Episode 339: Neurology VMR – left facial numbness for 5 days
Jun 8, 2024
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Dr. Aaron Berkowitz, a neurologist, joins the discussion on left facial numbness in a young woman. The hosts explore the differential diagnosis of conditions like multiple sclerosis and trigeminal neuropathy. They discuss the importance of understanding subjective descriptions, conducting a thorough neurological examination, and differentiating between central and peripheral nystagmus patterns. The podcast also covers the use of MRI imaging in identifying lesions and tumors like vestibular schwannoma, as well as treatment options for benign tumors causing facial numbness.
Consider subacute onset for non-vascular causes like Bell's Palsy.
Localized mass causing cranial nerve symptoms requires surgical intervention.
Collaborative neurology-neurosurgery approach crucial in managing cerebellopontine angle tumors.
Deep dives
Summary of the Patient's Presentation
A 32-year-old female presents with left facial numbness for five days. During the discussion, subacute onset is noted, ruling out an immediate vascular cause. Differential diagnoses include Bell's Palsy triggered by an infection, migraines, and episodes of multiple sclerosis. Consideration is given to trigeminal neuralgia and peripheral neuropathy. Detailed examination reveals lower motor neuron facial palsy, reduced sensation, and left hearing loss.
Localization and Time Course Analysis
The discussion shifts to localization and time course assessment. A distinction is made between acute and hyper-acute onset to differentiate potential vascular events and immune-mediated processes like multiple sclerosis. The possibility of a demyelinating plaque causing facial numbness is considered. Further neurologic examination reveals findings suggesting multiple cranial neuropathies.
MRI Findings and Diagnosis Confirmation
MRI scan without contrast reveals a well-capsulated mass pressing into the brainstem and cerebellum, confirming a cerebellopontine angle tumor. The tumor's impact on the facial nerve and other structures is evident. This diagnosis aligns with the clinical presentation, including facial numbness, hearing loss, and other cranial nerve findings.
Treatment Plan and Surgical Intervention
Surgical intervention is recommended due to the mass effect and progressive symptoms. The patient undergoes surgery in Bangkok, involving a retrosigmoid approach with intraoperative neuromonitoring. Post-surgery, improvements in gait and facial numbness are noted, although facial palsy and reduced hearing worsen. Physical therapy is initiated to address the residual facial weakness.
Final Outcome and Follow-Up
Following the tumor removal, the patient experiences varying improvements and setbacks in symptoms. While certain aspects show progress, facial weakness and hearing function demonstrate challenges post-operatively. The need for ongoing management and rehabilitative measures is highlighted.
Conclusion and Reflective Notes
The complex case underscores the importance of thorough assessment, imaging, and multidisciplinary care in managing cerebellopontine angle tumors. The collaborative approach between neurology and neurosurgery is crucial for accurate diagnosis, treatment planning, and post-operative care to address the diverse neurological manifestations associated with such neoplasms.
Episode 339: Neurology VMR – left facial numbness for 5 days
We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Aye presents a case of left facial numbness for 5 days to Andrea and Sridhara.
Aye graduated from University of Medicine, Mandalay, Myanmar, and has been working with her mentor neurologist, one of only three neurologists covering the Upper Myanmar region of 23 million population. Through her experiences witnessing the challenges faced by patients in underserved areas and hearing their stories, Aye is dedicated to advancing health equity, global health initiatives, and various aspects of neurology, both in clinical practice and medical education. She is going to apply for a neurology residency program this year. Outside of work, she spends time playing piano, jogging along trails, and listening to music.
Andrea Mendez Colmenares
@andreamendez92
Andrea Mendez Colmenares is a Venezuelan medical doctor and cognitive neuroscientist. She recently completed her PhD and postdoctoral fellowship in Colorado and will begin her neurology residency at Duke University in North Carolina in the summer of 2024. Outside of medicine, she enjoys playing guitar, discovering new coffee shops, hiking, and climbing mountains.
Sridhara Yaddanapudi
@syaddana_neuro
Sridhara is a board-certified internist, neurologist, vascular neurologist, and hypertension specialist. Currently, he holds the position of Clinical Assistant Professor at Thomas Jefferson University Hospital and serves as the Director of Neurology for Jefferson New Jersey. As a medical professional, he is passionate about case-based learning, clinical reasoning, and teaching decision-making while avoiding the pitfalls of heuristics. His goal is to bridge the ever-growing gap between neurology and internal medicine, an area in which he has a keen interest.