SAQs Daniel Normansell,1 Preeti Dalawari,1 Timothy Jang2 1
Division of Emergency Medicine, St Louis University School of Medicine, St Louis, Missouri, USA 2 Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA Correspondence to Dr Timothy Jang, Department of Emergency Medicine, Harbor-UCLA Medical Center, 1000 W. Carson St., Torrance, CA 90509, USA; [email protected]
To cite Normansell D, Dalawari P, Jang T. Emerg Med J 2014;31:1027–1028.
Contributors All authors contributed to the write-up of this case. DN and PD saw the patient initially. TJ assisted in the write-up and content.
1
Emerg Med J 2014;31:1027–1028. doi:10.1136/emermed-2014-203806
REFERENCES 2
Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
3 4
Shields D, Robinson P, Crowley TP. Iliopsoas abscess—a review and update on the literature. Int J Surg 2012;10:466–9. Takada T, Terada K, Kajiwara H, et al. Imaging-negative psoas abscess. Lancet 2014;383:280. Taiwo B. Psoas abscess: primer for the internist. South Med J 2001;94:2–5. Hsieh MS, Huang SC, Lohel W, et al. Features and treatment modality of iliopsoas abscess and its outcome: a 6-year hospital-based study. BMC Infect Dis 2013;13:578.
IMAGES IN EMERGENCY MEDICINE
An unusual gaze after head injury A 51-year-old woman sustained a head injury with brief loss of consciousness during a car accident. She was immediately taken to our emergency department and presented with severe headache, dizziness and diplopia. On physical examination, she showed extraocular movements with failed adduction of the right eye while looking left (figure 1) but normal gaze while looking right. The adduction of both eyes on convergence test was intact (figure 2). Orbital and skull fractures were excluded by CT scan. Subsequent brain MRI demonstrated an acute infarct of the right medial longitudinal fasciculus (MLF; figure 3). Internuclear ophthalmoplegia (INO) is an impaired conjugate gaze characterised by adduction paresis of the affected eye and abduction nystagmus of the contralateral eye, leading to horizontal diplopia. It usually occurs in multiple sclerosis or cerebrovascular disease, but is extremely rare after head injury.1 The pathogenesis might be associated with shearing forces from head angular acceleration/deceleration, which damages MLF nerve fibres or impairs circulation of perforating branches of the basilar artery, contributing to local MLF infarction.2 INO often persists for months, and comorbid neurological deficits might be correlated with a worse prognosis for the resolution of diplopia.3 Our patient received conservative treatment and recovered within 3 days. 1
2
3
Wen-Cheng Liu, Chih-Weim Hsiang, Chang-Hung Hsu
1 Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Figure 3 Brain MRI with diffusion-weighted imaging showing a marked hyperintensity in the right dorsomedial pontine tegmentum (arrowhead), indicating an acute infarct in the right medial longitudinal fasciculus. 2
Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
3
Correspondence to Dr Chang-Hung Hsu, Department of Neurology, Tri-Service General Hospital and National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan; [email protected] Contributors C-HH planned the study. C-WH interpreted and edited all images. W-CL wrote and submitted the study. All authors participated in the work. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed.
Figure 1 Inability to adduct the right eye on looking towards the left.
To cite Liu W-C, Hsiang C-W, Hsu C-H. Emerg Med J 2014;31:1028. Accepted 20 December 2013 Published Online First 7 January 2014 Emerg Med J 2014;31:1028. doi:10.1136/emermed-2013-203462
REFERENCES 1 2 3
Figure 2 Preserved adduction of both eyes on convergence test. 1028
Keane JR. Internuclear ophthalmoplegia: unusual causes in 114 of 410 patients. Arch Neurol 2005;62:714–17. Hardman JM. The pathology of traumatic brain injuries. Adv Neurol 1979;22:15–50. Eggenberger E, Golnik K, Lee A, et al. Prognosis of ischemic internuclear ophthalmoplegia. Ophthalmology 2002;109:1676–8.
