Acute Horner syndrome secondary to glandular fever due to Epstein Barr virus infection.

We present a clinical situation where a 47-year old female patient consulted with left partial ptosis and miosis that started, two weeks before, with an episode of glandular fever secondary to Epstein-Barr infection. Apraclonidine 0.5% and Phenylephrine 1% drop testing was performed with results consistent with suspected left Horner Syndrome (HS), with a probable postganglionic location. Magnetic Resonance Angiography (MRA) at the moment of the acute presentation did not show any image suggesting carotid arterial dissection but showed irregular narrowing of the left internal carotid artery on its paravertebral extracranial way, consistent to enlarged intra-carotid sheath lymphoid tissue. A week later, a Doppler ultrasound was performed, showing bilateral images compatible with internal carotid arterial dissection. When Postganglionar HS is suspected, the first aetiology to rule out is a carotid arterial dissection because of its potentially fatal outcome and for being a more described entity as postganglionic HS aetiology. However, it is also evidenced that a certain diagnose is not always possible. Furthermore, we describe the enlarged internal carotid artery sheath lymphoid tissue as a possible cause of sympathetic nerve disruption causing a Postganglionar HS, although not common.

Síndrome de Horner agudo secundario a mononucleosis infecciosa por virus de Epstein Barr / Acute Horner syndrome secondary to glandular fever due to Epstein Barr virus infection

Presentamos el caso clínico de una mujer de 47 años que consultó por miosis y ptosis del ojo izquierdo cuyo inicio coincidió, 15 días antes, con un episodio de mononucleosis infecciosa con serología positiva para virus de Epstein-Barr. Se realizaron test con colirios de apraclonidina al 0,5% y fenilefrina al 1%, que apoyaron el diagnóstico de síndrome de Horner(SH) izquierdo posganglionar. En el momento agudo se practicó una angiografía por resonancia magnética que descartó disección carotídea, pero evidenció una imagen de arrosariamiento de la arteria carótida interna izquierda a lo largo de su trayecto extracraneal paravertebral compatible con inflamación del tejido linfático de la capa adventicia de la arteria. Una semana más tarde la ecografía Doppler de troncos supraaórticos con la que se completó el estudio mostraba una imagen compatible con disección de la arteria carótida interna bilateral. Ante un caso de SH posganglionar la primera causa a descartar por su gravedad, y por ser una entidad más ampliamente descrita como etiología del SH de 3.ª neurona, es la disección carotídea. Sin embargo, con este caso ponemos de manifiesto que no siempre se puede llegar a un diagnóstico certero. Asimismo, describimos la inflamación del tejido linfático carotídeo como posible etiología de una lesión de la cadena simpática cervical como causa infrecuente de SH posganglionar (AU)

We present a clinical situation where a 47-year old female patient consulted with left partial ptosis and miosis that started, two weeks before, with an episode of glandular fever secondary to Epstein-Barr infection. Apraclonidine 0.5% and Phenylephrine 1% drop testing was performed with results consistent with suspected left Horner Syndrome (HS), with a probable postganglionic location. Magnetic Resonance Angiography (MRA) at the moment of the acute presentation did not show any image suggesting carotid arterial dissection but showed irregular narrowing of the left internal carotid artery on its paravertebral extracranial way, consistent to enlarged intra-carotid sheath lymphoid tissue. A week later, a Doppler ultrasound was performed, showing bilateral images compatible with internal carotid arterial dissection. When Postganglionar HS is suspected, the first aetiology to rule out is a carotid arterial dissection because of its potentially fatal outcome and for being a more described entity as postganglionic HS aetiology. However, it is also evidenced that a certain diagnose is not always possible. Furthermore, we describe the enlarged internal carotid artery sheath lymphoid tissue as a possible cause of sympathetic nerve disruption causing a Postganglionar HS, although not common (AU)

Hemorragia cerebral fatal en una paciente en tratamiento con Ginkgo biloba. ¿Se puede plantear una relación causal? / Fatal brain hemorrhage in a patient in treatment with Ginkgo Biloba. Can we raise a causal relationship?)

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Microsangrados silentes en pacientes con enfermedad cerebrovascular sintomática / Silent microhemorrhages in patients with symptomatic cerebrovascular disease

Introducción. La secuencia T2* eco de gradiente en resonanciamagnética cerebral (RM-T2*) permite detectar microsangrados(MS) producidos de modo silente y cuyo significadoclínico es en gran medida desconocido.Objetivo. Establecer la frecuencia de MS en una muestrade pacientes consecutivos con enfermedad cerebrovascularsintomática (ECS), analizando su asociación con distintosfactores de riesgo vascular y su posible significación clínica.Método. Examinamos mediante RM-T2* a 198 pacientesconsecutivos ingresados por ECS. Se analiza la asociación entre lapresencia y número de MS con distintos factores de riesgo vascular(FRV), subtipo de ictus y toma de medicación antitrombótica.Resultados. El 52,5% de nuestros pacientes presentaronMS. La mayor frecuencia (72,2%) se encontró en pacientes conhemorragia intracraneal (HIC), siendo el accidente isquémicotransitorio el subtipo con la menor proporción (42,9 %). Enanálisis bivariante los factores asociados con la presencia deMS fueron edad avanzada (72,4±10,5 frente a 67,7±12,7 años;p 0,004), hipertensión arterial (HTA) (65,4 frente a 51,1%;p 0,041), diabetes (35,6 frente a 22,3%; p 0,041) y el tratamientoantitrombótico (45,2 frente a 28,7%; p 0,017). En análisismultivariante fueron predictores de la presencia de MS la edadavanzada (p 0,019; OR: 1,03 [1,01-1,06]), HTA (p 0,031; OR: 1,97[1,06-3,65]), tratamiento antitrombótico previo (p 0,038;OR: 1,95 [1,04-3,65]) y haber sufrido un ictus hemorrágico(p 0,028; OR: 3,63 [1,15-11,46]).Conclusiones. La presencia de MS es frecuente entrepacientes con ECS, siendo especialmente elevada entre pacientescon ictus hemorrágico. Se asocian a FRV clásicamenteasociados con enfermedad de pequeño vaso y a la tomade tratamiento antitrombótico previo (AU)

