Ipilimumab-induced Adenohypophysitis and Orbital Apex Syndrome: Importance of Early Diagnosis and Management.

Ipilimumab is a novel anti-melanoma agent known to infrequently cause multi-organ autoimmunity. We report a case of pituitary hypophysitis and orbital inflammation followed by an orbital apex syndrome. A 64-year-old woman with a history of skin melanoma, receiving ipilimumab treatment, was seen for near total loss of vision in the right eye and proptosis. Headache of 3-month duration preceded the onset of diplopia followed by severe loss of vision in the right eye. Neuro-ophthalmologic examination was consistent with an orbital apex syndrome. Extensive blood work and magnetic resonance imaging of the brain and orbit suggested an inflammatory process, rather than a metastatic lesion. Accordingly, the patient received high-dose methylprednisolone followed by tapering oral prednisone. At the 6-month follow-up visit, visual acuity on the right eye had significantly improved but diplopia remained, associated with large amplitude esotropia that improved incompletely though while on prednisone. The favourable outcome supported a final diagnosis of ipilimumab-induced inflammatory orbital apex syndrome and clinically silent pituitary adenohypophysitis. The case presented herein highlights unexpected ipilimumab-associated adverse effects and proposes the possibility of and interaction between inflammatory and immune mechanisms.

Neuroimaging "HINTS" of the Lateral Medullary Syndrome.

A series of neuroimaging studies illustrates many of the key findings of the lateral medullary syndrome.

Free Floating Thrombus in Carotid Artery in a Patient with Recurrent Strokes.

We present a case of 72-year-old male with reported past medical history of recurrent transient ischemic attacks (TIAs) presenting with myriad of neurological symptoms. Patient was transferred from outlying hospital with complaints of right sided facial droop and dysarthria. Computed tomography angiography (CTA) showed high grade proximal left internal carotid artery (ICA) stenosis along with interesting finding of a free floating thrombus (FFT) in the left ICA. After discussion with the neurosurgical team, our case was treated conservatively with combination of antiplatelet therapy with Aspirin and anticoagulation with Warfarin without recurrence of TIAs or strokes on six-month follow-up.

Magnetic resonance spectroscopy imaging characteristics of cerebral Blastomycosis.

BACKGROUND: Blastomycosis is a dimorphic fungus that is endemic to the midwest and southwestern United States. Involvement of the central nervous system (CNS) is thought to only represent 5-10% of cases of disseminated Blastomycosis. CASE DESCRIPTION: A 54-year-old Caucasian female presented to the Neurosurgery service with a 1-day history of progressive right sided hemiparesis. Magnetic resonance imaging (MRI) demonstrated a 2 × 4 cm heterogeneous intracranial mass lesion involving the left motor cortex and extending into the ipsilateral parietal lobe. Single-voxel magnetic resonance spectroscopy (MRS) over the enhancing area demonstrated diminished N-acetyl aspartate (NAA) to creatine ratio (1.10), normal choline to NAA ratio (0.82), normal choline to creatine ratio (0.9), and a diminished myoinositol to creatine ratio (0.39). There appeared to be peaks between 3.6 and 3.8 ppm over the enhancing area that were not present in the contralateral normal brain and thought to represent a "trehalose" peak. Due to worsening symptoms and uncertain preoperative diagnosis, the patient underwent a left fronto-parietal craniotomy for open surgical biopsy with possible resection approximately one month after presentation. Pathological analysis confirmed the diagnosis of Blastomycosis. CONCLUSION: We present the second documented case of intracranial Blastomycosis with MRS imaging. There appears to be a characteristic peak between 3.6 and 3.8 ppm that is thought to represent a "trehalose" peak. This peak is rather specific to fungi and can be helpful in differentiating fungal abscesses from pyogenic abscesses and malignant neoplasms.

Cortical vision loss as a prominent feature of H1N1 encephalopathy.

A 20-year-old woman infected with the 2009 H1N1 strain of influenza A developed bilateral visual loss. Brain MRI showed restricted diffusion of the parietal and occipital lobes, and her spinal fluid did not contain inflammatory cells. This report describes an unusual case of H1N1 influenza A virus infection primarily affecting the posterior visual pathways.

Radiology update in neuro-ophthalmology.

PURPOSE OF REVIEW: Radiologic imaging is indispensible for the diagnosis and management of many neuro-ophthalmologic conditions. Advances in the radioimaging of neuro-ophthalmologic disorders may evolve from the clinical or the radiological side, meaning there is a constant stream of new information for the clinician. RECENT FINDINGS: Functional MRI, diffusion tensor MRI, magnetization transfer imaging, and magnetic resonance spectroscopy are examples of nonstandard radiographic techniques, which have expanded the knowledge of neuro-ophthalmologic conditions. Studies using conventional MRI have also led to advances in understanding optic neuropathies, the ocular motor system, pseudotumor cerebri, posterior reversible encephalopathy syndrome and migraine. SUMMARY: This article discusses recent radiologic advances relevant to neuro-ophthalmology.

Spine infection/inflammation.

This article discusses the imaging of infectious and other inflammatory conditions that affect the spinal cord, spinal column, intradural spinal nerve roots, and spinal meninges with emphasis on magnetic resonance (MR) imaging. Inflammatory lesions of the spine are often indistinguishable on imaging and even on pathologic examination. However, infectious causes are treatable so it is important for the radiologist to make the diagnosis. The most common inflammatory and infectious conditions affecting the anatomic compartments of the spine are described, following an external to internal anatomic approach. Subsequently, several infectious pathogenic agents are discussed individually as they affect the spinal column and its contents.