Vascular neuro-otology: vestibular transient ischemic attacks and chronic dizziness in the elderly

PURPOSE OF REVIEW

To explore the differential diagnosis of posterior fossa transient ischemic attacks (TIA) associated with vertigo and/or imbalance.To review the contribution of cerebral small vessel (SVD) disease to balance dysfunction and dizziness in the elderly.

MAIN FINDINGS

TIAs involving vestibular structures that mediate the vestibulo-ocular and vestibulospinal reflexes remain a diagnostic challenge because they overlap with causes of benign episodic vertigo. Here, we summarize the results of multidisciplinary specialty efforts to improve timely recognition and intervention of peripheral and central vestibular ischemia. More papers confirm that SVD is a major cause of gait disability, falls and cognitive disorder in the elderly. Recent work shows that early stages of SVD may also be responsible for dizziness in the elderly. The predominant location of the white matter changes, in the frontal deep white matter and genu of the corpus callosum, explains the association between cognitive and balance dysfunction in SVD related symptoms.

SUMMARY

The evaluation of patients with intermittent vascular vertigo represent a major diagnostic challenge, recent reviews explore the ideal design approach for a multidisciplinary study to increase early recognition and intervention. Hemispheric white matter microvascular ischemia has been the subject of research progress - advanced stages are known to cause gait disorder and dementia but early stages are associated with "idiopathic" dizziness in the elderly.

Late-Onset Leber's Hereditary Optic Neuropathy with Concurrent Retinal Detachment and Retrobulbar Visual Pathway Involvement

We report a case of late-onset Leber's hereditary optic neuropathy (LHON) with concurrent retinal detachment, mild retinal pigment epithelial changes, cataract and hyperintensity on fluid-attenuated inversion recovery magnetic resonance imaging affecting the entire retrobulbar visual pathway. We also documented that progression of the visual field defect correlated with retinal nerve fibre layer and ganglion cell layer-inner plexiform layer changes on optical coherence tomography. Our case provides further understanding of LHON as a disorder of the entire pre-geniculate pathways and also highlights that detailed history taking in addition to recognition of typical sequential optic disc appearance and visual field characteristics at different stages of LHON remain critical even in this era of modern imaging, autoimmune biomarkers and genetic testing.

Expanded Clinical Phenotype, Oncological Associations, and Immunopathologic Insights of Paraneoplastic Kelch-like Protein-11 Encephalitis

Importance

Recognizing the presenting and immunopathological features of Kelch-like protein-11 immunoglobulin G seropositive (KLHL11 IgG+) patients may aid in early diagnosis and management.

Objective

To describe expanding neurologic phenotype, cancer associations, outcomes, and immunopathologic features of KLHL11 encephalitis.

Design, Setting, and Participants

This retrospective tertiary care center study, conducted from October 15, 1998, to November 1, 2019, prospectively identified 31 KLHL11 IgG+ cases in the neuroimmunology laboratory. Eight were identified by retrospective testing of patients with rhomboencephalitis (confirmed by tissue-based-immunofluorescence and transfected-cell-based assays).

Main Outcomes and Measures

Outcome variables included modified Rankin score and gait aid use.

