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A case of
bilateral visual loss
Dr. Manoj
Kumar Majhi,
Dept. Neurosurgery,
Apollo Hospitals, Chennai, India.
A 38
years old right handed Bangladeshi lady came to us with the
complaints of
1.
Sudden diminution of vision in both eyes, since
last 6 months.
2.
Difficulty in balancing while walking and tendency to fall
towards left side, since last 6 months.
3.
Numbness over left half of face since 4 months.
4.
Heaviness of head on and off.
Patient was apparently
alright 6 months ago. In the 3rd trimester of her last
pregnancy about 6 months back she had sudden
deterioration of her vision in both eyes and also
developed unsteadiness of gait which was gradual
in onset. After the delivery she
didn't improve vision wise.
There
was no history of any redness, excessive lacrimation, abnormal
protrusion of the eyes or retro orbital pain.
no history of any double vision, headache,
swelling of extremities altered sensorium or seizures.
However, her hospital
records revealed that she has had antihypertensive medications (?pre
eclampsia) in the past.
She
noticed imbalance while walking with a tendency to fall towards the
left side, which was gradual in onset and progressive in
course. There was no associated with any giddiness or
vertigo.
She
was able to appreciate the texture of the floor.
There
was no difficulty in walking in low light.
She
was able to take her food to the mouth.
There
was no history of any change in voice or cough during drinking
liquids.
The numbness over
the left half of face started about 4 months ago. It
was gradually worsening.
It was
constant, and not precipitated by cold air, water or touch.
It was
not associated with facial weakness or difficulty in closing the eye
or pain.
She
was able to appreciate heat and cold, but not as much as
on right half of face.
There was
no
difficulty in chewing the food.
Her
hearing in the left ear started reducing at the same time. No
history of any ringing sensation in the ear.
On and
off, she used to complain of heaviness of head.
There was
no history of
vomiting, seizure, loss of conscious, or weakness or
sensory blunting in the limbs.
There was
no speech
dysfunction or sphincteric dysfunction.
She
was not a known diabetic or asthmatic. There was no history of any
other major systemic illness.
There
was no history of such complaints in her near relatives.
On examination, she was
conscious,
alert and oriented, with normal higher intellectual
functions.
Her
pupills were equal and reacting to light, and ocular movements were
full.
Her
fundi revealed blurred disc margins bilaterally.
Visual
acuity was 2/36 bilaterally.
Reduced sensation in
all the 3 divisions of left fifth nerve, with no motor
involvement.
There was
sensorineural deafness
in left ear.
Other
cranial nerve functions were normal.
Long tract
signs were normal with normal DTRs, and down going plantars
bilaterally.
Cerebellar signs -
Minimal finger nose in-coordination on left side.
Gait -
Sways towards left side while walking.
Rombergs sign -
Negative.
There
was no neck stiffness.
Skull
and spine - NAD.
MRI
brain (plain and contrast.) revealed thickening of the
intracranial portion of both optic nerves and chaisma.
Two
enhancing lesionin the cerebellum, one in the left
cerebellar vermis and pons junction.
The left
cerebellar hemispheric lesion was predominantly cystic.
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| bilateral optic nerve thickening |
enhancing lesion at the chiasma |
multiple enhancing
cerebellar
lesions |
Routine ultrasound
abdomen had revealed a mass lesion in the head of pancreas. So a
diagnosis of possible carcinoma of the head of pancreas with
metastasis to brain was thought of CT guided biopsy of
the lesion done. This came as non contributory.
At
this stage patient was referred to us.
As her
neurological status was deteriorating rapidly, a biopsy of the
brain lesions was planned for further management.
We had
the following differential diagnosis in our mind at that
stage
1.
Carcinoma pancreas with multiple brain metastases.
2.
Multifocal tuberculosis with infiltrative optic
neuropathy.
3.
Lymphoma
4.
Multicentric glioma
5.
Neurofibromatosis-optic Nerve glioma with cerebellar
astrocytoma
6.
Multiple infarcts as a complication of pre
eclampsia.
She underwent a
left suboccipital craniectomy. The dura was lax.
The
peripheral lesion of the left cerebellar
hemisphere was tapped. Thick dirty yellow colored
fluid came out. The solid portion of the
tumor was soft and
relatively vascular.
Macrosopic total
excision of the lesion done.
The
histopathologic report was as grade III - Grade IV astrocytoma.
Multifocal gliomas can
be categorized as
'Connected'
(microscopic parenchymal connection or satellite lesions) or
'Disconnected' (no
detectable microscopic connection)' and as
'Synchronous' (if
present on initial presentation) or
'Metachronous' (if
developed during follow-up).
They
are termed
'multiple', if
present at the same time but are separate spatially, and
'multicentric', if
they are independent spatially as well as
temporarily.
Although
multiple astrocytomas may arise independently within a single
patient, the majority are probably represent the presence of a
single neoplastic disease.
Reportedly,
the multifocality occurs in 2.3% bto 9.1% of cases.
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