Ophthalmoplegic Migraine Paediatric Oculomotor Schwannoma

Ophthalmoplegic Migraine Paediatric Oculomotor Schwannoma Corresponding Author: Dr.R.Subasree Title : Ophthalmoplegic Migraine and Paediatric Oculomotor Schwannoma: Cause or Co-Incidence? Structured Abstract: Objective: To report a case of Ophthalmoplegic migraine with Pediatric Oculomotor Schwannoma which is very rare. Methods: A 16 year old boy admitted as inpatient at our tertiary referral centre and University hospital in South India, with history of recurrent headaches and oculomotor palsy of 14 years duration was evaluated in detail to rule out posterior fossa, orbital fissure, parasellar lesions, granulomatous disorders and aneurysms. Results: Initial CT Brain revealed a nodular non-enhancing lesion in the interpeduncular cistern, MR Imaging along with CISS 3D sequence done two years later after CT, revealed a small enhancing nodular lesion at the level of midbrain in the interpeduncular cistern at nerve exit level suggestive of schwannoma of third nerve. Practice: Patient was treated with analgesics, nimodipine and valproate with which there was a partial response. During his subsequent 2 year follow-up, his frequency and severity of attacks had reduced. Conclusion: Oculomotor nerve schwannomas are extremely rare. Only 12 children under the age of 18, without neurofibromatosis have been sufficiently documented. The coexistence of OM and Oculomotor schwannoma suggests that it is not a coincidence. Awareness and suspicion is required to identify cranial cephalalgia /OM and it warrants thorough investigation to rule out intrinsic lesions mimicking OM. Implications. Controversies exist till date regarding etiology, pathophysiology, imaging findings and management guidelines of OM. The rare association reported in our report gives insight into better understanding of the pathophysiology and clinico-radiological correlations in OM. Keywords: Ophthalmoplegic migraine, Oculomotor Schwanomma Introduction Ophthalmoplegic migraine is very rare with annual incidence being 0.7 per million. It most often occurs in infancy or childhood. There are recurrent attacks of headache in association with ophthalmoplegia due to paresis of cranial nerve III, IV, or VI .The episodes of ophthalmoplegia may persist for several hours to several weeks, months, or permanently. Most often it is self-limited condition. Ophthalmoplegic migraine is also recognized as a cranial neuralgia according to 2004 edition of the International Classification of Headache Disorders. [1] .Paediatric Oculomotor Schwannoma is extremely rare and it can mimic OM. We describe a young boy with recurrent ophthalmoplegic migraine and oculomotor schwannoma in MR imaging. Clinical Observation A 16 year old boy presented with history of left hemicranial headache of 14year duration. The headache was throbbing, severe associated with drooping of left eye, blurring of left eye vision, photo-phonophobia, nausea and vomiting. The frequency of attacks was around 15 per month each lasting for 3-48 hours. During the attack, he was found to have left sided ptosis, poorly responsive normal sized pupil and mild left elevation and adduction restriction. (Figure 1).There was persistent residual vision loss in left eye with acuity of 6/60. Fundus was normal. There were no other deficits. Investigations were carried out to rule out posterior fossa, orbital fissure and parasellar lesions. Initial CT Brain revealed a nodular non-enhancing lesion in the interpeduncular cistern , MR Imaging along with CISS 3D sequence done two years later (Figure 3a, 3b) revealed a small enhancing nodular lesion at the level of midbrain in the interpeduncular cistern at nerve exit level suggestive of schwannoma of third nerve. MR Angiography was normal. (Figure 3c). Patient was treated with analgesics, nimodipine and valproate with which there was a partial response. Steroids were not administered. During his subsequent 2 year follow-up, his frequency and severity of attacks had reduced. Paediatric Oculomotor Schwanomma is present as painless oculomotor deficit or may be asymptomatic and detected incidentally. Its presence with OM poses a question whether it was a mere coincidence or the cause of OM. Discussion: Ophthalmoplegic migraine is a rare distinct neurologic syndrome characterized by recurrent headache and ophthalmoplegia. The third cranial nerve is most commonly affected. Most patients recover completely within days to weeks, but a minority are left with persistent neurologic deficits. [1] .As per the International Classification of Headache, ophthalmoplegic migraine is defined as at least 2 attacks of ‘‘migraine-like’’ headache followed within 4 days by paresis of the third, fourth, and/or sixth cranial nerves, including ophthalmoparesis, ptosis, or mydriasis .