Eyes Verbal Motor Does not open eyes Makes no noise (1) No motor response to pain Opens eyes to painful stimuli Moans, makes unintelligible noises (2) Extensor response (decerebrate) Opens eyes upon loud verbal command Talks but nonsensical (3) Flexor response (decorticate) Opens eyes spontaneously Seems confused and disoriented (4) Moves parts of body but does not remove noxious stimuli Alert and oriented (5) Moves away from noxious stimuli (6) Follows simple motor commands Treatment and Prognosis Patients with head trauma need to be referred to an emergency department, and a neurosurgical consultation is important. All patients known to be unconscious for more than 10 to 15 minutes, or with a skull fracture or a neurologic abnormality, require hospital admission and observation, because the possibility exists of delayed deterioration from expanding mass lesions (Gennarelli and Kotapa 1992).
The AQP4 autoantibody (NMO-IgG) may be a marker for disease course and prognosis [ 145-147 ], though the available data are inconsistent [ 92 ]. In patients with recurrent optic neuritis, retrospective evidence suggests that NMO-IgG seropositivity is associated with poor visual outcome and development of NMO [ 146 ]. A prospective study of 29 patients presenting with longitudinally extensive spinal cord lesions found 55 percent of the patients seropositive for NMO-IgG relapsed within one year or converted to NMO, while none of seronegative patients relapsed [ 147 ]. In contrast, a subsequent report noted that seronegative and seropositive NMO were similar in terms of relapse rate, severity, and long-term outcomes [ 92 ]. The discrepancy in these results may be due in part to small numbers of patients with seronegative NMO and to differences in the sensitivities of the AQP4 antibody assays.
As mentioned earlier, optic disc edema is always present in the acute phase of NAION (the reason will be discussed in the section under Pathophysiology) and comes in two varieties, diffuse or segmental. Segmental (typically altitudinal) is more common but it does not consistently correspond to the accompanying area of visual field loss 15. The edema is typically hyperemic and rarely pallid. Pallid edema is common in AAION and should alert the clinician to the possibility of giant cell arteritis. Peripapillary splinter hemorrhages are seen in nearly three-quarters of patients 12 and its presence can sometimes help to differentiate NAION from optic neuritis since they will be present in 5-15% of patients with optic neuritis 16, 17. Retinal exudates are uncommon but both hard and soft exudates were reported in up to 7% of patients in the IONDT 12 and the retinal arterioles can be focally narrowed in the peripapillary region in two-thirds of patients 18.