Happy 70 degree weather day!!!! Break out the shorts!!
Go Blue, baby!!! Exclamation points!!!!!
And now to our regularly scheduled program of Daily Sinai Pearls:
55 yo Filipino male with past medical history of Parkinson’s, hypertension and deafness presents with head laceration after mechanical fall, tetanus up to date. No lost of consciousness, seizure activity noted by patient or wife. No vomiting, amnesia. At baseline mental status, AAOx3 and GCS of 15.
During exam you notice a left facial droop that is new to patient’s wife and not noticed by patient. Its been two hours after the fall. Patient otherwise looks well and with no other findings. As those noted above. What is the next best management?
A. Fix the laceration and discharge
B. Consult neurology
C. Get a head ct scan
D. Call stroke code
E. C+D
Indications for CT head in trauma:
By trauma definitions, this patient does not need a head CT. However, because there is a new finding of left facial droop, there is a concern for a possible stroke versus TIA versus other intracranial pathology.
Given that the finding is new, a stroke code should be activated. One can argue that the facial droop may not be new, however, since we are not the patient’s PMD and do not know the patient on a long term basis prior to his arrival, it is best to err on the side of caution given time to PTA is critical.
Conclusion:
Patient obtained a head CT scan that revealed a left sided vestibular schwannoma aka acoustic neuroma. He subsequently underwent successful surgery to remove the neuroma with no complications.
Vestibular schwannoma
– Schwann cell-derived tumor, often from the vestibular portion of the 8th CN
-Rare in childresn except in Neurofibromatosis type 2.
-Risk factors: Loud noise exposure, childhood radiation, parathyroid adenoma, cell phones (controversial)
Presentation:
– 95% have symptomatic cochlear nerve involvement (hearing loss, tinnitus).
– 61% have unsteadiness, fluctuating in severity. Unusual to have true vertigo given slow progression of tumor
– 17% trigeminal nerve (numbness, pain)
– 6% have involvement of the facial nerve as our patient presented
Thanks to Eugene Kim for the morning report from whence this pearl comes.