Eduardo Genaro Mutarelli

Hypersexuality following bilateral thalamic infarction: case report

Hypersexuality is a rare but well recognized condition following brain injury. It has been described secondarily to dysfunction in the hypothalamus, the temporal and frontal lobes. We report a 63 year-old man that developed neuropsychological disturbances with hypersexuality as a prominent feature, disinhibition and moderate memory loss, hypersomnia and irritability after a bilateral paramedian thalamic infarction. A SPECT showed frontal hypoperfusion. We believe that these findings are expression of frontal-subcortical circuits dysfunction, particularly the orbitofrontal circuit, secondary to dorso medial thalamic infarction which probably plays a role in the determination of human sexual behavior. This case favors a thalamic modulation of frontal function.

Complete motor recovery after acute paraparesis caused by spontaneous spinal epidural hematoma: case report

BackgroundSpontaneous spinal epidural hematoma is a relatively rare but potentially disabling disease. Prompt timely surgical management may promote recovery even in severe cases.Case presentationWe report a 34-year-old man with a 2-hour history of sudden severe back pain, followed by weakness and numbness over the bilateral lower limbs, progressing to intense paraparesis and anesthesia. A spinal magnetic resonance imaging scan was performed and revealed an anterior epidural hematoma of the thoracic spine. He underwent an emergency decompression laminectomy of the thoracic spine and hematoma evacuation. Just after surgery, his lower extremity movements improved. After 1 week, there was no residual weakness and ambulation without assistance was resumed, with residual paresthesia on the plantar face of both feet. After 5 months, no residual symptoms persisted.ConclusionsThe diagnosis of spontaneous spinal epidural hematoma must be kept in mind in cases of sudden back pain with symptoms of spinal cord compression. Early recognition, accurate diagnosis and prompt surgical treatment may result in significant improvement even in severe cases.

Hashimoto's encephalopathy.

Dra. Renata Telles Rudge de Aquino – Rua Ourânia 408 05445-030 São Paulo SP Brasil. E-mail: renata_aquino@uol.com.br Hashimoto’s encephalitis (HE), encephalitis which responds to steroids and is associated with auto-immune thyroiditis, was described by Brain et al. in 1966. Since then, about 100 cases have been described. It is probably under diagnosed as it is not well known. It presents with acute or sub-acute encephalopathy, tremor, myoclonus, ataxia, fits, psychosis or stroke like events, progressive or relapsing, high titres of anti-thyroid antibodies but independent of thyroid function. Its two sub-types can co-exist: multiple stroke like events, and diffuse progressive, with dementia and psychiatric symptoms. Diagnostic criteria are encephalopathy with elevated anti-thyroid antibodies in the absence of infection, tumour or alteration in the cerebral vascular system. A good response to corticoteroids is typical.

Minor blunt cervical spine trauma associated with esophageal perforation and epidural empyema.

Esophageal perforation in the setting of minor blunt trauma is rare, and diagnosis can be difficult due to atypical signs and symptoms.The mechanism of esophageal injury associated with blunt cervical spine trauma is the traction and hyperextension of the neck. Cervical spine fracture and anterolisthesis may also contribute to the mechanism of esophageal perforation. The previous reports have demonstrated its association with high-energy trauma and severe spinal injury [1–3]. Current management of esophageal perforation focuses on early diagnosis and aggressive treatment that may include surgical drainage, attempt of primary repair, and abscess drainage when indicated [1, 2]. Case report

Laceration of the posterior inferior cerebellar artery by suboccipital puncture of the cisterna magna: case report

We report the case of a 27 year old man who presented to the emergency room of a hospital with headache, vomiting and an episode of loss of conciousness. A cranial CT scan was normal and the patient discharged. Ten hours later he came to the emergency room of our hospital with the same complaints. A technically difficult cisternal puncture in an anxious patient who moved during the needle introduction was done. The CSF sample showed 1600 intact red blood cells without other alterations. His headache worsened and after 6 hours he became drowsy, numb and exhibited decerebration signs. A new CT scan showed diffuse subarachnoid and intraventricular blood. An emergency angiogram demonstrated laceration of a left posterior-inferior cerebellar artery in its retrobulbar loop with a pseudoaneurysm. He was successfully treated by surgical clipping without injury. Sixteen days later he was discharged with a normal neurological exam.

Abscesso cerebelar por Nocardia: relato de caso

The authors describe a case of cerebellar abscess by Nocardiain a patient with the acquired immunodeficiency syndrome (AIDS) that was submitted to a posterior fossa craniectomy for diagnosis and treatment. Pathological and neuroimage findings are discussed as well as the surgical approach taking into account literature data on the subject.