Results

All 39 KLHL11 IgG+ patients were men (median age, 46 years; range, 28-73 years). Initial clinical presentations were ataxia (n = 32; 82%), diplopia (n = 22; 56%), vertigo (n = 21; 54%), hearing loss (n = 15; 39%), tinnitus (n = 14; 36%), dysarthria (n = 11; 28%), and seizures (n = 9; 23%). Atypical neurologic presentations included neuropsychiatric dysfunction, myeloneuropathy, and cervical amyotrophy. Hearing loss or tinnitus preceded other neurologic deficits by 1 to 8 months in 10 patients (26%). Among patients screened for malignancy (n = 36), testicular germ-cell tumors (n = 23; 64%) or testicular microlithiasis and fibrosis concerning for regressed germ cell tumor (n = 7; 19%) were found in 83% of the patients (n = 30). In 2 patients, lymph node biopsy diagnosed metastatic lung adenocarcinoma in one and chronic lymphocytic leukemia in the other. Initial brain magnetic resonance imaging revealed T2 hyperintensities in the temporal lobe (n = 12), cerebellum (n = 9), brainstem (n = 3), or diencephalon (n = 3). Among KLHL11 IgG+ patients who underwent HLA class I and class II genotyping (n = 10), most were found to have HLA-DQB1*02:01 (n = 7; 70%) and HLA-DRB1*03:01 (n = 6; 60%) associations. A biopsied gadolinium-enhancing temporal lobe lesion demonstrated T cell-predominant inflammation and nonnecrotizing granulomas. Cerebellar biopsy (patient with chronic ataxia) and 2 autopsied brains demonstrated Purkinje neuronal loss and Bergmann gliosis, supporting early active inflammation and later extensive neuronal loss. Compared with nonautoimmune control peripheral blood mononuclear cells, cluster of differentiation (CD) 8+ and CD4+ T cells were significantly activated when patient peripheral blood mononuclear cells were cultured with KLHL11 protein. Most patients (58%) benefitted from immunotherapy and/or cancer treatment (neurological disability stabilized [n = 10] or improved [n = 9]). Kaplan-Meier curve demonstrated significantly higher probability of wheelchair dependence among patients without detectable testicular cancer. Long-term outcomes in KLHL11-IgG+ patients were similar to Ma2 encephalitis.

Conclusions and Relevance

Kelch-like protein-11 IgG is a biomarker of testicular germ-cell tumor and paraneoplastic neurologic syndrome, often refractory to treatment. Described expanded neurologic phenotype and paraclinical findings may aid in its early diagnosis and treatment.

Oculomotor palsy from an unruptured posterior communicating artery aneurysm presenting with cerebrospinal fluid pleocytosis and enhancement of the third cranial nerve

✓ The authors describe a patient with an unruptured posterior communicating artery aneurysm presenting with enhancement of the third cranial nerve on magnetic resonance (MR) imaging and cerebrospinal fluid (CSF) pleocytosis. Pathological entities associated with enhancement of the third cranial nerve on MR imaging are discussed and the authors speculate about the possible explanation for the CSF pleocytosis.

Changes in visual acuity associated with shunt failure

OBJECT

The object of this article was to report on a retrospective analysis of the clinical findings in a series of patients with changes in visual acuity associated with shunt failure.

METHODS AND RESULTS

Over a 10-year period, 350 patients underwent revisions for shunt failure. The clinical course of patients who demonstrated changes in visual acuity (VA) before or during hospitalization were reviewed; follow-up was achieved using outpatient records and telephone calls with physicians, family, or caregivers. Six patients (4 male) ranging in age from 2.5 years to 40 years demonstrated changes in vision associated with shunt failure. The youngest patient lapsed into coma before transfer and showed bilateral occipital lobe infarctions on the CT scan. Three patients had no complaints referable to the visual system prior to revision. Two patients with symptoms lasting more than 21 days showed unequivocal signs of increased intracranial pressure. Serial CT scans remained unchanged in 2 patients. A 3rd patient showed questionable progression in ventricular volume, while another patient's ventricles dilated after a period of 48-72 h. Four patients demonstrated a pattern of aqueductal stenosis, long-term shunting without revision, small ventricles, and poor outpatient follow-up. Four patients showed partial or complete recovery following revision.

CONCLUSIONS

Changes in vision are uncommon and can be an isolated finding associated with shunt failure. Patients with aqueductal stenosis, long-term shunting without revision, and small, potentially non-compliant ventricles may be at risk of this complication. Misdiagnosis or inadequate follow-up places these patients at additional risk, but rapid revision can result in partial or complete recovery.

MR of oculomotor nerve palsy

PURPOSE

To assess the utility of MR in third cranial nerve palsy.

METHODS

We reviewed precontrast and postcontrast MR of 50 patients with third cranial nerve palsy.

RESULTS

MR demonstrated an appropriate lesion in 32 cases. Of these patients, 6 had brain stem lesions and 15 had involvement of the nerve in the cavernous sinus; lesions of the cisternal segment of the nerve were present in 11 patients, with enhancement of this segment observed in 9 patients. An inflammatory or infiltrative source of the palsy was indicated in 19 of these 32 cases. Of 7 patients with pupillary involvement suggestive clinically of a compressive lesion, 4 demonstrated thickening and enhancement consistent with an infiltrative lesion of the nerve. Eighteen patients with pupil-sparing third cranial nerve palsies and a history of diabetes or vascular disease had normal MR findings, with no enhancement of the third cranial nerve observed.

