Estudio de una ptosis ocular en un manuscrito iluminado del siglo XIII / Study of an ocular ptosis in a 13th century illuminated manuscript

Introducción: El hallazgo de una ptosis palpebral en un manuscrito del siglo xiii plantea el diagnóstico diferencial de lesión del tercer par craneal. Este nervio no fue diferenciado de los otros oculomotores hasta el s. xvi. En el s. xix se estableció una correlación clinicopatológica con su parálisis. Objetivo: Describir las características y diagnósticos diferenciales de una ptosis palpebral ilustrada en el Libro de las obras divinas (1173) de Hildegarda de Bingen. Desarrollo: En la obra en cuestión se retrata a la monja Richardis de Stade con su párpado izquierdo caído. Se describen dos signos notorios, ptosis y elevación de la ceja correspondiente, y se infiere la desviación del ojo hacia abajo y afuera por la forma que le imprime al párpado la posición del ojo y la curvatura de la córnea. El cuadro es consistente con una parálisis aislada del motor ocular común. Se discuten las causas de ptosis: aponeurótica por dehiscencia del levator palpebrae; miógenas, congénitas y adquiridas; de la unión neuromuscular; y neuropática, que es la más probable en este caso y de mecanismo compresivo. Conclusiones: El retrato de Richardis de Stade muestra una parálisis del motor ocular común siglos antes de que se conocieran su anatomía, función y expresión clinicopatológica. Su inesperada muerte de causa natural hace presumir la ruptura de un aneurisma cerebral. El mérito de esta descripción original debe concedérsele a Hildegarda, cuya vocación médica ha sido largamente reconocida.(AU)

Introduction: The finding of an eyelid ptosis in a manuscript of the xiii century raises the differential diagnosis of injury to the third cranial nerve. This nerve was not differentiated from the other oculomotors until the xvi century and only in the xix century a clinicopathological correlation was established for its paralysis. Aim: Describe the characteristics and differential diagnoses of an eyelid ptosis illustrated in the Book of Divine Works (1173) by Hildegard of Bingen. Development: In the mentioned work the nun Richardis of Stade is portrayed with her left eyelid drooping. Two conspicuous signs are described, ptosis and corresponding raising of the eyebrow. The deviation of the eye downward and outward is inferred from the shape that adopts the eyelid by the position of the eye and the curvature of the cornea. The picture is consistent with an isolated paralysis of the oculomotor nerve. The causes of ptosis are discussed: aponeurotic due to levator palpebrae dehiscence; myogenic, congenital and acquired; of the neuromuscular junction, and neuropathic, the latter being the most probable in this case and of a compressive mechanism. The nun’s unexpected natural death suggests a ruptured brain aneurysm. Conclusions: Richardis of Stade’s portrait shows an oculomotor paralysis centuries before its anatomy, function, and clinicopathological expression were known. Credit for this original description must go to Hildegard, whose medical vocation has long been recognized.(AU)

Surgical Anatomy and Prevalence of Intracranial Aneurysms in Patients With Spontaneous Subarachnoid Hemorrhage.

Objective To assess the surgical anatomy and prevalence of intracranial aneurysms in patients with spontaneous subarachnoid hemorrhage. Materials and methods The current research investigated a total of 119 individuals from Peshawar, Pakistan. All the adult patients in the age range of 30 to 60 years, of both genders, presenting with spontaneous subarachnoid hemorrhage were included. A thorough history was taken, as well as a full, general, physical, systemic, and neurological examination was done. All individuals who arrived with a rapid onset of severe headache, with or without loss of consciousness, and had a CT scan showing spontaneous subarachnoid hemorrhage were included. All patients were subjected to CT angiography in the hospital to ascertain any intracranial aneurysm. CT angiography was done by a consultant radiologist (FCPS) having at least five years of experience. All the above-mentioned information, including age, diabetes, obesity, smoking, gender, and hypertension, was recorded in a predesigned proforma. Results The current study found that among 119 patients, 24 (20%) were of age 30-40 years, 44 (37%) were between 41 and 50 years, and 51 (43%) were of age 51 to 60 years; 73 (61%) were male and 46 (39%) were female; 67 (56%) were obese and 52 (44%) were not obese; 81 (68%) patients were hypertensive and 38 (32%) patients were non-hypertensive; 75 (63%) patients were diabetic and 44 (37%) patients were non-diabetic; 49 (41%) patients were smokers and 70 (59%) patients were non-smokers. Moreover, 96 (81%) patients had intracranial aneurysms and 23 (19%) patients did not have intracranial aneurysms. Conclusion As has been observed, the prevalence of intracranial aneurysms and surgical anatomy was 81% in individuals from Peshawar, Pakistan, with spontaneous subarachnoid hemorrhage.

