Weber syndrome secondary to brain stem tuberculoma

This case report describes a rare presentation of presumed brain stem tuberculoma in a 28-year-old male who presented with acute onset of third cranial nerve palsy with contralateral hemiparesis (Weber syndrome) and upgaze palsy. Isolated midbrain tuberculoma is rare, presenting with varied clinical manifestations and radiological findings posing as a diagnostic dilemma. Weber syndrome is commonly caused by midbrain infarct secondary to occlusion of branches of the posterior cerebral artery and rarely from a tuberculoma. The patient is a case of disseminated tuberculosis with granuloma in midbrain causing pressure effect, thereby presenting with features consistent with Weber syndrome and upgaze palsy. The patient had good recovery with antitubercular treatment and systemic steroids.

The Neuro-ophthalmic Presentation of Intracranial Aneurysms

PURPOSE: To investigate the neuro-ophthalmic diagnosis and clinical manifestations of intracranial aneurysm. METHODS: A retrospective survey of 33 patients who were diagnosed with intracranial aneurysm and underwent neuro-ophthalmic examination from April 2008 to December 2016. Frequency of the first diagnosis of intracranial aneurysm in ophthalmology, neuro-ophthalmic diagnosis, location of intracranial aneurysm, examination of intracranial aneurysm rupture, and neurologic prognosis of Terson's syndrome patients were analyzed by image examination, neurosurgery, and ophthalmology chart review. RESULTS: Of the 33 patients, most patients (n = 31, 94%) were diagnosed with intracranial aneurysm at the neurosurgical department and only 2 patients were diagnosed initially at the ophthalmology department. Causes and association were: Terson's syndrome (n = 10, 30%), third cranial nerve palsy (n = 10, 30%), internclear ophthalmoplegia (n = 4, 12%), visual field defect (n = 3, 9%), optic atrophy (n = 3, 9%), sixth cranial nerve palsy (n = 2, 6%), and nystagmus (n = 1, 3%). The location of intracranial aneurysms were: anterior communicating artery (n = 13, 39%), medial communicating artery (n = 12, 36%), and posterior communicating artery (n = 5, 15%). Ten of 33 patients had Terson's syndrome, and 6 patients (60%) with Terson's syndrome had apermanent neurological disorder such as agnosia, gait disorder and conduct disorder. CONCLUSIONS: Third cranial nerve palsy was the most common neuro-ophthalmic disease in patients presenting with intracranial aneurysm. The neuro-ophthalmic prognoses for those diseases were relatively good, but, if Terson's syndrome was present, neurological disorders (agnosia, gait disorder, conduct disorder) were more likely to remain after treatment.

Gossypiboma: el sempiterno problema de los cuerpos extraños retenidos y el privilegio del internista / Gossypiboma: the always present problem of surgical strange object`s retention and the internis` privilege

La retención de objetos quirúrigicos o cuerpos extraños durante un acirugía, es un problema ampliamente reconocido en el sistema de atención de la salud. Causa daño a los pacientes, proveedores, hospitales, comunidades y al sistema de atención dela salud como todo. También resulta en gastos inncesarios. La retención de objetos quirúrgicos es un problema totalmente evitable. Se presenta el caso de una mujer diabética que presentó una parálisis incompleta tercer nervio central y durante la explotación física integral, privilegio del internista, se encontró un tumor abdominal asintomátco. La tomografía computarizada fue compatible con una retención de objetos quirurgicos. Este artículo exmina los factores de riesgo para que ocurra la retención, examina los métodos actuales de prevención y los estudios de las nuevas tecnologías que se han desarrollado para evitar este error médico

The retention of surgical objects is a widely recognized problem within the health care system. It causes harm to patients, providers, hospitals, communities, and to the health care system as a whole. It also results in needless expense. The retention of surgical objects is a problem completely preventable. We presented the case of a diabetic woman who presented with incomplete third nerve palsy and incidentally, as an internist`s privilege, an asymptomatic abdominal tumor was clinicaly found. The computarized tomography scan was compatible with a retention of surgical objects. This article reviews the risk factors for retention of surgical objects, examines the current methods of prevention, and surveys the new technologies that have been developed to prevent this medical error

Pituitary Apoplexy Presenting as Isolated Third Cranial Nerve Palsy with Ptosis : Two Case Reports

Pituitary apoplexy is a clinical syndrome caused by an acute ischemic or hemorrhagic vascular accident involving a pituitary adenoma or an adjacent pituitary gland. Pituitary apoplexy may be associated with a variety of neurological and endocrinological signs and symptoms. However, isolated third cranial nerve palsy with ptosis as the presenting sign of pituitary apoplexy is very rare. We describe two cases of pituitary apoplexy presenting as sudden-onset unilateral ptosis and diplopia. In one case, brain magnetic resonance imaging (MRI) revealed a mass in the pituitary fossa with signs of hemorrhage, upward displacement of the optic chiasm, erosion of the sellar floor and invasion of the right cavernous sinus. In the other case, MRI showed a large area of insufficient enhancement in the anterior pituitary consistent with pituitary infarction or Sheehan's syndrome. We performed neurosurgical decompression via a transsphenoidal approach. Both patients showed an uneventful recovery. Both cases of isolated third cranial nerve palsy with ptosis completely resolved during the early postoperative period. We suggest that pituitary apoplexy should be included in the differential diagnosis of patients presenting with isolated third cranial nerve palsy with ptosis and that prompt neurosurgical decompression should be considered for the preservation of third cranial nerve function.

Suprasellar Cysticercosis Associated With Partial Third Cranial Nerve Palsy Relieved by Surgical Cyst Removal

PURPOSE: To report a case of partial third cranial nerve palsy in a patient with suprasellar cysticercosis. Surgical removal of the cyst was followed by symptom improvement. CASE SUMMARY: A 36-year-old man presented with binocular diplopia for 3 months. His best corrected visual acuities were 20/20 in both eyes, and both slit lamp and fundus examinations were unremarkable. The alternate prism cover test revealed four prism diopters (Delta) of exotropia and 4Delta of left hypotropia. Supraduction and adduction was mildly limited in the left eye. Pupil size was larger in the left eye and anisocoria was greater under bright light. Color test and visual field examination were normal. Neurologic examination showed a weakness of grade IV in the upper and lower extremities. Brain magnetic resonance imaging revealed a well-encapsulated cystic mass of homogeneous low intensity signal in the suprasellar area extending into the midbrain. Craniotomy and cyst removal were performed, and histologic findings were compatible with neurocysticercosis. Two weeks postoperatively the patient was free of diplopia and limb weakness. CONCLUSIONS: Neurocysticercosis of a suprasellar origin may produce mass effects on the midbrain, inducing focal neurologic deficits of partial third cranial nerve palsy along with limb weakness. Masses of suprasellar origin can be successfully treated by surgical removal of the cyst.

Resolution of Third Cranial Nerve Palsy Following Endovascular Treatment of the Posterior Communicating Artery Aneurysm

Third cranial nerve palsy may indicate the presence of an intracranial aneurysm, most commonly in the posterior communicating artery. The effect of endovascular management of posterior communicating artery aneurysms on recovery from third cranial nerve palsy is not well documented. We report two patients with third cranial nerve palsy caused by posterior communicating artery aneurysms. Endovascular treatment resulted in subsiding of ptosis within two weeks. Resolution of extraocular muscle function occurred within one to three months after treatment. Endovascular treatment, which has recently been introduced into neurosurgical practice, is effective in preventing aneurysmal rupture, and in eliminating manifestations due to mass effects.