[2] Gap between the onset of headache and the cranial nerve palsy has varied between 2 days and10 weeks. [3]The exact aetiology of this condition remains unknown. Oculomotor nerve compression, ischemia, swelling of the posterior cerebral artery, pituitary swelling, vascular anomaly, benign viral infection, demyelinating neuropathy, activation of trigemino-vascular system are the various pathogenesis implicated. Diseases such as vascular malformation, granulomatous infections, pituitary apoplexy, sarcoidosis and chronic inflammatory, demyelinating polyneuropathies may have similar clinical presentation like OM. So contrast enhanced MRI and magnetic resonance angiography should be the investigations of first choice for the diagnosis of OM, followed by a careful clinical examination and spinal tap. Sometimes, conventional angiogram may be necessary to exclude an aneurysm. [4]. Mark et al. 1998.,[5]found focal thickening of the nerve in non-contrast studies, and further thickening was present on the contrast-enhanced images in the area of the exit zone of the nerve in the inter peduncular cistern. Carlow studied the magnetic resonance scans in six patients diagnosed with OM and did a retrospective literature survey in 17 patients with OM, all of whom showed thickened ipsilateral oculomotor nerves at the midbrain exit in noncontrast T 1 -weighted images. Contrast T 1 -weighted magnetic resonance scans showed enhancement of the ipsilateral oculomotor nerves. [6].Many cases show improvement in the enhancement of cranial nerve III with resolution of the symptoms, but the timing and degree of resolution has not been consistent in reports. Contrast enhancement on MRI is not a sine qua non for the diagnosis of OM. Gelfand AA et al., 2011 [1] systematically reviewed all cases of OM in literature between1995 to 2010. There were a total of 80 cases .The median age at the time of the first ophthalmoplegic migraine attack was 8 years (3-16 years) .The third cranial nerve was involved in the vast majority of cases (83%), sixth cranial nerve was involved in 20% and the fourth nerve in 2% of cases. The interval between headache onset and ophthalmoparesis ranged from immediate to up to 14 days. The ophthalmoplegia tended to last longer (2 to 3 weeks to 2 to 3 months) .In 54%, persistent deficits were observed. Of 52 patients who had a contrast brain MRI during an acute attack, 75% had contrast enhancement of the third nerve and 76% had nerve thickening. There was a benefit from corticosteroid treatment in 54%. Schwannomas are benign peripheral nerve sheath tumours with great propensity to arise from vestibular nerves. Oculomotor nerve schwannomas are extremely rare. There are only 40 cases reported in the literature. Only 12 children under the age of 18, without neurofibromatosis have been sufficiently documented. [7] In 1982, Leunda et al. [8] reported a case in an 11-year-old boy whose tumour was resected en bloc and ranked as the largest oculomotor nerve schwannoma documented at that time, with a 55-mm diameter. Since then, another 11 histologically proven paediatric cases have been described successively in the literature. The average diameters of the paediatric tumours size is 19.5 mm. Oculomotor nerve paresis was the most common neurological sign and a variable degree of oculomotor nerve dysfunction, including ptosis, diplopia, or dilated pupil, was present in all but one . Duration of preoperative symptoms and signs ranged from 2 weeks to 12 years. Authors opine that lesion size did not correlate with the degree of oculomotor nerve deficit. Ipsilateral ophthalmoplegic migraine was found in two cases of cisternal microlesions involving the initial