NANOSNET

that is very helpful. thank you! I actually hadn't noticed the EOM asymmetry as much but as I run through it again I do see that as well. I will add on IGG4 labs and try to push for steroids again.

Re the nerve enhancement to me I still think there is proper enhancement within the nerve itself not just the sheath esp in the coronal cuts 

that is very helpful. thank you! I actually hadn't noticed the EOM asymmetry as much but as I run through it again I do see that as well. I will add on IGG4 labs and try to push for steroids again.

Re the nerve enhancement to me I still think there is proper enhancement within the nerve itself not just the sheath esp in the coronal cuts 

that is very helpful. thank you! I actually hadn't noticed the EOM asymmetry as much but as I run through it again I do see that as well. I will add on IGG4 labs and try to push for steroids again.

Re the nerve enhancement to me I still think there is proper enhancement within the nerve itself not just the sheath esp in the coronal cuts 

Thank you ! I agree my primary concern was for optic neuritis (though exact etiology is not yet clear to  me); I saw pt again this week and  is now pinholing to 20/300 ; her HVF was not very reliable and showed general constriction. OCT was stable w loss of GCL and RNFL thinning. She still declining steroids even in oral form (she has concern bc of her bipolar disorder for a severe manic episode). Also still declining LP. 

Plan is to observe for now but I am just unclear on the cause of the optic neuritis. 

that is very helpful. thank you! I actually hadn't noticed the EOM asymmetry as much but as I run through it again I do see that as well. I will add on IGG4 labs and try to push for steroids again.

Re the nerve enhancement to me I still think there is proper enhancement within the nerve itself not just the sheath esp in the coronal cuts 

An ischemic etiology though remote is not yet completely excluded if the MRI that was done after overnight worsening blur occurred ~3-21 days after the event (the window within which ischemic lesions could enhance post-GAD). Sounds like the PE post-COVID could indicate a latent coagulopathic process that was unmasked by the acute prothrombotic state during COVID. The other possibility is that the worsening over the years is 2/2 to persistent thrombosis in the setting of "long COVID"?.

RE: Poiseuille's law, the volume flow rate (Q) depends on the pressure difference (Δ P), pipe radius (r), fluid viscosity (η), and pipe length (L). In her case, there is patchy pipe radius according to the MRV findings you described (i.e., "...The left transverse and sigmoid venous  sinus is small, likely developmental. There may be additional narrowing along the lateral aspect of the left transverse venous sinus...". ) and INCREASE viscosity (pro-thrombotic state from long COVID +/- an undiagnosed PRE-COVID acquired or hereditary coagulopathy). This creates the perfect Virchow scenario for continued thrombosis and persistent elevated ICP that could've led to a sleeping-position dependent unilateral ischemic event; furthermore, unilateral involvement in IIH is not that farfetched.  This is like a DK rule #6-9 scenario (for those not familiar with DK rules, see attached). 

Does she have sickle disease/trait, a clotting disorder (from a hematologic or solid malignancy),  or some hereditary pro-thrombotic issue?  Re: her bipolar disorder, is she on lithium? That could be indirectly prothrombotic (adding to the mess). From an inflammatory standpoint, is it worth doing a gallium scan? Or PET? Any lesions in the chest?

Thank you ! I agree my primary concern was for optic neuritis (though exact etiology is not yet clear to  me); I saw pt again this week and  is now pinholing to 20/300 ; her HVF was not very reliable and showed general constriction. OCT was stable w loss of GCL and RNFL thinning. She still declining steroids even in oral form (she has concern bc of her bipolar disorder for a severe manic episode). Also still declining LP. 

Plan is to observe for now but I am just unclear on the cause of the optic neuritis. 

that is very helpful. thank you! I actually hadn't noticed the EOM asymmetry as much but as I run through it again I do see that as well. I will add on IGG4 labs and try to push for steroids again.

Re the nerve enhancement to me I still think there is proper enhancement within the nerve itself not just the sheath esp in the coronal cuts 

Interesting. What is the temporal relationship between the worsening and MRI? Could the gad enhancement be a manifestation of a subacute ischemic event? The worsening upon awakening is particularly interesting. What is the likelihood that the persistent elevated ICP caused a secondary ischemic event overnight due to isolated intracanicular (?watershed zone) ischemia from elevated pressure decreasing arterial flow? Any hx of OSA? Do we know if she was prone, supine, or in the L or R lateral decubitus position the night before the symptoms were discovered?  Any h/o BRCA mutation (and/or non-BRCA breast and/or ovarian Ca)? Any thrombocytosis and/or other cell line elevation? Any hx or signs of acquired or hereditary coagulopathies? I am assuming MRV or CTV head is normal, is the CTV/MRV neck also normal?...Was there any evidence of CSF pleocytosis (if yes, flow? cytopathy?) and/or CSF hyperproteinorachia? 

Her last MRV was May 2025; I did not repeat MRV as I was not suspecting an increased ICP component as the culprit for the sudden vision loss given her other eye has no edema at all and she has no current increased ICP symptoms on diamox and the MRI showing post contrast enhancement which is more consistent with optic neuritis. Thank you! 

this is the radiology read:

Head MRV: 
Dominant flow is seen from the superior sagittal sinus into the right 
transverse and sigmoid venous sinus. The left transverse and sigmoid venous 
sinus is small, likely developmental. There may be additional narrowing along 
the lateral aspect of the left transverse venous sinus. On the right side 
where there is no significant narrowing, the overall caliber of the lateral 
transverse venous sinus and sigmoid venous sinus is somewhat small relative to 
the jugular bulb and proximal transverse venous sinus. This decrease in 
caliber is also more pronounced when compared to the preceding study from 
7/24/2021. The superior sagittal sinus, internal cerebral veins, vein of 
Galen, straight sinus and adjoining cortical veins are relatively unremarkable 
for technique.