Subdural Spread of Local Anesthetic Mimicking Cerebrovascular Accident: A Case Report of Horner's Syndrome, Upper Limb Paresthesia, and Motor Weakness After Thoracic Epidural Analgesia.

A 53-year-old woman underwent a thoracic epidural placement for a scheduled laparotomy. Postoperatively the patient had no appreciable epidural level after multiple epidural boluses and was noted to be severely hypotensive with right upper extremity weakness and numbness. She subsequently developed right-sided Horner's syndrome with worsening right upper extremity weakness and decreased sensation from C6 to T1. She regained full motor and sensory function in her right upper extremity with epidural removal. This unusual case raises awareness of the variability in the presentation of subdural spread and provides an example of an epidural complication that can mimic a cerebrovascular accident (CVA).

Real-world safety profile of tetracyclines in children younger than 8 years old: an analysis of FAERS database and review of case report.

BACKGROUND: The study aims to obtain the real-world safety profile of tetracyclines in children younger than 8 years old and provide reference for clinical drug applications. RESEARCH DESIGN AND METHODS: We made a disproportionality analysis of the FDA Adverse Event Reporting System (FAERS) database through OpenVigil 2 and conducted a review of case reports regarding adverse drug reactions (ADRs) of tetracyclines in children younger than 8-year-old. RESULTS: FAERS analysis identified 32 ADRs of tetracyclines in children younger than 8-year-old. Respiratory, thoracic, and mediastinal disorders contained the most frequent ADRs among all system organ classes (SOCs). The top three positive signals with the highest proportional reporting ratio (PRR) were laryngeal injury, Horner's syndrome and methaemoglobinaemia. Sixteen published tetracyclines-associated cases in children younger than 8-year-old were identified in the literature, concentrating in three SOCs. Gastrointestinal disorders were the most commonly reported cases (n = 12). CONCLUSIONS: Several ADRs were newly reported only in children younger than 8-year-old in our research, including Horner's syndrome and methemoglobinemia. We recommended that the clinical practitioners should pay attention to the ADRs both in instruction and beyond the label. Take close care of children and timely intervene when the treatment is inevitable.

[Horner's syndrome in the delivery room : a rare complication of labour epidural analgesia]. / Cas clinique. Syndrome de Claude Bernard Horner en salle de travail : une complication rare de l'analgésie péridurale obstétricale.

Horner's syndrome is a rare and benign complication of neuraxial analgesia during labour. We report the case of a Gravida 1 patient complaining of ptosis, enophthalmia and meiosis during labour, a few hours after a lumbar epidural analgesia was initiated.

Le syndrome de Claude Bernard Horner est une complication rare et bénigne de l'analgésie neuraxiale pour le travail obstétrical. Nous présentons ici le cas d'une patiente primigeste présentant une symptomatologie associant ptosis, énophtalmie et myosis en cours de travail, quelques heures après l'initiation d'une analgésie péridurale lombaire.

Horner syndrome after cervical spine corticosteroid injection.

Horner syndrome is a rare condition caused by a lesion of the sympathetic cervical chain. Multiple cervical disorders are associated with such lesions. Here we report the first case of Horner syndrome after cervical facet joint corticosteroid injection.

Safety of apraclonidine eye drops in diagnosis of Horner syndrome in an outpatient pediatric ophthalmology clinic.

PURPOSE: To describe the efficacy and systemic side effects of apraclonidine drops 0.5% in children clinically suspected of having Horner syndrome. METHODS: The medical records of patients with clinically suspected Horner syndrome who underwent testing with apraclonidine 0.5% eyedrops were reviewed retrospectively. The following data were retrieved from the record: allergic reactions, somnolence, shallow respiration, pallor, or excessive fussiness noted by the examiner or parents. RESULTS: A total of 46 patients presenting with anisocoria and tested with apraclonidine 0.5% were included. Of these, 15 had a positive result, with reversal of anisocoria. The mean age of patients was 3.2 years (median, 0.91; mode, 0.25 years). Twenty-four patients were ≤1 year of age; 19 were ≤6 months. No systemic side effects were noted during the examination or reported by parents in any patients. CONCLUSIONS: The use of topical apraclonidine eyedrops has been described as an effective test for Horner syndrome. However, concerns have been raised regarding the potential systemic side effects in children, especially those under the age of 6 months. In our cohort, no systemic side effects were reported, including in those under 6 months of age.

[Horner's syndrome during vaginal delivery with epidural analgesia]. / Epidural analjezi ile vajinal dogum sirasinda gelisen Horner sendromu.