prepontine segment of oculomotor nerve. [7].Total removal of schwannoma usually resulted in severe postoperative parent nerve paresis. Surgical tr eatment was indicated only for large tumours that presented in association with consciousness disturbance, other cranial nerve signs, or hemiparesis due to mass effect, or in cases where the lesion showed malignant features with rapid enlargement. Murakami et al., 2005 [9] described a case of an 11-year-old girl with oculomotor nerve schwannoma who had been suffering from symptoms mimicking OM. Her attacks became more frequent and were not controlled by medication. After surgery, the frequency of OM attacks reduced. This was the first report to describe a pathologically confirmed case of oculomotor nerve schwannoma mimicking OM. Riahi A et al., 2014[10] described a 12 year old girl with recurrent painful ophthalmoplegia, who on examination was found to have left oculomotor palsy. Her third MRI focusing on third nerve revealed schwannoma of the oculomotor nerve in left cisternal portion. Kawasaki et al., 1999 [11] reported a case of the coexistence of OM and ipsilateral 3rd nerve schwannoma .The authors had an acute and a follow-up MRI during a recovery phase and noticed no difference. The coexistence of two rare conditions suggests that a mere coincidence is unlikely. It has been proposed that repeated inflammation could lead to a demyelination/ remyelination process with Schwann cell proliferation and onion bulb formation. There are no published treatment trials for ophthalmoplegic migraine. Oral steroids may be of possible benefit in treating acute exacerbations based on available case series. Prompt steroid therapy at the time of attack might minimize permanent sequelae of OM, including residual weakness of the third cranial nerve and pupillary dysfunction. Bharucha et al., 2007 [4] state that various treatments have been described, including steroids acutely and flunarizine, acetazolamide, propranolol, cyproheptadine, or verapamil prophylactically. OM is a heterogeneous disorder that needs adequate scrutiny, periodic magnetic resonance monitoring, and clinical correlation before we can conclude and draw management guidelines. Conclusion: Awareness and suspicion is required to identify cranial cephalalgia /OM as it is a rare entity and diagnosis even by headache experts is made by exclusion. It warrants thorough investigation to rule out intrinsic lesions mimicking OM. The rare association reported in our report gives insight into pathophysiology and clinico-radiological correlations in OM. Bibliography 1. Gelfand AA, Gelfand JM, Prabakhar P et al. Ophthalmoplegic ‘‘Migraine’’ or Recurrent Ophthalmoplegic Cranial Neuropathy: New Cases and a Systematic Review. Journal of Child Neurology.2011; 27(6):759-766 2. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004; 24(suppl 1):9–160. 3. Ravi Shankar. K. Ophthalmoplegic Migraine: Still a Diagnostic Dilemma? Current Pain and Headache Reports. 2008; 12: 285 – 291 4. Diana X. Bharucha, Timothy B. Campbell, Ignacio Valencia. MRI Findings in Pediatric Ophthalmoplegic Migraine: A Case Report and Literature Review. Pediatric Neurology .2007; 37: 59–63 5. Mark AS, Casselman J, Brown D, et al.: Ophthalmoplegic migraine: reversible enhancement and thickening of the cisternal segment of the oculomotor nerve on contrast enhanced MRI images. AJNR Am J Neuroradiol .1998; 19: 1887– 1891. 6. Carlow TJ: Oculomotor ophthalmoplegic migraine: is it really migraine? J Neuroophthalmol .2002; 22: 215– 221. 7. Yang S, Li Z, Liu X et al.Pediatric Isolated Oculomotor Nerve Schwannoma: A New Case Report and Literature Review. Pediatric Neurology.2013; 48(4):321–324 8. Leunda G,Vaquero J,Cabezudo J et al. Schwannoma of the oculomotor nerves .Report of four cases .J Neurosurg.1982;57:563-565 9. T. Murakami, M. Funatsuka, M. Komine et al.Oculomotor nerve schwannoma mimicking ophthalmoplegic migraine.Neuropediatrics.2005; 36:395–398 10. Riahi A, Youssef-Turki I.B, Walha K et al. Recurrent painful ophthalmoplegia: ophthalmoplegic migraine or oculomotor nerve schwannomas? Neurological Practice –FMC. 2014; 5:205-208 11. Kawasaki A. Oculomotor nerve schwannoma associated with ophthalmoplegic migraine. Am J Ophthal 1999; 128:658–60.