Introduction. T2*-weighted gradient echo MRI sequences(T2*-MRI) have made it possible to detect cerebralmicrohemorrhages (MH) that have been consideredas subclinical but whose clinical significance is largelyunknown.Objective. To establish the frequency of MH in asample of consecutive symptomatic cerebrovascular disease(SCD) patients, analyzing its associations with differentvascular risk factors (VRF) and its clinical significance.Methods. A total of 198 patients with SCD were consecutivelyexamined using T2*-MRI. Preferential locationof MH and associations between MH presence and MHnumber with VRF, previous antithrombotic treatment andSCD subtypes were analyzed.Results. A total of 52.5% of our patients had MH.The highest frequency of MH was found in hemorrhagicstrokes (72.2%), Transitoy ischemic attack (TIA) (42.9%)being the group with the lowest frequency. According tothe bivariate analysis, the factors associated with the presenceof MH were elderly age (72.4±10.5 vs 67.7±12.7;p 0.004), hypertension (65.4 vs 51.1%; p 0.041), diabetes(35.6 vs 22.3 %; p 0.041) and being under antithrombotictreatment (45.2 vs 28.7 %; p 0.017). According to the multivariateanalysis, elderly age (p 0.019; OR: 1.03 [1.01-1.06]), hypertension (p 0.032; OR: 1.97 [1.06-3.65]), use ofantithrombotic treatment (p 0.038; OR: 1.95 [1.04-3.65])and having a hemorrhagic stroke (p 0.028; OR: 3.63 [1.15-11.46]) were predictors of MH presence.Conclusions. The presence of MH is frequent amongpatients with SCD, this being especially elevated in patientswith hemorrhagic stroke. Cerebral MHs are classically associatedwith VRF classically related with small vessel diseaseand previously taking antithrombotic treatment(AU)

[Silent microhemorrhages in patients with symptomatic cerebrovascular disease]. / Microsangrados silentes en pacientes con enfermedad cerebrovascular sintomática.

INTRODUCTION: T2*-weighted gradient echo MRI sequences (T2*-MRI) have made it possible to detect cerebral microhemorrhages (MH) that have been considered as subclinical but whose clinical significance is largely unknown. OBJECTIVE: To establish the frequency of MH in a sample of consecutive symptomatic cerebrovascular disease (SCD) patients, analyzing its associations with different vascular risk factors (VRF) and its clinical significance. METHODS: A total of 198 patients with SCD were consecutively examined using T2*-MRI. Preferential location of MH and associations between MH presence and MH number with VRF, previous antithrombotic treatment and SCD subtypes were analyzed. RESULTS: A total of 52.5% of our patients had MH. The highest frequency of MH was found in hemorrhagic strokes (72.2%), Transitory ischemic attack (TIA) (42.9%) being the group with the lowest frequency. According to the bivariate analysis, the factors associated with the presence of MH were elderly age (72.4+/-10.5 vs 67.7+/-12.7; p 0.004), hypertension (65.4 vs 51.1%; p 0.041), diabetes (35.6 vs 22.3 %; p 0.041) and being under antithrombotic treatment (45.2 vs 28.7 %; p 0.017). According to the multivariate analysis, elderly age (p 0.019; OR: 1.03 [1.01- 1.06]), hypertension (p 0.032; OR: 1.97 [1.06-3.65]), use of antithrombotic treatment (p 0.038; OR: 1.95 [1.04-3.65]) and having a hemorrhagic stroke (p 0.028; OR: 3.63 [1.15- 11.46]) were predictors of MH presence. CONCLUSIONS: The presence of MH is frequent among patients with SCD, this being especially elevated in patients with hemorrhagic stroke. Cerebral MHs are classically associated with VRF classically related with small vessel disease and previously taking antithrombotic treatment.

Mucocele gigante de seno esfenoidal con extensión orbitaria e intracraneal / No disponible

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Síndrome del seno carotídeo secundario a infiltración tumoral del espacio carotídeo cervical / Carotid sinus syndrome secondary to invasion of the cervical carotid space due to tumoral infiltration

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Topiramato y glaucoma agudo / Topiramate and acute glaucoma

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Hipotensión intracraneal espontánea: evolución de la imagen en resonancia magnética y confirmación mediante ventriculografía isotópica / Spontaneous intracranial hypotension: progression of the images obtained by magnetic resonance and confirmation by means of a gated blood pool scan

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Cefalea por abuso de triptanes / Triptans overuse headache

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Cavernomatosis múltiple. Diagnóstico diferencial por eco-gradiente / Multiple cavernomatosis. Differential diagnosis by gradient-echo

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