Kelly A. Malloy

Anterior Temporal Chordoid Meningioma Causing Compressive Optic Neuropathy

Purpose. Optic neuropathy associated with proptosis and ocular motility restrictions is suggestive of a compressive etiology. This raises concern for a mass lesion involving the orbit or orbital apex. Meningiomas, which account for 4% of all intraorbital tumors and 20 to 30% of all intracranial tumors, are capable of compressing critical anatomic structures within the orbit or orbital apex, and thereby impairing both afferent and efferent visual function. The purpose of this case report is to present a case of chordoid meningioma associated with compressive optic neuropathy. Methods. A 51-year-old woman presented with clinicopathological features pathognomonic of compressive optic neuropathy and orbital apex syndrome. Radiologic and neuropathologic evaluation revealed a large right anterior temporal atypical meningioma with chordoid features associated with frontal intraparenchymal edema. The therapeutic intervention consisted of orbitozygomatic craniotomy and radiotherapy. Results. Postoperatively, the patient progressed very well with considerable improvement of her visual and oculomotor function. The MIB-1 labeling index of 5 to 7% calls for close observation because of an increased probability of recurrence. Conclusions. This case highlights the importance of prompt diagnosis and treatment, because chordoid meningiomas exhibit a more aggressive biological behavior, with the potential to cause significant morbidity because of mass effect and higher risk of recurrence. To our knowledge, this is the first report of a rare case of a chordoid meningioma in the anterior temporal lobe that presented as a compressive optic neuropathy. The details of this case are presented with a review of relevant literature.

Progressive visual and hearing loss secondary to neurosyphilis.

Purpose There is a rising incidence of syphilis in economically advanced countries. Early diagnosis can spare the patient devastating vision and hearing loss, as well as other significant morbidity. Ocular presentations of neurosyphilis are varied and numerous, requiring syphilis to be considered in many clinical situations, even if a negative medical history is reported. Features of Argyll Robertson pupils, however, are virtually pathognomonic of syphilis; therefore, careful pupil testing can be the key to making a correct and timely diagnosis. Case Report A 51-year-old woman with a history of unexplained hearing loss presented for a third opinion for progressive vision loss OU, which was previously labeled as functional loss. A review of records indicated significant worsening of visual acuity and visual fields over 6 months, with minimal remaining visual function. She exhibited features of optic neuropathy as well as 2 mm miotic pupils, with evident light-near dissociation bilaterally. Evaluation showed a reactive fluorescent treponemal antibody absorption and rapid plasma reagin (1:8 titer) and positive cerebral spinal fluid Venereal Disease Research Laboratory test. A diagnosis of neurosyphilis was made, and a 2-week course of intravenous penicillin treatment was completed. Despite treatment, her vision decreased to no light perception OU owing to the advanced course of the disease at the time of treatment. Conclusions Neurosyphilis can occur at any stage of infection and needs to be considered in the differential diagnosis for many visual and ocular problems, especially in the setting of other systemic signs and symptoms. In this case, the combination of light-near dissociation and optic neuropathy with hearing loss was instrumental in dismissing the past diagnosis of functional vision loss and in pursuing the diagnosis of neurosyphilis. A timely diagnosis of neurosyphilis needs to be made to prevent devastating vision loss as seen in this case.

Ocular manifestations uncover chronic subdural hematoma secondary to abuse.

BACKGROUNDnAn abduction deficit or cranial nerve VI palsy can have many potential etiologies. However, a cranial nerve VI palsy in the setting of disc edema suggests increased intracranial pressure, requiring emergent work-up.nnnCASE REPORTnAn 18-year-old woman presented with significant headaches and horizontal diplopia, which she claimed began after giving birth 3 months prior. Her examination found a right cranial nerve VI palsy and mild disc edema of the left eye. This combination of findings was suggestive of increased intracranial pressure. Emergent workup uncovered a large chronic subdural hematoma requiring immediate neurosurgical intervention. She ultimately admitted to being abused by her partner.nnnCONCLUSIONnDiplopia and disc edema in a young, nonoverweight patient with an altered mental state is very concerning. Meningitis and complications of spinal anesthesia, although rare, need to be considered in patients who have recently given birth. However, other causes of increased intracranial pressure, including subdural hemorrhage secondary to trauma, also have to be considered, even if the patient denies any history of trauma. Abused patients often deny trauma.