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  1. #1
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    Opthalmology/cranial nerve/bwain experts

    Disconcerting symptoms in my ten year old niece who is here visiting myself and her granny.

    The following started two days ago after playing in high temps:

    Paroxysmal nystagmus (bilateral), lasting one second. Complains of headaches in R occiput after the episodes.

    Began with one epsisode, and her dad tells me has increase to app. four to five episodes today.

    No other neuro S/S or deficits that I can determine, aside from the post-episode HA's.

    Went to walk-in clinic last night. They said not concerned, and did not give any instructions for further follow up. Hmmmmm...???

    I have no access at the moment to do a little digging on-line.

    Pediatrics (or eyeballs) are not my gig, but I told her dad to get her to an opthalmologist in short order.

    Anyone have any clues?

  2. #2
    You're Not the Boss of Me
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    Short answer is "no" but screw the opthalmologist... She needs an MRI, right?
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  3. #3
    Scary Teddy Bear
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    She

    needs a thorough neurologic evaluation with a professional...

    She likely needs, and without seeing her this is just going on very limited information, an MRI/MRA of the brain and neck. This could represent a posterior circulation issue, but without knowing a WHOLE lot more...it's hard to say....

    This might be vestibular in origin, but the headache is worrisome......

    Good luck...
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  4. #4
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    I would agree. Nastagmus with headaches is not an ocular issue but neurological. Go to ER and get consult. MRI and what ever scan they have now. PET, CAT, etc

  5. #5
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    Y'all use big words. I'm saying hire a pro. Other than that, I've got nothing because I don't speak medicalese.
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  6. #6
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    Thanks all.

    Much appreciated.

  7. #7
    Matnlely Dregaend
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    Seems like some sort of epileptic episode to me. Does she experience auras? Definitely a neurological issue that needs to be followed up though. It could be something quite benign, like heat exertion, or something much more serious.
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  8. #8
    Dr. Flats a lot
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    Your best option is to go to a pediatric emergency department. This will invariably be at an academic institution and they will have the necessary consulting services. It's worth the extra drive.
    I agree she needs an MRI. Trying to get this done through a pedi office will be a bear, as it will need to get pre-approved by insurance company in most cases. Likewise getting a rapid appointment with a pediatric neurologist is going to be tough.
    If it was my kid I wouldn't put a lot of trust in the basic ER docs ability to assess this. Chances are they would order a CT scan. Not horrible, but she still will need an MRI regardless of the result, and the CT is a lot of ionizing radiation she could do without. Depends on the kid, but most of them will have a problem not freaking out. MRI's are super scary machines, and likely will require some sedation. Again, better to have a pediatric specialist handling this.
    Chances are it is something benign like an inner ear infection or a complex migraine...but there are not the symptoms one would expect and not the age for migraines, acoustic neuromas etc...
    Last edited by zoikz; 07-11-2012 at 08:23 PM.

  9. #9
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    Quote Originally Posted by DrSmile View Post
    Seems like some sort of epileptic episode to me. Does she experience auras? Definitely a neurological issue that needs to be followed up though. It could be something quite benign, like heat exertion, or something much more serious.
    My firt questions to her dad as well but no, no auras/prodromal or post ictal S/S.

    Post-nystagmus HA's last for about 10 minutes is all...

    I'm hoping for something "simple" like vascualar spasms of some sort.

    I managed to convince her dad to "run don't walk" for further eval.( without freaking him out).She just had another episode.
    Last edited by OldEndicottHiway; 07-11-2012 at 08:44 PM.

  10. #10
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    Make sure they get a lumbar puncture to look for aseptic meningitis, Lyme in particular.

  11. #11
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    Quote Originally Posted by zoikz View Post
    Your best option is to go to a pediatric emergency department. This will invariably be at an academic institution and they will have the necessary consulting services. It's worth the extra drive.
    I agree she needs an MRI. Trying to get this done through a pedi office will be a bear, as it will need to get pre-approved by insurance company in most cases. Likewise getting a rapid appointment with a pediatric neurologist is going to be tough.
    If it was my kid I wouldn't put a lot of trust in the basic ER docs ability to assess this. Chances are they would order a CT scan. Not horrible, but she still will need an MRI regardless of the result, and the CT is a lot of ionizing radiation she could do without. Depends on the kid, but most of them will have a problem not freaking out. MRI's are super scary machines, and likely will require some sedation. Again, better to have a pediatric specialist handling this.
    Chances are it is something benign like an inner ear infection or a complex migraine...but there are not the symptoms one would expect and not the age for migraines, acoustic neuromas etc...

