Recurrent Third Nerve Paresis with Migraine: A Case Report and Review of the Literature.

Ophthalmoplegic migraine (OM), first described by Charcot in 1870, is a disorder characterised by recurrent episodes of migraine associated with ophthalmoplegia. It has been extensively described in children and is rarer in adults. Commonly, the third nerve is affected with pupillary involvement and, more rarely, the fourth or the sixth nerve. OM is now believed to be an inflammatory demyelinating neuropathy. However, in the largest series of OM so far, by Lal et al. it most commonly involved the sixth nerve, started with a crescendo migraine and was accompanied by no enhancement of the cranial nerves. This has led to a rethink about the role of migraine, in the pathogenesis of OM. We describe a 14-year-old boy, with a 10-year history of intermittent headache followed by drooping of right eyelid and diplopia. The current episode started with a migrainous headache, which increased in severity over 3 days, followed by right third nerve paresis with pupillary involvement. Contrast-enhanced magnetic resonance imaging (MRI) of the brain with contrast showed nodular thickening at the root entry zone of the right oculomotor nerve with bright enhancement. The child responded to oral prednisolone, which was tapered over a month. Migraine prophylaxis with propranolol was concurrently added. His repeat MRI brain showed complete disappearance of enhancement of the lesion at 1 year.

Spinal cord infarction: a rare but serious complication of pneumococcal meningoencephalitis.

Here, we report the case of a woman in her 40s who came with pyogenic meningitis and infarcts in the brain. While on treatment with antibiotics, she developed new-onset weakness involving bilateral lower limbs and one upper limb 2 weeks into the course of illness. MRI of the spine showed an infarct in the spinal cord. Spinal cord infarction as a complication of pyogenic meningitis is not well recognised unlike tuberculosis meningitis. Unlike ischaemic strokes where thrombolysis is done, for stroke related to infections, there are no definite strategies. Our patient was treated with physiotherapy, continued on antibiotics and slowly recovered over months and at 18-month follow-up, she was walking with a walker. The exact mechanism of thrombosis is not known but may be due to inflammation of the arterial wall and activation of the procoagulant cascade by infection-triggered inflammation. Spinal cord infarction can occur at any phase of the infection and may occur despite appropriate response to antibiotic treatments.

Spontaneous Intracranial Hypotension: A Review of Neuroimaging and Current Concepts.

Spontaneous intracranial hypotension (SICH) is the emerging cause of orthostatic headache as it has been better recognized in recent years. SICH happens due to spinal cerebrospinal fluid (CSF) leak; however, the manifestations are predominantly cranial and hence imaging in SICH includes brain and spine. There are few characteristic brain imaging features to be concerned about to diagnose SICH in patients with vague symptoms or low clinical suspicion. Spine screening is recommended in these patients to assess spinal CSF leaks. While neuroradiologists play a significant role from the time of diagnosis to treatment of SICH, there is a need for all the general radiologists to be aware of the condition. Computed tomography myelogram and digital subtraction myelogram are performed for diagnostic and therapeutic management of SICH. There is a known risk for SICH recurrence in patients with sagittal longitudinal epidural collection and hence, targeted blood patch should be used instead of blind patch. Most importantly, slow mobilization is recommended following the patch to avoid recurrence.

Transfacial venous embolisation of a spontaneous indirect paediatric caroticocavernous fistula.

We present a rare case of a spontaneous indirect caroticocavernous fistula (CCF) in an early adolescent, who exhibited a 1-month history of redness, decrease in vision and proptosis of the right eye without a history of trauma or connective tissue disorder. An MRI of the brain and orbit and a digital subtraction angiography confirmed the diagnosis of Barrow type D CCF. The same was then treated with coiling and a liquid embolising agent using the transfacial venous route, resulting in complete obliteration. Reduction in conjunctival congestion with mild improvement in visual acuity was noted postprocedure. Complete recovery was noted at the 6-month follow-up visit. CCF, though rare in the paediatric population, should be highly considered in the differential diagnosis when the above-mentioned complaints are present. Early diagnosis and intervention have favourable outcomes.