Central nervous system magnetic resonance imaging aspects of superficial siderosis.

A 68-year-old man was evaluated with progressive gait difficulties, first noticed three years before. Neurological examination disclosed paraparetic spastic gait and lower limbs hyperreflexia with bilateral Babinski sign; mild left upper limb cerebellar ataxia; and left hearing loss. The magnetic resonance imaging (MRI) showed rims of hypointensity on T2 around the brainstem, cerebellum, and spinal cord, which was consistent with radiological diagnosis of superficial siderosis1 (Figs 1 to 3). There was no previous history of central nervous system (CNS) bleeding or trauma. Conventional angiographies were unremarkable. This rare case of primary superficial siderosis highlights the classic triad of hearing loss, ataxia, and myelopathy and its pathognomonic MRI findings2.

Neurological manifestations and their predictive risk factors in coronary artery bypass graft surgery with extracorporeal circulation

This study reports the leading neurological manifestations subsequent to a coronary artery bypass surgical procedure (CAPS) with attending extracorporeal circulation (ECC). The predictive risk factors for these changes are also reported. Eighty-eight subjects submitted to a coronary artery bypass surgical procedure with extracorporeal circulation at the Instituto do Coração da Faculdade de Medicina da USP were included. A total of 22 (25%) subjects displayed neurological changes. Twelve patients (13.6%) presented encephalopathy, 9 (10.2%) presented a peripheral neuropathy, 4 (4.5%) presented an ischemic stroke and 1 (1.1%) patient presented seizures. A total of 86 distinct pre-, intraand post-operative variables were examined to determining risk factors for the emergence of neurological complications. In order to assess all possible risk factors, the 22 subjects with a documented neurological dysfunction were added to 2 deceased subjects and these 24 subjects were compared to the complication-free group of subjects. Four subjects with a diagnosis of isolated peripheral neuropathy were included in the complication-free group in order to assess the actual risk factors for CNS complications. Thirty-four subjects sustaining a decrement of one or more points in the MMS score were compared with 51 subjects without any decrement in the MMS. Additionally, 11 subjects sustaining a decrement of 3 or more points in the MMS score were compared to 74 subjects without any decrement in the MMS. Moreover, the association of an altered MMS score and/or other neurological changes were assessed in order to evaluate the presence of a nervous system dysfunction. The risk factors that were associated with the presence of neurological complications in a statistically significant fashion were: low educational background, previous ischemic stroke, changes in the pre-operative systolic and diastolic measures of arterial blood pressure, a previously altered MMS score, prolonged extracorporeal circulation time and a decreased blood flow through the ECC perfusion pump. Multivariate logistic regression analysis demonstrated that assessment of bilateral carotid artery pulse or carotid murmur were not predictive factor for neurological complications. It also demonstrated that low educational background, a low pre-operative MMS score, prolonged ECC time and elevated pre-operative hematocrit count did show a predictive value for the emergence of neurological changes in subjects undergoing a coronary artery bypass surgical procedure with extracorporeal circulation. The low educational background, altered pre-operative MMS score, the presence of a heart murmur and history of a previous ischemic stroke were predictive for a lower MMS score. Previous history of ischemic stroke and subjective complaints of disordered sleep displayed to be predictive for neurological changes and/or a decreased MMS score in subjects undergoing a coronary artery bypass surgical procedure with its accompanying extracorporeal circulation. Additionally, it was concluded that cardio-thoracic surgery and extracorporeal circulation procedures must be monitored by neuropsychological tests and neurological exams performed by a neurologist, both performed in a successive fashion in order to assess the success of the CAPS. Moreover, most of the neurological changes are totally reversible and benign in nature displaying a good prognosis.

Neurological complications of coronary arteriography

The authors report a 46 year-old female who was submitted to a right femoral artery coronary arteriography. During the procedure she presented an upward, downward and convergence gaze paresis; an upbeating nystagmus. A NMRI showed a change in T-2 weighted signal of the left paramedian mesencephalic region. A diagnosis of stroke was made and dextran 40 was prescribed. Vertical gaze paresis progressively disappeared. Convergence paresis and nystagmus improved partially only. The possible pathophysiological basis underlying this clinical picture are: catheter-induced dislodgement of an atheromatous plaque; small thrombi formation and release from the catheter tip; catheter-induced vascular lesion with subsequent thromboembolism or dissection of the intima; cardiac arrhythmia; catheter-induced or contrast medium-induced arterial spasm; a combination of two or more of these.