One of the most severe pains that women can experience throughout their lives is birth pain. Epidural analgesia is the ideal method to provide pain control in vaginal delivery. Horner syndrome is a rare complication of epidural analgesia. In pregnant women, Horner syndrome may be seen more frequently due to epidural analgesia. It is characterized by ptosis, myosis, enophthalmos, anisocoria, conjunctival hyperemia, flashing on the affected face and sweating record (anhydroz). It usually resolves without a permanent neurological defect. Stellate, cervical and brachial plexus blocks, thoracic, lumbar and sacral region epidural anesthesia applications are among the most common causes of Horner syndrome associated with anesthesia applications. The non-anesthetic causes of Horner syndrome include head and neck surgery, hypothalamus-thalamus and brainstem-related lesions, trauma to the head and neck, and pulmonary apical tumors associated with malignancy. In this case report, we want-ed to present Horner syndrome in vaginal delivery with epidural analgesia. All pregnant women undergoing epidural analgesia should be closely followed up, taking into account possible complications and taking necessary precautions.

Atypical presentation of subdural block resulting in Horner's syndrome and loss of consciousness.

Horner's syndrome is a rare side effect for patients receiving epidural anaesthesia. Studies described Horner's syndrome due to cephalic spread of injected anaesthetics, a high spinal anaesthesia, or a sign of an inadvertent subdural block. A 31-year-old woman (Gravida 1 Para 0) at 40 weeks and 2 days had a caesarean section secondary to second stage arrest. Fourteen minutes after she received the lidocaine bolus, she became unresponsive with nystagmus, unequal pupils and no pupillary reflex. Head CT and MRI showed no intracranial haemorrhage and 2 hours later, she had spontaneous resolution of neurological symptoms with no further sequelae. Although Horner's syndrome is a benign, transient process, clinicians should be mindful regarding epidural catheter placement causing subdural blocks resulting in spontaneous, reversible neurological deficits.

Horner's Syndrome with Unilateral Brachial Plexus Blockade Mimicking Cerebrovascular Accident Following Lumbar Combined Spinal Epidural Analgesia for Labor.

Horner's Syndrome (HS) with brachial plexus involvement following lumbar epidural anesthesia may be a startling event for the patient and providers. We present a case of Horner's Syndrome and complete brachial plexus blockade following epidural bolus of lidocaine for labor analgesia that was initially misdiagnosed as a cerebrovascular accident. Use of the catheter was discontinued and the episode resolved with expectant management. This complication is otherwise benign and resolves without sequelae.

Delayed Onset and Prolonged Horner Syndrome in Two Children After Single-Shot UltrasoundGuided Infraclavicular and Subclavian Perivascular Brachial Plexus Blocks for Upper Extremity Surgery: Case Reports.

Horner syndrome is a known complication of cervical approaches to brachial plexus blocks due to local anesthetic-induced oculosympathetic paresis. It has rarely been described in relation to ultrasound-guided brachial plexus blocks in children. This syndrome is usually self-limiting but may cause apprehension to the child, parents, and the treating physicians until its resolution. We report delayed manifestations of Horner syndrome in 2 children following ultrasound-guided infraclavicular and subclavian perivascular blocks.

Horner's Syndrome and Upper Extremity Weakness After Quadratus Lumborum Block for Postcesarean Section Analgesia: A Case Report.

A healthy, 34-year-old primigravida at 41 weeks gestational age presented for cesarean delivery due to a category 2 fetal heart tracing remote from delivery. After completion of the surgery under epidural anesthesia, bilateral quadratus lumborum blocks were performed for postoperative pain. Approximately 4 hours later, the patient developed left-sided arm weakness, left miosis, and ptosis. These symptoms resolved within 24 hours. Considering the time course of her symptoms, we believe that the quadratus lumborum block was the likely culprit.

[Horner syndrome following combined spinal-epidural anesthesia]. / Kombine spinal-epidural anestezi sonrasi Horner sendromu.

Horner syndrome is rarely observed in connection with epidural anesthesia. It is characterized by ptosis, enophthalmos, miosis, anisocoria, and conjunctival hyperemia in the affected eye, as well as anhydrosis and flushing on the affected side of the face. It is usually a complication spontaneously resolved without permanent neurological deficits. Intraoral anesthesia; stellate ganglion, cervical or brachial plexus blocks; thoracic, lumbar or caudal epidural anesthesia, and intrapleural analgesia are the main causes for Horner syndrome related to anesthesia. Among other causes of Horner syndrome are head and neck surgery, trauma, and puncture of internal jugular vein. The present case of unilateral Horner syndrome appeared in the aortobifemoral bypass after lumbar spinal- epidural anesthesia.