CONCLUSIONS

Patients who do not have a history of diabetes or hypertension and in whom a complete or incomplete third cranial nerve palsy develops with or without pupil sparing should undergo MR imaging initially (unless there are clear symptoms or signs of subarachnoid hemorrhage) to exclude the presence of an infiltrative lesion or intraparenchymal process. Patients who have a history of vascular disease and a clinical presentation that is suggestive of an ischemic event may be observed initially, but should undergo imaging if improvement does not occur within 3 months.

Intracranial hypertension in a dieting patient

We report a case of encephalopathy with paranoid psychosis in association with intracranial hypertension. This occurred in a patient whose diet consisted almost solely of walnuts, ginseng tea, and vitamin A supplements. The patient was found to be severely iron- and vitamin B12-deficient. She was vitamin A toxic. Venous sinus thrombosis was also present. Symptoms remitted with serial lumbar punctures, normalization of diet, and repletion of vitamin B12 and iron stores. Physicians should be alerted to the possibility of a potentially confusing clinical presentation with coexistent and seemingly mutually exclusive neurologic conditions in patients with extremely restricted or fad diets.

Papillophlebitis and arteriolar occlusion in a pregnant woman

Among the pathologic findings affecting the eye during pregnancy, microvascular abnormalities affecting both choroidal and retinal circulation have been reported in cases of complicated pregnancy. We report a case of papillophlebitis and arteriolar occlusion in a pregnant woman without any complications throughout her pregnancy. The patient was placed on glucocorticoids and her vision, visual fields and funduscopic appearance improved almost to normal. Despite the improvement with treatment, the contributing role of glucocorticoids in this case could not be fully determined. Papillophlebitis and arteriolar occlusion should be included among gestational-related vasculopathies.

[Paraneoplastic retinopathy simulating cone dystrophy with achromatopsia]

A 72-year-old woman developed recurrent blindness on exposure to bright light (sunlight). Examination revealed total achromatopsia; bilateral central scotomas, predominant suppression of the cone response by electroretinography, and narrowing of the retinal arteries on ophthalmoscopy. The general examination revealed a pelvic tumor that later proved to be a pleomorphic carcinoma of presumed uterine origin. The patient died of metastatic disease 9 months after the ocular symptoms developed. Histopathologic examination of the eyes revealed loss of the photoreceptors, most extensive in the macular regions, and selective loss of the cones from the rest of the retinas. No ocular metastases of inflammation were found. The changes described are interpreted as paraneoplastic retinopathy of autoimmune origin.

Neuro-ophthalmologic manifestations of Lyme disease

Lyme disease is a tick-borne spirochetal infection characterized by skin rash, neurologic, cardiac, and arthritic findings. The authors report six patients with Lyme disease who had neuro-ophthalmologic manifestations. One patient had meningitis with papilledema, two had optic neuritis, and one had neuroretinitis. Three patients had sixth nerve paresis, two of whom cleared quickly, whereas multiple cranial nerve palsies and subsequent optic neuropathy developed in another. Early recognition of neuro-ophthalmologic findings can help in the diagnosis and treatment of Lyme disease.

Neuroretinitis in cat scratch disease

We report a patient with neuroretinitis, whose associated lymphadenopathy, exposure to cats, and strongly positive cat scratch antigen skin tests suggested the diagnosis of cat scratch disease. Cat scratch disease should be added to the list of infectious agents believed to produce the clinical picture of neuroretinitis.

