HSV-Encephalitis Resembling Acute Cerebral Infarction in a Patient With Atrial Fibrillation: Beware of Stroke Mimics.

INTRODUCTION: Herpes simplex virus-1 (HSV-1) encephalitis, the most common and potentially life-threatening type of encephalitis, may rarely present as a stroke mimic. Prompt diagnosis is of paramount importance for the timely initiation of antiviral treatment and to avert intravenous thrombolysis. CASE REPORT: A 60-year-old man with a history of lone paroxysmal atrial fibrillation without prior antithrombotic treatment was admitted due to mild gait unsteadiness and intermittent dysarthria of acute onset. On admission, the patient was afebrile, whereas neurological examination revealed only a mild pronator drift on the left. Brain magnetic resonance imaging (MRI) showed an extensive right temporo-occipital and thalamic lesion with restricted diffusion and 3 small-sized hemorrhagic foci. Brain MR-angiography did not show large vessel stenosis or occlusion. On the basis of careful observation and the depiction of several imaging discrepancies, such as early vasogenic edema and hemorrhagic transformation, as well as uncus involvement, but also the lack of significant neurological deficits despite the size of the brain lesion we suspected viral encephalitis which was confirmed by the detection of HSV-1 DNA in the cerebrospinal fluid. CONCLUSION: HSV-encephalitis might occasionally result in the development of unilateral brain MRI lesions with extensive cytotoxic edema, resembling an acute ischemic stroke. Therefore, HSV-encephalitis must be considered in the differential diagnosis of acute ischemic stroke with atypical presentation. The presence of a significant dissociation between the brain MRI lesion volume and the neurological deficits, as well as certain brain MRI imaging discrepancies might serve as "red flags" to extend the diagnostic workup.

Bilateral, Unaugmented, Loop Myopexy Performed for a Severe Case of Heavy Eye Syndrome.

AIM: To report the clinical features and surgical outcomes of one patient with heavy eye syndrome who underwent bilateral, unaugmented, full loop myopexy. METHODS: A 47-year-old lady with high myopia, high axial length, progressive esotropia, slippage of the lateral rectus (LR) inferiorly and superior rectus (SR) medially on magnetic resonance imaging (MRI) was diagnosed with heavy eye syndrome. Unaugmented loop myopexy without medial rectus (MR) recession was offered. RESULTS: On follow-up at 30 months, a small residual esotropia of 6 prism diopters (PD) at near and 10 PD at distance was achieved. Both abduction and elevation were improved in both eyes. CONCLUSIONS: The high angle of esodeviation can be challenging to correct adequately with surgery, with many options available: resection-recession, hemitranspositions (Yamada's procedure), partial loop myopexy (modified Jensen's procedure) and full loop myopexy (Yokoyama's procedure). It remains unclear which procedure is optimal for severe disease. In this case, we present bilateral, unaugmented, full loop myopexy as our preferred choice for high esotropia.