Effect of interscalene anaesthesia on cerebral oxygen saturation.

Interscalene blockade (ISB) is commonly associated with Horner's syndrome, indicating spread of injectate to the cervical sympathetic chain. Cervical sympathetic nerve activity (SNA) is believed to influence cerebral autoregulation, and a decrease in sympathetic tone may alter cerebral blood flow (CBF). This study investigated whether ISB influenced CBF in patients undergoing shoulder surgery. Patients (n=30) scheduled for elective shoulder arthroscopy were recruited. Cerebral oxygen saturation (ScO(2)) of the left and right frontal cortices was continuously measured during ISB administration, sedation and anaesthetic induction. Baseline ScO(2) was similar in blocked and unblocked sides (74 ± 5% and 73 ± 5% respectively, P=0.70). ScO(2) decreased with sedation (-3 ± 3% and -4 ± 3%, P=0.93), and increased with pre-oxygenation and general anaesthesia (P <0.01). Following ISB there was no change in ScO(2) between blocked and unblocked sides (P=0.18), or any difference between right- or left-sided ISB. ISB is not associated with an increase in CBF as indicated by ScO(2), despite the presence of Horner's syndrome.

Horner's Syndrome after Superficial Cervical Plexus Block.

Ultrasound-guided nerve blocks are becoming more essential for the management of acute pain in the emergency department (ED). With increased block frequency comes unexpected complications that require prompt recognition and treatment. The superficial cervical plexus block (SCPB) has been recently described as a method for ED management of clavicle fracture pain. Horner's syndrome (HS) is a rare and self-limiting complication of regional anesthesia in neck region such as brachial and cervical plexus blocks. Herein we describe the first reported case of a HS after an ultrasound-guided SCPB performed in the ED and discuss the complex anatomy of the neck that contributes to the occurrence of this complication.

Transient Horner's syndrome following thoracic epidural anesthesia for mastectomy: a prospective observational study.

PURPOSE: Transient Horner's syndrome is an uncommon complication of epidural anesthesia, though its exact incidence in thoracic epidural anesthesia is not clear. Therefore, this study prospectively evaluated the incidence of Horner's syndrome after thoracic epidural anesthesia for mastectomy. METHODS: Patients scheduled for mastectomy, with or without breast reconstruction, were enrolled in this prospective observational study from September 2010 to December 2013. Intraoperative thoracic epidural anesthesia was established using 0.375% or 0.5% ropivacaine 15 mL with thoracic epidural analgesia continued postoperatively with a continuous infusion of 0.15% ropivacaine 2 mL·hr(-1) with fentanyl 8 µg·hr(-1). Signs of Horner's syndrome (miosis, ptosis, and hyperemia) were assessed at one and two hours as well as one, two, and three days postoperatively. RESULTS: Thoracic epidural anesthesia was successful in 439 patients, with six (1.4%) of these patients acquiring Horner's syndrome. All signs of Horner's syndrome resolved gradually within 180 min of discontinuing the epidural infusion. In one patient with Horner's syndrome, a radiographic contrast injection confirmed that the drug had spread to the cervical epidural level. CONCLUSION: The incidence of Horner's syndrome following thoracic epidural anesthesia and continuous thoracic epidural analgesia for mastectomy was 1.4%. The mechanism was consistent with cephalic spread of the epidural local anesthetic. This trial was registered at: Clinicaltrials.gov, number: NCT02130739.

Naphazoline as a confounder in the diagnosis of carotid artery dissection.

Diagnosing Horner Syndrome can be difficult in the setting of an incomplete triad. A 27-year-old man presented with unilateral eyelid droop and intermittent ipsilateral headaches, having already seen 7 physicians. Physical examination revealed unilateral ptosis but no pupillary miosis or facial anhidrosis. Inspection of his clinical photographs revealed elevation of the ipsilateral lower eyelid, suggesting sympathetic dysfunction. On further questioning, he admitted to naphazoline dependence. Reexamination after ceasing the naphazoline unveiled the anisocoria. Vascular imaging subsequently revealed carotid dissection, and the patient was started on anticoagulant and antiplatelet therapy. The ptosis persisted after conjunctival Müllerectomy. External levator resection was recommended, but patient declined. This case underscores the importance of clinical photography, meticulous medical record review, and complete medication history including over-the-counter preparations. Clinicians should meticulously inspect the lower eyelid in cases of atypical blepharoptosis and consider the effects of eye drops when inspecting pupils for miosis.