7: Clinical ndings that are subtle in .NET Implementation 2d Data Matrix barcode in .NET 7: Clinical ndings that are subtle

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7: Clinical ndings that are subtle use .net data matrix barcodes implementation tocreate datamatrix on .net GS1 Barcode Types Table 7.2 Causes of downbeat nystagmus Idiopathic and fami lial cerebellar degeneration Compressive lesions Chiari malformation foramen magnum meningioma vertebrobasilar dolichoectasia Stroke Demyelinating disease Paraneoplastic syndromes Syringobulbia Trauma Hydrocephalus Metabolic derangements magnesium depletion thiamine de ciency (Wernicke s) Toxins alcohol toluene Anti-convulsants diphenylhydantoin carbamazepine lamotrigine Heat stroke Encephalitis. Table 7.3 Symptoms of Chiari I malformation Headache or neck pa in Ataxia Sensory disturbance Vertigo Oscillopsia Diplopia Syncope Limb weakness Palpitations Tinnitus Dysphagia Dysarthria Apnea. cerebellar structur .NET DataMatrix es through the foramen magnum. Chiari I malformation is the least severe and is limited to downward displacement of the cerebellar tonsils.

Minor degrees of displacement are often asymptomatic. In patients who undergo MR scanning for vague, non-speci c symptoms, the radiographic presence of a Chiari I malformation does not necessarily imply a causal relationship to the patient s symptom(s). Deciding whether or not a Chiari I malformation is symptomatic can, at times, be challenging.

Focal de cits related to brainstem, cerebellar or spinal cord dysfunction can be con dently attributed to the malformation. In patients with non-localizing symptoms such as fatigue and chronic headache, a causal relationship may be more dif cult to establish. Patients with a symptomatic Chiari I malformation usually present in late adolescence to early adulthood.

Cases in childhood are increasingly recognized, however, and patients who present in. mid-life often repo rt that they have always had poor balance and coordination. The most common symptom is headache, usually in the occipital or posterior cervical region. Severe paroxysmal pain may be provoked by a Valsalva maneuver such as coughing, sneezing, laughing or straining, sometimes referred to as cough headache.

Diverse neurologic and systemic symptoms (see Table 7.3) may lead to diagnostic confusion with multiple sclerosis, bromyalgia, dysautonomia and even hysteria. Exercise, particularly activities involving neck extension, can precipitate symptoms related to hindbrain herniation.

Such a history of worsening neurologic symptoms with exercise may be misinterpreted as Uhthoff s phenomenon, as in the patient under discussion, and may further the impression of occult demyelinating disease. While downbeat nystagmus is the most common neuro-ophthalmic manifestation of Chiari syndrome, a variety of ocular motor abnormalities occur in these patients, including other forms of nystagmus (periodic alternating, rebound, see-saw and convergence), as well as other involuntary ocular oscillations (ocular utter and dysmetria) (see Table 7.4).

Patterns of ocular misalignment include esotropia (due to divergence insuf ciency, sixth nerve palsy and convergence spasm), skew deviation and internuclear ophthalmoplegia (see 5, Low cerebellar tonsils). In patients. 7: Clinical ndings that are subtle Table 7.4 Ocular motor abnormalities associated with Chiari I malformation Downbeat nystagmus barcode data matrix for .NET Horizontal nystagmus (primary or on lateral gaze) Periodic alternating nystagmus Rebound nystagmus Positional nystagmus Skew deviation (often alternating) Impaired pursuit Internuclear ophthalmoplegia Comitant esotropia. Farmer with an adduction de cit Case: A 70-year-old .NET ECC200 farmer developed acute onset of horizontal diplopia that was worse on left gaze. There was no pain and no other focal neurologic de cits or recent systemic symptoms.

Examination showed limitation of adduction in the right eye with otherwise full eye movements. There was no ptosis and pupils were isocoric with brisk responses to light stimulation. He was thought to have a right internuclear ophthalmoplegia (INO), most likely due to a brainstem stroke.

An MRI was normal and he was subsequently referred for neuro-ophthalmic consultation. Ocular motor examination con rmed an adduction de cit of the right eye (Figure 7.9A).

Testing of re xation eye movements showed prominent slowing of right medial rectus saccades for large amplitude (20 degree) movements. When the patient was instructed to make small amplitude (5 degree) re xation movements, however, medial rectus saccades. suspected of harbor ing a Chiari I malformation, the neurologic evaluation should particularly address the presence of cerebellar de cits, lower cranial nerve dysfunction, associated syrinx, skeletal anomalies of the cervical spine, scoliosis and evidence of increased intracranial pressure. The natural history of a symptomatic Chiari malformation usually involves slow progression over time. Patients with minimal symptoms may be followed conservatively or treated symptomatically.

De nitive treatment consists of posterior fossa decompression. Success rates vary, depending on the clinical manifestations and the presence of an associated syrinx. Symptoms that are related to tonsillar impaction and increased intracranial pressure (e.

g. headache, neck pain and oscillopsia) tend to respond more favorably to surgery than focal de cits due to brainstem or spinal cord compression. Surgical decompression prevents further progression of neurologic de cits and about half of patients report improvement of symptoms.

. Diagnosis: Downbeat 2d Data Matrix barcode for .NET nystagmus due to Chiari I malformation Tip: Small amplitude nystagmus may be visible only on eccentric gaze or with direct ophthalmoscopy. The presence of downbeat nystagmus directs attention to the cerebellum and craniocervical junction.

. Figure 7.9 Tensilon test in the above 70-year-old man with a pseudo-INO . (A) There is no adduction past midline in the right eye.

(B) Following administration of 6 mg of edrophonium chloride (Tensilon), there is complete reversal of the adduction de cit. In retrospect his previous ptosis, attributed to dermatochalasis, was also myasthenic, now improved with Tensilon..

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