    They're headed back to Seattle tomorrow.

    Told him to hit Children's first.

    She's a fearless kid and will cope with an MRI in stride.


    Thanks again to all for being a sounding board.


    I'm sure she'll be fine.

  12. #12
    Roll Out Jeremy
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    Hasn't it been hotter than the hubs O'hell over there?

    Is she hydrated? You know, she has had no opportunity to acclimatize given the cold spring we have had. Just makes me wonder....
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  13. #13
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    Off topic here, but what could a family do, if they didn't have insurance? Would a hospital even do expensive tests on a patient without insurance?



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  14. #14
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    Her PCP called the Neuro folks here in my town this AM, to try and get her seen but they refused to eval her since she is "less than 12."

    So, they advised her to Children's Hospital ER in Seattle.

    One CT without contrast and a few neuro tests in the ED later, and they are scratching their heads "... but she looks so healthy."

    I reminded her dad of the "treat 'em and street 'em" mindset in the ER...

    They did advise a pediatric neuro consult. Good 'nuff.

    And I am glad tonight there is not glaringly obvious b ad news. ;)
    Last edited by OldEndicottHiway; 07-13-2012 at 04:50 AM.

  15. #15
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    Neuroophthalmologist would have been my first choice.....kinda getting it all in one doc.
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  16. #16
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    Quote Originally Posted by Fordy View Post
    Is she hydrated? You know, she has had no opportunity to acclimatize given the cold spring we have had. Just makes me wonder....
    +1 Heat will affect the young and elderly the most and quickly. Hopefully its something this simple and nothing more complicated.

  17. #17
    Dr. Flats a lot
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    Quote Originally Posted by OldEndicottHiway View Post
    Her PCP called the Neuro folks here in my town this AM, to try and get her seen but they refused to eval her since she is "less than 12."

    So, they advised her to Children's Hospital ER in Seattle.

    One CT without contrast and a few neuro tests in the ED later, and they are scratching their heads "... but she looks so healthy."

    I reminded her dad of the "treat 'em and street 'em" mindset in the ER...

    They did advise a pediatric neuro consult. Good 'nuff.

    And I am glad tonight there is not glaringly obvious b ad news. ;)
    Glad for the update.
    As a comment, the diagnostic priority of an emergency physician is to rapidly and accurately identify medical conditions than need an acute intervention. That does not mean we are able to identify all the disease processes we come accross.
    One of the most common pieces of advise I give to my patients, is that among the medical tests available to use, often the most insightful is the test of time. Seeing how signs and symptoms evolve over time has a tremendous diagnostic effectiveness.
    I would say that pediatric EM docs, have a huge amount of training and are generally very capable. They require a full residency training in pediatrics or adult emergency medicine, then need to apply and be accepted by a ped's EM fellowship and then undergo another 2-3 years of training.
    She stills needs an MRI though. Not sure why they did the contrast study.....guess they were looking for an aneurysm.

  18. #18
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    Quote Originally Posted by zoikz View Post
    Glad for the update.
    As a comment, the diagnostic priority of an emergency physician is to rapidly and accurately identify medical conditions than need an acute intervention. That does not mean we are able to identify all the disease processes we come accross.
    One of the most common pieces of advise I give to my patients, is that among the medical tests available to use, often the most insightful is the test of time. Seeing how signs and symptoms evolve over time has a tremendous diagnostic effectiveness.
    I would say that pediatric EM docs, have a huge amount of training and are generally very capable. They require a full residency training in pediatrics or adult emergency medicine, then need to apply and be accepted by a ped's EM fellowship and then undergo another 2-3 years of training.
    She stills needs an MRI though. Not sure why they did the contrast study.....guess they were looking for an aneurysm.


    Thanks Zoikz (and all) for the input.

    I completely agree, and at least the ED provided some solid, baseline data early on.

    She has had a couple more episodes, and is being followed up with her primary.

  19. #19
    disgruntled pigskin fan
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    Very strange indeed. As others have said, she needs an MRI of the brain and brain stem.

  20. #20
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    Any update on this?
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