ABSTRACT
The most frequently diagnosed complication of vertebrobasilar dolichoectasia (VBD) is the compression of structures adjacent to the vertebral and basilar arteries. A giant VBD with only slight compressive symptoms is unusual. In this setting, the diagnosis of VBD may be casually revealed after the occurrence of a posterior circulation stroke, another potential complication. We report a 48-year-old woman who presented a two-month history of continuous buzz and a slight right-sided hearing loss that was followed by a cerebellar ischemic stroke. Brain CT and MRI revealed a marked compression of the brainstem due to an ectatic, tortuous and partially thrombosed basilar artery (BA). The largest cross-sectional diameter of BA was 18 mm. The patient had a good functional recovery within the two-month follow-up after stroke with modified Rankin scale score (mRSS)=2. At the one-year follow-up, patient still kept the complaints of continuous buzz, slight right-sided hearing loss and the mRSS was the same. We call attention for an unusual giant VBD that caused an impressive brainstem compression with displacement of important structures in an oligosymptomatic patient. Diagnosis was made only after the occurrence of a stroke. Despite of the good functional recovery after stroke, the presence of significant atherosclerotic changes and the large BA diameter may indicate a poor outcome. However, after one year, she remains oligosymptomatic.
A complicação mais freqüentemente encontrada na dolicoectasia vertebrobasilar (DVB) é a compressão de estruturas adjacentes às artérias vertebrais e à artéria basilar. Uma DVB gigante apenas com sintomas compressivos leves é infreqüente. Nesse caso, o diagnóstico pode ser descoberto ao acaso após uma isquemia da circulação posterior, outra complicação possível da DVB. Relatamos o caso de uma mulher de 48 anos com história de zumbido e perda auditiva leve a direita por 2 meses, desenvolvendo, a seguir, uma isquemia cerebelar. A tomografia e a ressonância magnética demonstraram uma compressão acentuada do tronco cerebral devido a uma artéria basilar (AB) ectásica, tortuosa e preenchida parcialmente por trombo. O maior diâmetro axial da AB tinha 18 mm. A paciente apresentou boa recuperação funcional dentro dos primeiros dois meses após a isquemia, com escore de Rankin modificado (ERM)=2. Após um ano, a paciente ainda mantinha as queixas de zumbido e perda auditiva leve à direita, e o ERM ainda se mantinha=2. Chamamos a atenção para um caso raro de DVB gigante que causou impressionante compressão do tronco cerebral, com deslocamento de importantes estruturas, numa paciente oligossintomática. O diagnóstico só foi realizado após a ocorrência da isquemia. Apesar da boa recuperação funcional inicialmente observada, a presença de alterações ateroscleróticas e o grande diâmetro da AB podem indicar um prognóstico ruim. Contudo, após um ano a paciente ainda se mantinha oligossintomática.
Subject(s)
Female , Humans , Middle Aged , Nerve Compression Syndromes/etiology , Stroke/etiology , Vertebrobasilar Insufficiency/complications , Basilar Artery/pathology , Brain Stem/pathology , Cerebral Infarction/etiology , Dilatation, Pathologic , Magnetic Resonance Angiography , Magnetic Resonance Imaging , Tomography, X-Ray Computed , Vertebrobasilar Insufficiency/diagnosisABSTRACT
A patogênese da dissecção arterial cervical espontânea não é totalmente conhecida. O dano à parede arterial causado ou mediado por processos infecciosos pode ser um importante fator desencadeante. Descrevemos o caso de um homem de 21 anos que apresentou uma infecção do trato respiratório (broncopneumonia) diagnosticada e tratada poucos dias antes da dissecção da artéria carótida interna direita. O paciente apresentou lesões isquêmicas na retina e no território estriatocapsular, ambos à direita. Baseados na revisão da literatura, discutimos a possibilidade de uma relação causal entre infecção e dissecção arterial.
Subject(s)
Adult , Humans , Male , Carotid Artery, Internal, Dissection/etiology , Respiratory Tract Infections/complications , Brain Ischemia/etiology , Carotid Artery, Internal, Dissection/diagnosis , Respiratory Tract Infections/diagnosis , Stroke/etiologyABSTRACT
OBJETIVO: Dada a ausência de estudos de séries brasileiras de pacientes com dissecção arterial cervical espontânea, com o objetivo de descrever os fatores de risco, sintomas precedentes, manifestações clínicas, resultados da investigação, tratamento e evolução. MÉTODO: realizamos a análise retrospectiva dos prontuários e laudos radiológicos [angiografia digital(AD), ressonância magnética(RM) e ângio-ressonância(ARM)] dos pacientes com esse diagnóstico atendidos no Serviço de Neurologia do HC/USP entre 1997 e 2003. RESULTADOS: 48 pacientes (24 homens), média de idade 37,9 anos; 26 pacientes com dissecção carotídea (DC) unilateral, 15 com vertebral (DV) unilateral e 7 com multiarterial, todos com déficits neurológicos. Os principais fatores de risco para doença vascular foram hipertensão arterial, tabagismo e dislipidemia. Mais de 80 por cento apresentaram pelo menos um sintoma precedente, na maioria cefaléia têmporo-parietal. Cervicalgia foi referida por 44 por cento dos pacientes com DV e por 3,4 por cento dos com DC. O tempo médio entre o primeiro sintoma e o déficit foi 5,4 dias para as DC e 13,5 para as DV. AD foi o principal método diagnóstico (93 por cento), associado a RM e ARM em 42 por cento dos casos. Em 3 pacientes a RM cervical com supressão de gordura foi isoladamente suficiente. 75 por cento dos pacientes receberam anticoagulação. Dois pacientes fizeram trombólise endovenosa sem complicações. A evolução foi boa, exceto por dois óbitos (DC bilateral). CONCLUSAO: Os resultados são semelhantes aos da literatura, exceto pela baixa freqüência de cervicalgia nos casos de DC e pelo predomínio de cefaléia têmporo-parietal nas dissecções arteriais cervicais. Fatores de risco para doença vascular isquêmica foram frequentes.