Incapacitating peripheral neuropathy as a manifestation of chronic graft-versus-host disease

A 35-year-old caucasian man developed mild and transient signs of chronic graft-versus-host disease (GVHD) 5 months after bone marrow transplantation. At 16 months he presented with painful cramps in hands, feet, and truncal muscles. Electrophysiological studies revealed generalized sensory neuropathy. There was occasional fasciculation and high frequency motor units during involuntary muscle contractions, and agonist/antagonist cocontractions of peripheral muscle groups (non-continuous). A sural nerve biopsy showed Schwann cells and macrophages with myelin debris, and Schwann cell stacks with collagen pockets. The patient's symptoms responded to treatment with glucocorticoids and azathioprine. We propose that this patient's incapacitating polyneuropathy was a major manifestation of chronic GVHD, suggesting that the peripheral and possibly central nervous systems can be targets of chronic GVHD.

Cochleovestibular toxicity related to dichloromethotrexate

A 69-year-old man receiving monotherapy for lung cancer with dichloromethotrexate (DCM), and without exposure to other chemotherapeutic agents or known ototoxic drugs, developed profound cochleovestibular dysfunction. The initial presentation was vestibular. This resolved, but unilateral hearing loss ensued and continued to progress to a total of 80 db loss in the low frequency range and 40 db in the high range, despite discontinuation of the drug. Because DCM may be used in combination with the known ototoxin cisplatin, the potential of DCM as an ototoxin should also be considered in such patients.

Magnetic resonance imaging of cysticercosis

Images

An unusual cause of hypokalemic muscle weakness

A 36-year-old woman presented with proximal muscle weakness, cramps, and a serum potassium level of 2.7 mEq/l. During her hospitalization she was noted to use excessive quantities of a snuff preparation containing glycyrrhizinic acid, a potent mineralocorticoid analogue. With discontinuation of this substance, her potassium returned to normal values and her strength improved. This case is submitted as a hypokalemia myopathy induced by snuff dipping.

Neurophthalmologic signs in headache syndromes

Visual and oculomotor changes may be the only abnormalities in patients complaining of headache. Ocular signs are common during episodes of migraine and cluster headache. Temporal arteritis may be an extracranial cause of ocular signs. Intracranial disorders include painful ophthalmoplegia, pseudotumor cerebri and various causes of increased intracranial pressure. Neurophthalmologic evaluation in headache patients must include assessment of visual acuity and visual fields, examination of pupils (including pharmacologic testing), ophthalmoscopic examination and auscultation for bruits.

Cavernous hemangioma of optic chiasm, optic nerves and right optic tract. Case report and review of literature

Diminishing right ocular visual acuity for three weeks in a 30 year old man was confirmed by examination. Bilateral scotomata and bitemporal hemiachromatopsia indicated a chiasmal lesion; reduced visual acuity and Marcus Gunn pupil of the right eye and left relative temporal hemianopia indicated asymmetric involvement. Erythrocytes in the CSF verified a suspected subarachnoid bleed; contrast-enhanced CAT scan demonstrated a suprasellar mass. A cystic, multiloculated, bluish mass distorted the right optic nerve, tract, and chiasm. A hematoma was evacuated and biopsy revealed a cavernous hemangioma of the right optic nerve. Post-operatively, visual acuity has recovered in the right eye but a left homonymous temporal hemianopia has developed.

Diagnostic approaches to pituitary adenomas

The utility of diagnostic tests for pituitary adenoma was compared in 12 patients. Endocrine and radiologic studies were always abnormal, even when neuro-ophthalmologic tests were normal. In most cases, both tomography of the sella turcica and CT scan revealed a mass in the region of the sella turcica. For more precise definition of suprasellar extension of the mass, metrizamide CT cisternography or tomographic pneumoencephalography with metrizamide provided similar details, although CT cisternography was much more easily done. Angiography provides a means to exclude an aneurysm or vascular malformation, a vascular tumor, or an aberrant course of the internal carotid artery.

Venous angioma of the optic chiasm

A 30-year-old man presented with decreased vision in the right eye of three weeks' duration. Examination indicated a chiasmal syndrome and evidence of subarachnoid hemorrhage. CAT scan showed a large suprasellar mass. Surgical intervention confirmed the presence of a globular lesion filled with blood clots involving mainly the right side of the optic chiasm. Following removal of the clots, the chiasm regained its shape and anatomical landmarks. Biopsy of the mass demonstrated a venous angioma located within the optic chiasm as well as recent and old bleeding. Following surgery the patient did well and recovered vision in the right eye, though a left homonymous hemianopia persisted.