Multiple cerebral aneurysms originating from previously resected cardiac myxoma

Primary cardiac tumors are very rare, accounting for 0,001 ­0,03% in autopsy series, cardiac myxoma (CM) account for approximately 50% of them. Association between CM and cerebral aneurysm is well documented in this condition but the occurrence of cerebral aneurysm after resection of CM is very rare, with only 40 reports in medical literature. We present a case of a 45 years old female patient with multiple cerebral aneurysms 2 years after a successful resection of cardiac myxoma, submitted to radiosurgery for 2 bigger aneurysms with good results. This report ads to literature new clinical findings and a hypothesis of radiosurgery as an effective option of treatment for cerebral aneurysms with origin in CM. Keywords: Cardiac Myxoma; Cerebral aneurysm; Radiosurgery; Neurosurgery.

Regeneración aberrante del III nervio craneal por aneurisma cerebral bilateral. Reporte de caso / Aberrant regeneration of the III cranial nerve due to bilateral cerebral aneurism

RESUMEN Los trastornos de la motilidad ocular constituyen motivo de consulta periódica en Oftalmología. La regeneración aberrante, trastorno muy poco reportado, es considerada la sincinesia oculomotora de mayor invalidez y complejidad. Diversas condiciones neuroftalmológicas están implicadas en la etiopatogenia de la enfermedad, la mayoría de las cuales puede ocasionar la muerte. El manejo de los síntomas y signos provocados por paradójicos movimientos oculares conjugados es difícil. Se reportó un caso con remisión tardía a neuroftalmología por diagnóstico inicial y evolución desfavorable. La historia psicofísica arrojó diagnóstico definitivo de regeneración aberrante del III nervio craneal secundario, a aneurisma cerebral de la carótida interna bilateral, agravado por reanastomosis quirúrgica. Una rigurosa, obligatoria e impostergable historia neuroftalmológica, se impone ante toda parálisis del III nervio craneal para brindar un diagnóstico etiológico preciso y de esta forma proteger la vida.

ABSTRACT The disturbances in ocular motility are the cause of periodical consultation in Ophthalmology. The aberrant regeneration, a scarcely reported disturbance, is considered the oculomotor synkinesis of highest disability and complexness. Several neuro-ophthalmologic conditions are implicated in the disease ethiopathogeny, and most of them could lead to death. The management of the symptoms and signs caused by paradoxical conjugated ocular movements is difficult. A case is reported of late remission to Neuro-ophthalmology due to unfavorable diagnosis and evolution. The psycho-physical history led to a definitive diagnosis of aberrant regeneration of the III secondary cranial nerve, to cerebral aneurism of the bilateral internal carotid, worsened by surgical re-anastomosis. In front of any paralysis of the III cranial nerve, it is necessary a rigorous, obligatory and immediate neuro-ophthalmological history to arrive to a precise etiological diagnosis, protecting life in that way.

Regeneración aberrante del III nervio craneal por aneurisma cerebral bilateral. Reporte de caso / Aberrant regeneration of the III cranial nerve due to bilateral cerebral aneurism

RESUMEN Los trastornos de la motilidad ocular constituyen motivo de consulta periódica en Oftalmología. La regeneración aberrante, trastorno muy poco reportado, es considerada la sincinesia oculomotora de mayor invalidez y complejidad. Diversas condiciones neuroftalmológicas están implicadas en la etiopatogenia de la enfermedad, la mayoría de las cuales puede ocasionar la muerte. El manejo de los síntomas y signos provocados por paradójicos movimientos oculares conjugados es difícil. Se reportó un caso con remisión tardía a neuroftalmología por diagnóstico inicial y evolución desfavorable. La historia psicofísica arrojó diagnóstico definitivo de regeneración aberrante del III nervio craneal secundario, a aneurisma cerebral de la carótida interna bilateral, agravado por reanastomosis quirúrgica. Una rigurosa, obligatoria e impostergable historia neuroftalmológica, se impone ante toda parálisis del III nervio craneal para brindar un diagnóstico etiológico preciso y de esta forma proteger la vida (AU).

ABSTRACT The disturbances in ocular motility are the cause of periodical consultation in Ophthalmology. The aberrant regeneration, a scarcely reported disturbance, is considered the oculomotor synkinesis of highest disability and complexness. Several neuro-ophthalmologic conditions are implicated in the disease ethiopathogeny, and most of them could lead to death. The management of the symptoms and signs caused by paradoxical conjugated ocular movements is difficult. A case is reported of late remission to Neuro-ophthalmology due to unfavorable diagnosis and evolution. The psycho-physical history led to a definitive diagnosis of aberrant regeneration of the III secondary cranial nerve, to cerebral aneurism of the bilateral internal carotid, worsened by surgical re-anastomosis. In front of any paralysis of the III cranial nerve, it is necessary a rigorous, obligatory and immediate neuro-ophthalmological history to arrive to a precise etiological diagnosis, protecting life in that way (AU).