Subject(s)
Humans , Male , Female , Child , Adolescent , Adult , Middle Aged , Carotid Artery, Internal, Dissection/physiopathology , Vertebral Artery Dissection/physiopathology , Age Distribution , Carotid Artery, Internal, Dissection/diagnosis , Magnetic Resonance Imaging , Retrospective Studies , Risk Factors , Vertebral Artery Dissection/diagnosisABSTRACT
Partial oculosympathetic palsy followed by ischemic manifestations in brain or retina are the main symptoms of extracranial internal carotid artery (ICA) dissection. Unusually, cranial nerves may be affected. Isolated oculomotor nerve palsy is found only rarely. CASE: We present a 50-year-old nondiabetic man who experienced acute onset of right occipital headache which spread to the right retro-orbital region. Five days later he noticed diplopia and right blurred vision sensation. Neurologic examination disclosed only impaired adduction and upward gaze of right eye, slight ipsilateral pupillary dilatation, without ptosis. Brain MRI was normal. Angiography showed right internal carotid artery dissection with forward occlusion to the base of the skull. Intravenous heparin followed by warfarin was prescribed. The headache and the oculomotor nerve deficit gradually resolved in the next three weeks. DISCUSSION: Isolated oculomotor nerve palsy is underrecognized as a clinical presentation of extracranial ICA dissection. If the angiographic evaluation is incomplete without careful study of extracranial arteries, misdiagnosis may lead to failure to initiate early treatment to prevent thromboembolic complications. For this reason we draw attention to the need for careful evaluation of cervical arteries in patients with oculomotor nerve palsy. Mechanical compression or stretching of the third nerve are possible mechanisms, but the direct impairment of the blood supply to the third nerve seems to be the most plausible explanation
Subject(s)
Humans , Male , Middle Aged , Carotid Artery, Internal, Dissection , Oculomotor Nerve Diseases , Cerebral AngiographyABSTRACT
Subclavian steal syndrome refers to the association of neurological symptoms related to vertebrobasilar insufficiency and the phenomenon of subclavian steal. We report the case of a 63 year-old male patient that presented subclavian steal syndrome and severe proximal (80 percent) stenosis of the left subclavian artery. The patient was submitted to percutaneous transluminal angioplasty and stenting on the left SA. The procedure was well tolerated and immediately afterwards, there was complete remission of the symptoms and of the phenomenon of subclavian steal evaluated by angiography and transcranial doppler. We propose that percutaneous transluminal angioplasty with stenting placement is a good therapeutic option for subclavian steal syndrome
Subject(s)
Humans , Male , Middle Aged , Angioplasty, Balloon , Stents , Subclavian Artery , Subclavian Steal Syndrome/therapy , Coronary Artery Bypass , Coronary Disease , Subclavian Artery , Subclavian Steal Syndrome/complicationsABSTRACT
Spinal myoclonus is a rare movement disorder characterized by myoclonic involvement of a group of muscles supplied by a few contiguous segments of the spinal cord. Structural lesions are usually the cause, but in primary spinal myoclonus the etiology remains unknown. We present the case of a 26-year-old woman with cervical spinal myoclonus in which both clinical and electromyographic findings pointed to the segment C1-C3 as the origin of the myoclonus. Laboratorial examinations were normal and no structural lesion was found in magnetic resonance imaging (MRI). Botulinum toxin type A was injected in infrahyoid muscles and cervical paraspinal musculature. The patient remained free of symptoms for almost five months. The pathophysiology of spinal myoclonus remains speculative, but there is evidence that various possible mechanisms can be involved: loss of inhibitory function of local dorsal horn interneurons, abnormal hyperactivity of local anterior horn neurons, aberrant local axons re-excitations and loss of inhibition from suprasegmentar descending pathways
Subject(s)
Humans , Female , Adult , Myoclonus , Spinal Cord Injuries , Botulinum Toxins, Type A , Injections, Intramuscular , Magnetic Resonance Imaging , Myoclonus , Neuromuscular Agents , Spinal Cord InjuriesABSTRACT
Espasmo hemifacial bilateral é um distúrbio de movimento raro geralmente associado à compressäo vascular dos nervos faciais. Caracteriza-se clinicamente por contrações assimétricas e assíncronas da musculatura facial e por longa latência entre a instalaçäo dos movimentos em cada hemiface. Deve ser diferenciado de outras condições como blefaroespasmo, miocimia facial, tiques faciais, distonia oromandibular e espasmo hemimastigatório. O tratamento sintomático mais eficaz e menos invasivo consiste em aplicações de toxina botulínica mas abordagem cirúrgica de descompressäo microvascular é outra alternativa terapêutica. Relatamos o caso de homem de 70 anos com espasmo hemifacial bilateral e fazemos uma breve revisäo da literatura
Subject(s)
Humans , Male , Aged , Hemifacial Spasm , Botulinum Toxins , Decompression, Surgical , Hemifacial Spasm , Magnetic Resonance Angiography , Neuromuscular AgentsABSTRACT
Movement disorders induced by central nervous system trauma are well recognized. However, over the last few years, attention has been drawn to the role of peripherally induced movement disorders. We describe three patients presenting respectively dystonia, tremor and choreoathetosis associated with tremor and dystonia of the body parts previously exposed to traumatic injuries. Pathophysiological mechanisms underlying these phenomena are not entirely known, but functional changes in afferent neuronal input to the spinal cord and secondary affection of higher brain stem and subcortical centers are probably involved