Instagram Term Paper

AMA COMPUTER LEARNING CENTER COLLEGE Tagbilaran City, Bohol INSTAGRAM (Android Application) A term paper submitted in partial fulfillment of the Requirements for the degree of BACHELOR OF SCIENCE in INFORMATION TECHNOLOGY by: Josie Marie Mosqueda Edralyn Tutor 2012 ABSTRACT Today the folks responsible for one of the most popular social photography apps in the world  have brought that entertainment to  Android– and here we’re going to review it! What you’ll find is that this app is extremely similar to the iOS version, it having the ability to snap photos, edit them in brief, and send them out to several social networks.This Android version is said to be superior to the iOS version in several ways by its developers. This app got extremely popular on iOS because it allowed (and still allows) you to do three different activities in one app – photography, sharing, and editing of photos. Here on Android you’ve got several of those abilities built in – the HTC One series in-particular has some pretty amazing photo editing, taking, and sharing abilities. INTRODUCTION An important application for the tech-savvy crowd, Instagrams are all about the beauty of capturing moments through man-made lenses and sharing it with your near and dear!As Will Smith says â€Å" Life is not about number of breadths you take, it is about number of moments take your breath away†. Moments like that don’t happen everyday, but can be captured and cherished for the rest of your lives, thanks to the app called Instagram! Instagrams are solely for the Apple person, that is compatible with Iphones, Ipads, Ipod Touch with an iOS version of 3. 1. 2 or above. Instagram, the popular photo sharing application which gained prominence on iOS – is now available for Android. Complete with a beautiful user interface and a full feature-set, it seems to have been worth the nail biting.It is a free photo sharing application which helps you to click pictures, apply fresh effects on them using their inbuilt filters and then post it online on any social networking site like Foursquare, Facebook, Twitter, Flickr etc. A list of the most popular filters are the Walden Filter, the X Pro II, the Lomo-Fi, the Brannan, the Hefe, the Earlybird, the Sutro, the Poprocket, the Nashville and the Gotham. HISTORY Below is a short Infographic on Instagram’s history. TIMELINE DISCUSSION Felling the walled gardenInstagram and  Hipstamatic, a digital photography application for iOS devices, entered into a partnership that would allow photos from the app to be directly ported into Instagram. â€Å"I’m a huge fan of what Hipstamatic is doing and all they’ve accomplished,† Systrom  said. â€Å"They were iPhone App of the Year in 2010 and we got 2011. We have a huge amount of respect for that whole team both as fellow photographers and entrepreneurs. † â€Å"Really it comes down to this: People post Hipst amatic photos on Instagram all the time, and we just want to make that experience easier. †Pictures paint more than a thousand words Instagram already has seven million users all over the world and the number is only going to get bigger when the Android app launches. There are loads of awesome photos available on Instagram today and these photos are inspiring others to follow suit. Taking Photos with Instagram Instagram has a built-in camera function, making it easy to quickly snap a photo to share in the app. You can also pull photos directly from your iPhone photo library, so you can share older photos taken with your iPhone or photos synced from your iPhoto library on your computer.All Instagram photos are square, so after you take or select a shot you are presented with an easy interface to scale and crop it. Transforming Photos with Instagram After your photo is cropped, you can transform the look of it with a variety of filters. Most of the filters are designed to give y our photo a vintage look, bringing back polaroids and old black-and-white pictures. While quick Photoshop style filters are often considered cheap tricks, people have embraced Instagram because it simply makes photo sharing fun. Photo Sharing with InstagramWhen you are done editing an Instagram, you can choose to share it just within the app or on Twitter, Facebook, Flickr, Posterous, Tumblr and Foursquare. Instagram also creates a web page with your image that you can link to, but that's as far as the website goes. It is not the place to follow people, view galleries or submit photos. All of that functionality is reserved for the app itself, where you can view photos from your friends, see popular photos, and find people to follow and more. FEATURES OF INSTAGRAM * 100% free custom designed filters and borders The Lux: A new feature given by the makers to bring out the inner nuances in your picture with nothing but a tap on the picture! Best part in using Lux is that it can be used even without a filter. * Instant sharing to Facebook, Twitter, Tumblr, and Foursquare (Flickr coming very soon) * A new filter called the Sierra. * Interact with friends through giving ; receiving likes and comments * Works with Android versions 2. 