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59yo male with pulsatile tinnitus, progressive dementia, hypobulia, Parkinsonism and right hemiparesis developing over 10 years, worsening in the preceding 3 months.
Dural arteriovenous fistula is an uncommon but treatable cause of dementia, but can manifest clinically in a myriad of ways, the most common of which include pulsatile tinnitus, intracerebral haemorrhage (parenchymal, subarachnoid or subdural), dementia, focal neurological deficit, visual disturbance, headache and seizure. The most important feature to recognise in the diagnosis of DAVF is the presence or absence of retrograde flow into cortical veins (retrograde leptomeningeal venous drainage), because this indicates a significant risk of haemorrhage ranging from 5-40%, depending on the type and location of the shunt. This patient was treated with embolisation in two stages and, by 2 months post-treatment, had returned to his premorbid status with only very mild impairment of short term memory. Cerumen impaction is caused by abnormal self cleansing mechanism of the skin lining external canal in these patients. 30 years old male patient came with complaints of foul smelling discharge from his right ear - 10 days. Otoscopy picture shows a tongue of granualtion tissue over the inferior quadrant of the ear drum. 7th cranial nerve and 8th cranial nerve functions can be tested by performing this investigation. Blow-Out Fracture Blow out fracture, white eye ? In children, might cause muscle entrapment and ischemia, ? Risk of bradycardia.


Herpes zoster ophthalmicus Herpes zoster involving the ophthalmic division of cranial nerve V (V1) is more likely to have ocular involvements if the tip of the nose is involved, Hutchinson sign Complications : Keratitis, corneal perforation, scar Iritsis, secondary glaucoma, cataract, Cranial nerve palsy …. Herpes Zoster Ophthalmicus Management ? Oral antiviral ? In cases of conjunctival involvement erythromycin ? Refer to ophthalmologist ? Steroid should be prescribed by ophthalmologist, if needed. Cornea Tips ? Keratoconus ? Bilateral thinning and bulging of the cornea ? Associated with down’s syndrome, atopy, CL use?(Toronto notes) ? irregular astigmatism, scar, stromal edema ? Rx: spectacle, CL, cross linking, penetrating keratoplasty, ? Kayser-Fleischer ring ? Wilson disease ? Arcus senile ? Hypercholesterolemia if under 40 yrs.
Pterygium ? It is a benign growth of fibro-vascular triangular tissue over the cornea ? Sun exposure ? More common on the nasal side of the conjunctiva ? In an early stage into maybe managed with use of artificial tears and topical vasoconstrictors ? Excision in chronic inflammation, cosmesis, threat to visual axis, ? 5% recurrence rate if with conjunctival autograft.
Subconjunctival hemorrhage Asymptomatic Can be associated with HTN, or vasculopathy, or anticoagulant therapy, specially in recurrent one Resolve spontaneously in 2-3 weeks No need for stopping NSAID or Systemic anticoagulant for resolution.. Acute angel closure glaucoma What is your next plan: ? Refer to ophthalmologist for laser iridotomy What would be the next plan ? Laser iridotomy ? Aqueous suppression with BACH ? Beta-blocker. Temporal Arteritis Immediately ESR, CRP, A low or normal sedimentation rate does not exclude the diagnoses The most common cranial nerve paralysis that occur involves the third cranial nerve. Physical examination revealed a pulse-synchronous bruit over his posterior scalp and left postauricular region, and bilateral papilloedema. The condition is acquired, and is thought to result from aberrant recanalisation of a previously thrombosed dural sinus (not unlike cavernous transformation of the portal vein following previous thrombosis).


Glomus jugulare - associated with pulsatile tinnitus, conductive deafness, positive Brown's sign. To identify those patients who require abdominal ultrasound Wang's criteria should be used. It is classically seen in bone conduction audiogram of patients as a dip centered around 2000Hz.
MRI (not shown) demonstrated restricted diffusion in the basal ganglia and multiple distended cortical veins over both hemispheres and in the posterior fossa suggestive of a high-flow arteriovenous shunt.
The prevalence of the disease is estimated at between 2 and 4 per 1,000,000 in the Western Hemisphere.
Selective angiography, left external carotid artery shows typical features of a dural arteriovenous fistula of the transverse sinus, with multiple distended branches of the occipital, posterior auricular, ascending pharyngeal and middle meningeal arteries connecting directly to the mid-transverse sinus.



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Comments to «Pulsatile tinnitus visual disturbances often»

  1. azal writes:
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