Episode 379: Neurology VMR – Double Vision for One Day
Feb 14, 2025
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Aye Chan Moe Thant, a physician from Myanmar focused on global neurology, and Valeria Roldan, a recent medical graduate passionate about LGBTQ+ health, dive into the complexities of diagnosing double vision. They tackle a case involving a 73-year-old man with sudden-onset diplopia, exploring differential diagnoses like myasthenia gravis. The conversation also covers the intricacies of one and a half syndrome and the significance of precise clinical observations in neurology. Their insights illuminate the critical connection between eye movements and neurological health.
Understanding the difference between monocular and binocular diplopia is crucial for accurate diagnosis and management of underlying neurological issues.
Comprehensive patient history, including vascular risk factors and prior symptoms, enhances diagnostic accuracy and informs potential treatment paths for diplopia.
Neuroanatomy knowledge, particularly the interaction of cranial nerves within the brainstem, is essential for identifying specific clinical syndromes like 'one-and-a-half syndrome' in neurological practice.
Deep dives
Introduction to Diplopia
The podcast discusses the case of a 73-year-old male presenting with sudden onset of diplopia, or double vision, which raises important diagnostic considerations. Initial assessment differentiates between monocular and binocular diplopia, narrowing down potential causes. Binocular diplopia indicates eye misalignment, potentially due to neurological factors affecting eye movement coordination, often involving cranial nerves three, four, and six. Understanding these distinctions is crucial for directing further investigation and appropriate management.
Exploring Neurological Causes
A thorough evaluation of diplopia includes considering both ophthalmological and neurological factors contributing to the symptoms. Conditions like thyroid disease can affect muscle function around the eyes, while neurologists must explore possible nerve compressions, structural issues, or diseases affecting the brainstem where cranial nerve nuclei reside. Specific care is taken to note the time course of symptoms; sudden onset often suggests vascular causes, such as strokes or aneurysms. This awareness guides clinicians in forming a differential diagnosis and prioritizing urgent interventions.
The Importance of Patient History
Patient history plays a pivotal role in elucidating the etiology of diplopia, particularly regarding vascular risk factors and any previous symptomatology. The podcast emphasizes the necessity of gathering comprehensive details about pre-existing conditions, family history of stroke, and associated symptoms to strengthen diagnostic accuracy. In this case, the lack of headache or other neurological deficits, along with hypertension, supported the hypothesis of a vascular issue leading to acute diplopia. Understanding these nuances can significantly influence management decisions.
Neuroanatomy and Eye Movement Control
The discussion delves into the neuroanatomy governing eye movement, particularly the role of cranial nerves and their interaction within the brainstem. As the podcast highlights, proper eye movement requires coordination between cranial nerves three and six, facilitated by structures like the medial longitudinal fasciculus (MLF). This relationship elucidates why lesions in specific brainstem areas can lead to identifiable clinical syndromes, such as the 'one-and-a-half syndrome,' where patients show distinct movement abnormalities. Recognizing these anatomical pathways is essential for pinpointing the location of neurological lesions.
Diagnosis and Management Considerations
Ultimately, the presented case is diagnosed as a lacunar stroke in the dorsal pons, which correlates with the clinical observations of diplopia and specific eye movement patterns. The podcast underscores the significance of balancing the interpretation of imaging findings with clinical presentation, considering alternative causes like embolism despite a typical lacunar appearance. Clinicians are reminded to maintain a broad differential approach in acute settings, where missing an underlying condition can affect patient outcomes. This highlights the continuous learning integral to clinical practice and neurologists' responsibilities.
Episode description: We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Aye presents a case of double vision to Vale.
Aye Chan Moe Thant ( @AyeThant94 )
Aye is a physician from Myanmar and now working as a clinical research team member at the Department of Neurology, Washington University in Saint Louis. Throughout her career in Myanmar, she worked closely and received training from her mentor neurologist, one of only three neurologists available for the whole upper Myanmar of 23 million population. Witnessing the challenges faced by the patients from underserved areas, she is dedicated to advancing health equity, research, and global neurology. Aye is also very passionate about medical education and has been deeply involved in Clinical Problem Solvers mainly in neurology with the mentor Dr. Aaron Berkowitz. She is going to apply for neurology residency and very excited about the journey ahead!
Valeria Roldan
@valeroldan23
Valeria Roldan was born and raised in Lima, Peru. She recently graduated medical school at Universidad Peruana Cayetano Heredia and is excited to pursue a career in Neurology. She is passionate about LGBTQ+ health, particularly advocating for trans rights, as well as medical education. She would describe herself as an optimist and outside of medicine you probably will find her running or talking about pop culture over a glass of wine.