2 and above that support OpenGL ES 2 * Full front ; back camera support SCREENSHOTS ADVANTAGES OF INSTAGRAM Instagram is great especially if you are fond of taking pictures and uploading them right away for other people to see. * It is fast like when you took a picture, uploaded it and it will automatically be uploaded or posted on your facebook account, twitter and tumblr. * It offers a lot of effects, or if you want your photo to have a frame or not. * You can be updated on your friends’ happenings or your friends’ important announcements. * A great way of making or meeting new friends. * You can also advertise your own products if you have some business or shops.You can take a photo of your products and post it on instagr am and it can help you gain more customers. * Another great thing is that, there are some photo applications that you can directly upload on instagram the photos you have taken or edited. One of this is the photoshake, it's up to you if you want to upload the photo you took directly on instagram or just save it on your mobile phone or tablet. DISADVANTAGE OF INSTAGRAM * Privacy – where in, every detail and every photo that you will be uploading, a lot of people might see it.Rumors can also start by others seeing some photos of you not being good. Your life can be at danger especially if you always takes a photo of you on where you at and what are you doing. CONCLUSION Above all, Instagram is made for us to enjoy the convenient of taking some pictures with our loved ones. And take note, important pictures with our friends, family, classmates or any special ones. Instagram is not made to make rumors of other people, to make fun at them and to invade others privacy. The team has certainly come a long way, to create a better world for its users.

Beginning Thinker Essay

I would say that I am a beginning thinker, I have control of all of my own personal thoughts I know that I am not always correct most of the time during each step of the thought process but I feel that I have a really good understanding of how to fix some of the issues that I have when in thought. Although some of the conclusions that I come to either workout for the short-term or long-term issue or have a tendency to be the opposite of the outcome that I was hoping for. I sometimes catch myself making a quick decision without fully thinking through the whole concept or the outcome that it will have on the issue that I am working on. I think that I can fix this by not jumping to conclusions when I am in thought, having a system to make sure that I get to the best possible outcome is something that I think I will implement going forward just to make sure that the outcome for my decision is one that I will be happy with and not regret. Critical Thinking I would say that my current critical thinking skills could be a little better, mainly because I have a tendency to over think when I am trying to come to a resolution to a specific problem. My strategy mainly consists of me thinking about the different ways that I can get to the best outcome but I also have a tendency to throw in my own assumptions or bias when coming to a resolution, this is what I feel makes me to either make an incorrect decision or make a decision based off only what my own personal feelings are towards the situation. A way that I feel I can develop better skills as critical thinker is to take all bias out of my decisions and make sure that what I do is not only best for me but will also help me keep on a path to reach my ultimate goal.

Co Morbidity, Chronicity And Complexity Concepts - 1938 Words

Co-morbidity, chronicity and complexity concepts. Chronicity is when an individual has a permanent disease or disability that involves the total human environment for supportive care and self-care, maintenance of function, prevention and further disability (Lubkin Larsen, 2009, p. 6) To be counted as a chronic condition the disease or disability must last longer than six months and have a noteworthy impact on the individual’s day to day life (Farrell Dempsey, 2014, p.203). This applies to Emily as she suffers from two permanent diseases that may potentially get worse but will not get better. Symptoms may be relived and they may exacerbate at times however the disease will always be present. When an individual, such as Emily, suffers from two or more chronic diseases it is known to be a co-morbidity. The amount of co-morbidity an individual has increases with age and if they live an active or sedentary lifestyle (Farrell Dempsey, 2014, p.203) It is important to be knowledgeable about a patients co-morbidities as they may interact with each other and affect how they are treated both pharmaceutically and through lifestyle options. The complexity of an illness can increase or decrease depending on the time required to evaluate and treat the condition. For Emily her conditions are complex as her Crohns Disease and Diabetes Mellitus can interact together, increasing the time taken to diagnose the conditions and increasing the time taken to treat the illness.