hypotonia - 10% Optic atrophy 7% Neurosyphilis is divided into 2 general categories: (1) early involvement of the CNS limited to the meninges and (2) parenchymal involvement. The 6 delineated groups are as follows: Asymptomatic Acute

2014 eMedicine.com

126. Neurological History and Physical Examination (Follow-up)

error of metabolism typically associated with mental retardation (usually severe) and intimal thickening and necrosis of the media of blood vessels, resulting in strokes and coronary artery disease. See the image below. Pes cavus deformity can be associated with many conditions including spina bifida, other spinal dysraphisms, and homocystinuria. Ancillary Signs Anisocoria This refers to pupillary asymmetry, which may result from sympathetic or parasympathetic dysfunction. Sympathetic dysfunction

2014 eMedicine.com

127. Epilepsia Partialis Continua (Follow-up)

%) - Tetraparesis (4%), hemiparesis (23.3%), monoparesis (13.3%), oculomotor paresis (0.7%), facial paresis (10%), hypoglossal paresis (1.9%), soft palate paresis (0-3%) Sensory deficit (21%) - Hemihypoesthesia and hemianesthesia (9.7%), monohypoesthesia and monoanesthesia (4.4%), deep sensation (3.6%), stereognosis (3.3%) Anisocoria (1%) Conjugate deviation of eyes (1%) Homonymous hemianopsia (5%) Aphasia (14%) - Motor (8.3%), sensory (2.5%), amnestic (2.6%) Apraxia (1%) Alexia (2%) Neurological symptoms

2014 eMedicine.com

128. Epidural Hematoma (Follow-up)

, Polat G, Gurel I. Posterior fossa epidural hematomas: observations on a series of 73 cases. Neurosurg Rev . 1999. 22(1):34-40. . Cohen JE, Montero A, Israel ZH. Prognosis and clinical relevance of anisocoria-craniotomy latency for epidural hematoma in comatose patients. J Trauma . 1996 Jul. 41(1):120-2. . de Andrade AF, Figueiredo EG, Caldas JG, Paiva WS, De Amorim RL, Puglia P, et al. Intracranial vascular lesions associated with small epidural hematomas. Neurosurgery . 2008 Feb. 62(2):416-20

2014 eMedicine.com

129. Sports Physicals (Follow-up)

clearance without intervention for any person with visual acuity of 20/40 or better using both eyes. Skin: Certain sports, such as wrestling, disqualify athletes who have infectious dermatoses, which include impetigo, herpes, and forms of tinea. Other conditions (eg, acne, scabies, nevi) can be detected, and the athlete should be counseled in such cases. Eyes: Pupil reactivity and anisocoria should be noted. Knowledge of preexisting abnormalities can be useful information at a later time in case (...) reactions, as with insect bites History of loss or dysfunction of 1 of a pair of organs History of chronic illness requiring regular physician intervention History of drastic weight change For females only – First menstrual period, menstrual irregularity, last menstrual period Parental signature on history forms for minors A focused physical examination should emphasize the following: Vital signs (eg, height, weight, BP) Visual acuity Infectious dermatoses Anisocoria Wheezing Heart murmurs or irregular

2014 eMedicine.com

130. Horner Syndrome (Follow-up)

and life-threatening disorder. Careful direction of the history to rule out such life-threatening disorders is vital. Given that malignancy is a prominent feature of recently diagnosed preganglionic Horner syndrome, patients may avoid an unnecessary extensive workup for carcinoma if the lesion can be shown to be old or long-standing. To prove that a lesion is long-standing, inspect old photographs of the patient that might show ptosis or anisocoria. If the affected iris is blue and the other is brown (...) of the sympathetic interruption, because of the absence of endogenous norepinephrine in the synapse. For optimal accuracy, test results should be evaluated 30 minutes or longer after cocaine is administered. The maximal response is seen 40-60 minutes after instillation of the drops. Postcocaine anisocoria greater than 0.8 mm is sufficient to diagnose Horner syndrome. The disadvantages of the topical cocaine test are as follows: The drops are difficult to obtain because they must be made at a compounding pharmacy

2014 eMedicine.com

131. Horner Syndrome (Follow-up)

and life-threatening disorder. Careful direction of the history to rule out such life-threatening disorders is vital. Given that malignancy is a prominent feature of recently diagnosed preganglionic Horner syndrome, patients may avoid an unnecessary extensive workup for carcinoma if the lesion can be shown to be old or long-standing. To prove that a lesion is long-standing, inspect old photographs of the patient that might show ptosis or anisocoria. If the affected iris is blue and the other is brown (...) of the sympathetic interruption, because of the absence of endogenous norepinephrine in the synapse. For optimal accuracy, test results should be evaluated 30 minutes or longer after cocaine is administered. The maximal response is seen 40-60 minutes after instillation of the drops. Postcocaine anisocoria greater than 0.8 mm is sufficient to diagnose Horner syndrome. The disadvantages of the topical cocaine test are as follows: The drops are difficult to obtain because they must be made at a compounding pharmacy

2014 eMedicine.com

132. Horner Syndrome (Diagnosis)

and life-threatening disorder. Careful direction of the history to rule out such life-threatening disorders is vital. Given that malignancy is a prominent feature of recently diagnosed preganglionic Horner syndrome, patients may avoid an unnecessary extensive workup for carcinoma if the lesion can be shown to be old or long-standing. To prove that a lesion is long-standing, inspect old photographs of the patient that might show ptosis or anisocoria. If the affected iris is blue and the other is brown (...) of the sympathetic interruption, because of the absence of endogenous norepinephrine in the synapse. For optimal accuracy, test results should be evaluated 30 minutes or longer after cocaine is administered. The maximal response is seen 40-60 minutes after instillation of the drops. Postcocaine anisocoria greater than 0.8 mm is sufficient to diagnose Horner syndrome. The disadvantages of the topical cocaine test are as follows: The drops are difficult to obtain because they must be made at a compounding pharmacy