Normansell D, et al. Emerg Med J December 2014 Vol 31 No 12
Division of Emergency Medicine, St Louis University School of Medicine, St Louis, Missouri, USA 2 Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA Correspondence to Dr Timothy Jang, Department of Emergency Medicine, Harbor-UCLA Medical Center, 1000 W. Carson St., Torrance, CA 90509, USA; [email protected]
To cite Normansell D, Dalawari P, Jang T. Emerg Med J 2014;31:1027–1028.
Contributors All authors contributed to the write-up of this case. DN and PD saw the patient initially. TJ assisted in the write-up and content.
1
Emerg Med J 2014;31:1027–1028. doi:10.1136/emermed-2014-203806
REFERENCES 2
Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
3 4
Shields D, Robinson P, Crowley TP. Iliopsoas abscess—a review and update on the literature. Int J Surg 2012;10:466–9. Takada T, Terada K, Kajiwara H, et al. Imaging-negative psoas abscess. Lancet 2014;383:280. Taiwo B. Psoas abscess: primer for the internist. South Med J 2001;94:2–5. Hsieh MS, Huang SC, Lohel W, et al. Features and treatment modality of iliopsoas abscess and its outcome: a 6-year hospital-based study. BMC Infect Dis 2013;13:578.
IMAGES IN EMERGENCY MEDICINE
An unusual gaze after head injury A 51-year-old woman sustained a head injury with brief loss of consciousness during a car accident. She was immediately taken to our emergency department and presented with severe headache, dizziness and diplopia. On physical examination, she showed extraocular movements with failed adduction of the right eye while looking left (figure 1) but normal gaze while looking right. The adduction of both eyes on convergence test was intact (figure 2). Orbital and skull fractures were excluded by CT scan. Subsequent brain MRI demonstrated an acute infarct of the right medial longitudinal fasciculus (MLF; figure 3). Internuclear ophthalmoplegia (INO) is an impaired conjugate gaze characterised by adduction paresis of the affected eye and abduction nystagmus of the contralateral eye, leading to horizontal diplopia. It usually occurs in multiple sclerosis or cerebrovascular disease, but is extremely rare after head injury.1 The pathogenesis might be associated with shearing forces from head angular acceleration/deceleration, which damages MLF nerve fibres or impairs circulation of perforating branches of the basilar artery, contributing to local MLF infarction.2 INO often persists for months, and comorbid neurological deficits might be correlated with a worse prognosis for the resolution of diplopia.3 Our patient received conservative treatment and recovered within 3 days. 1
2
3
Wen-Cheng Liu, Chih-Weim Hsiang, Chang-Hung Hsu
1 Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Figure 3 Brain MRI with diffusion-weighted imaging showing a marked hyperintensity in the right dorsomedial pontine tegmentum (arrowhead), indicating an acute infarct in the right medial longitudinal fasciculus. 2
Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
3
Correspondence to Dr Chang-Hung Hsu, Department of Neurology, Tri-Service General Hospital and National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan; [email protected] Contributors C-HH planned the study. C-WH interpreted and edited all images. W-CL wrote and submitted the study. All authors participated in the work. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed.
Figure 1 Inability to adduct the right eye on looking towards the left.
To cite Liu W-C, Hsiang C-W, Hsu C-H. Emerg Med J 2014;31:1028. Accepted 20 December 2013 Published Online First 7 January 2014 Emerg Med J 2014;31:1028. doi:10.1136/emermed-2013-203462
REFERENCES 1 2 3
Figure 2 Preserved adduction of both eyes on convergence test. 1028
Keane JR. Internuclear ophthalmoplegia: unusual causes in 114 of 410 patients. Arch Neurol 2005;62:714–17. Hardman JM. The pathology of traumatic brain injuries. Adv Neurol 1979;22:15–50. Eggenberger E, Golnik K, Lee A, et al. Prognosis of ischemic internuclear ophthalmoplegia. Ophthalmology 2002;109:1676–8.
Normansell D, et al. Emerg Med J December 2014 Vol 31 No 12
