HEMIANOPSIA

Ask the Following Questions:

1. Is it intermittent? Intermittent hemianopsia, whether it is bitemporal or homonymous in type, would suggest migraine, carotid artery insufficiency, or vertebral basilar artery insufficiency.
2. Is the hemianopsia of sudden or gradual onset? Sudden onset of hemianopsia would suggest a vascular disorder such as cerebral thrombosis, embolism, or hemorrhage, but it may also suggest multiple sclerosis or a ruptured aneurysm. Gradual onset of hemianopsia would suggest a space-occupying lesion.
3. What type of hemianopsia is it? A bitemporal hemianopsia often suggests a pituitary tumor, especially if there are endocrine changes, but it may also be due to an aneurysm compressing the optic chiasm. Homonymous hemianopsia suggests involvement of the optic tract or occipital cortex. This may be by a space-occupying lesion, an aneurysm, arterial thrombosis, an embolism, or a hemorrhage.
4. Are there long tract signs? Neurologic signs of pyramidal tract involvement or posterior column involvement would suggest anterior or middle cerebral artery occlusion, epidural hematoma, or multiple sclerosis if it is acute and compression of the cortex by a subdural hematoma or brain tumor if it is chronic.
5. Are there endocrine changes? The presence of weight loss, hair loss, or diabetes insipidus would suggest a chromophobe adenoma of the pituitary. On the other hand, a protruding jaw, enlargement of the hands and fingers, and hypertrophy of the other tissues suggest acromegaly.
6. Is there macular sparing? The presence of macular sparing suggests that the lesion is in the optic cortex. This is most often a space-occupying lesion.

DIAGNOSTIC WORKUP

Referral to an ophthalmologist for a thorough visual field examination is suggested at the outset. A neurology consultation also needs to be obtained. The neurologist will probably order a CT scan of the brain to rule out a space-occupying lesion unless multiple sclerosis is suspected.

If multiple sclerosis is suspected, MRI would be the study of choice, even though it is more expensive. In addition, VEP studies and spinal fluid analysis may be ordered to rule out multiple sclerosis.

A carotid duplex scan will help diagnose carotid vascular insufficiency, but four-vessel cerebral angiography will most likely be done so that both carotid and vertebral basilar artery disease can be evaluated. If there are endocrine changes, an endocrinologist should be consulted.

If a cerebral embolism is suspected, a source for the embolism should be sought. A cardiologist can best determine what tests to order to search for an embolic source.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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