2014 eMedicine.com

133. Headache, Children (Diagnosis)

neurologic deficits, such as aphasia, anisocoria, and memory deficits, may also be seen. Benign paroxysmal torticollis of infancy is characterized by episodes of a head tilt, and benign paroxysmal vertigo of childhood is characterized by recurrent episodes of vertigo and ataxia. The torticollis typically occurs during the first year, whereas the vertigo occurs in young children (usually aged 2-3 years). Cyclic vomiting and recurrent abdominal pain frequently are considered migraine variants. Before

2014 eMedicine.com

134. Epidural Hematoma (Follow-up)

of injured cells. Phenytoin reduces the incidence of early posttraumatic seizures, although it does not affect late-onset seizures or the development of a persistent seizure disorder. In a small case series, ED skull trephination before transfer of patients with CT-proven epidural hematoma (EDH) and anisocoria resulted in uniformly good outcomes without complications. [ ] Time to relief of intracranial pressure was significantly shorter with trephination than without. Several treatment guidelines

2014 eMedicine Emergency Medicine

135. Neurosyphilis (Diagnosis)

proprioception, loss of vibratory sense, otosclerosis, vertigo, sensory ataxia, chorioretinitis) - 48% Pupillary changes (anisocoria, Argyll Robertson pupils, skew deviation) - 43% Cranial neuropathy - 36% Dementia, mania, or paranoia - 35% Romberg sign - 24% Charcot joint - 13% Hypotonia - 10% Optic atrophy 7% Neurosyphilis is divided into 2 general categories: (1) early involvement of the CNS limited to the meninges and (2) parenchymal involvement. The 6 delineated groups are as follows: Asymptomatic Acute

2014 eMedicine.com

136. Neurological History and Physical Examination (Diagnosis)

error of metabolism typically associated with mental retardation (usually severe) and intimal thickening and necrosis of the media of blood vessels, resulting in strokes and coronary artery disease. See the image below. Pes cavus deformity can be associated with many conditions including spina bifida, other spinal dysraphisms, and homocystinuria. Ancillary Signs Anisocoria This refers to pupillary asymmetry, which may result from sympathetic or parasympathetic dysfunction. Sympathetic dysfunction

2014 eMedicine.com

137. Oculomotor Nerve Palsy (Diagnosis)

with the other eye. The primary symptom is caused by misalignment of the visual axes, and the pattern of image separation is the key to diagnosing which particular ocular motor cranial nerve (and extraocular muscle) is involved. With unilateral third cranial nerve palsy (ie, oculomotor nerve palsy), the involved eye usually is deviated "down and out" (ie, infraducted and abducted), and there may be partial or complete ptosis. In addition, pupillary dilatation can cause anisocoria (greater in the light (...) . 36 (5):548-51. . BOTTERELL EH, LLOYD LA, HOFFMAN HJ. Oculomotor palsy due to supraclinoid internal carotid artery berry aneurysm. A long-term study of the results of surgical treatments on the recovery of third-nerve function. Am J Ophthalmol . 1962 Oct. 54:609-16. . Dhume KU, Paul KE. Incidence of pupillary involvement, course of anisocoria and ophthalmoplegia in diabetic oculomotor nerve palsy. Indian J Ophthalmol . 2013 Jan-Feb. 61 (1):13-7. . Jacobson DM. Pupil involvement in patients

2014 eMedicine.com

138. Idiopathic Orthostatic Hypotension and other Autonomic Failure Syndromes (Diagnosis)

the following: Constipation Nausea Urinary retention Erectile dysfunction Pure autonomic failure More specifically, symptoms of PAF include the following: Orthostatic hypotension: With an inappropriate lack of compensatory increase in heart rate with standing Gastroparesis: Associated with nausea or constipation Urinary retention: May cause bladder distention Decreased sweating: Manifesting as heat or exercise intolerance Ophthalmologic manifestations: Including ptosis, anisocoria, Horner syndrome

2014 eMedicine.com

139. Sports Physicals (Diagnosis)

clearance without intervention for any person with visual acuity of 20/40 or better using both eyes. Skin: Certain sports, such as wrestling, disqualify athletes who have infectious dermatoses, which include impetigo, herpes, and forms of tinea. Other conditions (eg, acne, scabies, nevi) can be detected, and the athlete should be counseled in such cases. Eyes: Pupil reactivity and anisocoria should be noted. Knowledge of preexisting abnormalities can be useful information at a later time in case (...) reactions, as with insect bites History of loss or dysfunction of 1 of a pair of organs History of chronic illness requiring regular physician intervention History of drastic weight change For females only – First menstrual period, menstrual irregularity, last menstrual period Parental signature on history forms for minors A focused physical examination should emphasize the following: Vital signs (eg, height, weight, BP) Visual acuity Infectious dermatoses Anisocoria Wheezing Heart murmurs or irregular

2014 eMedicine.com

140. Headache: Pediatric Perspective (Diagnosis)

neurologic deficits, such as aphasia, anisocoria, and memory deficits, may also be seen. Benign paroxysmal torticollis of infancy is characterized by episodes of a head tilt, and benign paroxysmal vertigo of childhood is characterized by recurrent episodes of vertigo and ataxia. The torticollis typically occurs during the first year, whereas the vertigo occurs in young children (usually aged 2-3 years). Cyclic vomiting and recurrent abdominal pain frequently are considered migraine variants. Before

2014 eMedicine.com

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