Disclosures. Visual Pathways. Visual Pathways. Visual Loss Understanding the Patterns. I have no financial disclosures. Tabby A.

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1 Visual oss Understanding the Patterns Tabby A. Kennedy, MD University of Wisconsin Department of adiology I have no financial disclosures Acknowledgements: indell Gentry Greg Avey JP Yu Judy Chen Disclosures Objectives By the end of the presentation, participants should be able to: 1. Understand the anatomy of the visual pathway 2. Have a systematic approach to analyzing images in patients presenting with visual loss Visual Pathways Vision is a complex choreographed sensation etinotopic organization maintained from globe to visual cortex Visual Pathways Visual Pathways

2 Visual Pathways Visual Pathways Temporal Field Nasal Field Nasal etina Temporal etina Integration of visual information occurs at the blink of an eye Nasal Field Temporal Field Temporal etina Nasal etina

3 Visual oss: Making the Diagnosis Age Acuity of Symptoms Visual Field Deficit Clinical History Clinical Differential Diagnosis Appropriate Imaging Make the Diagnosis Defining the Terms Cases Visual Deficits: Defining the Terms Scotoma (Greek, darkness): Partial visual field alteration All lesions are at the level of the globe No indication for imaging Monocular Vision oss

4 Differential Diagnosis Optic Nerve Children Congenital Infection ON Glioma Skull Base-mass effect - Neuroblastoma - Ewings Sarcoma - EG - Fibrous Dysplasia Trauma Adults Optic Neuritis Ischemic Optic Neuropathy Meningioma Aneurysm Trauma Monocular Vision oss Protocol: M Orbits and Brain Imaging Protocols: M Orbit Pre contrast Imaging Protocols: M Orbit Pre contrast PD PD /CISS Prop DWI Post contrast Imaging Protocols: M Brain 55 yo with endometrial cancer DWI Pre contrast 3D FAI 3D FAI+C Post contrast Consider doing 3D FAI post contrast +C 3D FAI + C 3D +C Black Blood

5 2 patients with Monocular Vision oss 2 patients with Monocular Vision oss 30 yo 2 yo Multiple Sclerosis Neurofibromatosis Acute onset, pain Painless, esotropia 2 patients with Monocular Vision oss 22 yo F with Decreased ight Monocular Vison +C Multiple Sclerosis Neurofibromatosis Key Point: ook at the brain for additional lesions Diffusion 22 yo F with Decreased ight Monocular Vison 22 yo F with Decreased ight Monocular Vison +C Diffusion +C 3D FAI + C 3D FAI + C

6 Optic Neuritis Optic Neuritis Visual recovery good 48-70% with isolated ON will have brain lesions consistent with demyelination Index Patient Multiple Sclerosis 72% patients with 1 or more brain lesions developed MS Only 25% developed MS with a normal brain M Index Patient Multiple Sclerosis Sarcoid Ulcerative Colitis Acute Myelogenous eukemia (Granulocytic Sarcoma) 22 yo F with AM Mixed Picture: Progressive enlargement of nerve But, the nerve no longer enhances 20 yo F acute onset visual symptoms & neck pain r/o dissection Postulated: elated to superimposed ischemic changes within the nerve and/ or post steroid effect 20 yo F acute onset visual symptoms & neck pain r/o dissection Vague Visual Symptoms 3D FAI 3d-PCA + C umbar Puncture Pressures elevated 50 Intracranial cm/h20 Hypertension Drusen - mimic of papilledema

7 Progressive ight Unilateral Visual loss; + Optocilliary Shunting 2 year old with CN 6 palsy and progressive bilateral visual loss Optic Nerve Sheath Meningioma Non Contrast Head CT 2 year old with CN 6 palsy and progressive visual loss 2 year old with CN 6 palsy and progressive visual loss 3D 3D + C ADC + C 2 year old with CN 6 palsy and progressive visual loss 3D + C Bitemporal Hemianopia

8 Children ON Glioma Pituitary/Sella Hypothalamus Third Ventricle DDx: Chiasm Adults Optic Neuritis Pituitary/Sella Meningioma Aneurysm Bitemporal Hemianopia Bitemporal Protocol: M Hemianopia Pituitary 55 year old with decreased vision x 1 year, rapidly progressed over 2 days 55 yo with Bitemporal Hemianopia Hemorrhagic Macroadenoma Urgent Neurosurgical and Endocrine Evaluation Homonymous Hemianopia

9 Differential Diagnosis Tract/adiations Children and Adults Stroke Tumor Abscess Demyelinating Disease (MS/ ADEM) PES Trauma Homonymous Hemianopia Homonymous Protocol: M Hemianopia Brain Occipital obe esions Occipital obe esions Homonymous Hemianopia PCA Infarct AVM Falcine Meningioma Astrocytoma 43 yo woman with left homonymous hemianopia Occipital obe esions DTI shows lateral displacement of terminal Optic adiations Cortical Blindness Prior HH now Cortical blindness

10 Occipital obe esions Occipital obe esions abile HTN Cardiac Valvular Disease PES PCA Infarcts Occipital obe Anatomy Occipital obe Anatomy Parieto-occipital sulcus Parieto-occipital sulcus Cuneus Cuneus ingual gyrus Calcarine fissure ingual gyrus Calcarine fissure 69 yo M with acute onset visual disturbance and confusion Summary