Dural ectasia of the optic nerve sheath: is it always benign?

A 36-year-old woman with a 3-month history of progressive visual loss had papilledema, dilatation of the optic nerve sheaths and normal cerebrospinal fluid pressures. She was diagnosed as dural ectasia of the optic nerve sheaths and surgical decompression was performed. In this case report, severe visual loss is described as a serious complication of this rare disease and the importance of early surgical intervention is emphasized.

Panuveitis associated with multiple sclerosis complicated by cerebral venous thrombosis

PURPOSE

To report cerebral venous thrombosis as a complication of intravenous corticosteroid treatment in a patient with multiple sclerosis.

METHOD

A case report. A 44-year-old woman with a previous diagnosis of multiple sclerosis presented with panuveitis and retinal perivasculitis. Intravenous pulse corticosteroid therapy was given for three days.

RESULTS

The panuveitis and retinal periphlebitis began to resolve within one week; however, ten days after the last corticosteroid dose, the patient was hospitalized with the diagnosis of cerebral venous thrombosis.

CONCLUSION

Although intravenous corticosteroid treatment for uveitis associated with multiple sclerosis can be very helpful, the patient should be monitored closely for systemic side effects.

Skewed X inactivation in an X linked nystagmus family resulted from a novel, p.R229G, missense mutation in the FRMD7 gene

AIMS

This study aimed to identify the underlying genetic defect of a large Turkish X linked nystagmus (NYS) family.

METHODS

Both Xp11 and Xq26 loci were tested by linkage analysis. The 12 exons and intron-exon junctions of the FRMD7 gene were screened by direct sequencing. X chromosome inactivation analysis was performed by enzymatic predigestion of DNA with a methylation-sensitive enzyme, followed by PCR of the polymorphic CAG repeat of the androgen receptor gene.

RESULTS

The family contained 162 individuals, among whom 28 had NYS. Linkage analysis confirmed the Xq26 locus. A novel missense c.686C>G mutation, which causes the substitution of a conserved arginine at amino acid position 229 by glycine (p.R229G) in exon 8 of the FRMD7 gene, was observed. This change was not documented in 120 control individuals. The clinical findings in a female who was homozygous for the mutation were not different from those of affected heterozygous females. Skewed X inactivation was remarkable in the affected females of the family.

CONCLUSIONS

A novel p.R229G mutation in the FRMD7 gene causes the NYS phenotype, and skewed X inactivation influences the manifestation of the disease in X linked NYS females.

Encephalopathy due to carnitine deficiency in an adult patient with gluten enteropathy

A 48-year-old male patient had two episodes of fever, headache, confusion and seizures following an upper respiratory tract infection. Electroencephalography (EEG) revealed diffuse slowing of background activity. Plasma free carnitine and serum lipid levels were low; fecal fat content and serum antigliadin antibodies were elevated. Duodenal biopsy was compatible with gluten enteropathy. Symptoms improved after the patient was started on a gluten-free diet and carnitine replacement therapy. No recurrence was observed within a four-year follow-up. Carnitine deficiency in adulthood is unusual, and encephalopathy due to carnitine deficiency as a result of celiac disease has not been described previously.

Economic impact of primary headaches in Turkey: a university hospital based study: part II

This study was planned to investigate the economic impact of headache on Turkish headache sufferers attending a tertiary care outpatient headache clinic.A total of 937 headache patients were included in this study and questioned using a questionnaire for the profile of patients and headache, quality of life of patients and economic impact of headache. The median total direct cost was found to be 88.0 USD and the median total cost was 160.7 USD. The drug treatment cost was the highest item followed by the specialist outpatient care cost. The average lost and inefficient work/school days was 1.5 (0-45) and 8.4 (0-100) days for one year. It was shown that loss of productivity was higher for migraine without aura group when compared with the episodic and chronic tension-type headache groups. The results of this nationwide university hospital based study methshowed that headache, especially migraine, has considerable economic impact on patients.

Neurologic features of horizontal gaze palsy and progressive scoliosis with mutations in ROBO3

OBJECTIVE

To review the neurologic, neuroradiologic, and electrophysiologic features of autosomal recessive horizontal gaze palsy and progressive scoliosis (HGPPS), a syndrome caused by mutation of the ROBO3 gene on chromosome 11 and associated with defective decussation of certain brainstem neuronal systems.

METHODS

The authors examined 11 individuals with HGPPS from five genotyped families with HGPPS. Eight individuals had brain MRI, and six had electrophysiologic studies.

RESULTS

Horizontal gaze palsy was fully penetrant, present at birth, and total or almost total in all affected individuals. Convergence, ocular alignment, congenital nystagmus, and vertical smooth pursuit defects were variable between individuals. All patients developed progressive scoliosis during early childhood. All appropriately studied patients had hypoplasia of the pons and cerebellar peduncles with both anterior and posterior midline clefts of the pons and medulla and electrophysiologic evidence of ipsilateral corticospinal and dorsal column-medial lemniscus tract innervation. Heterozygotes were unaffected.

CONCLUSIONS

The major clinical characteristics of horizontal gaze palsy and progressive scoliosis were congenital horizontal gaze palsy and progressive scoliosis with some variability in both ocular motility and degree of scoliosis. The syndrome also includes a distinctive brainstem malformation and defective crossing of some brainstem neuronal pathways.

The sensitivity and specificity of 0.5% apraclonidine in the diagnosis of oculosympathetic paresis

AIMS

To evaluate the sensitivity and specificity of 0.5% apraclonidine test in the diagnosis of oculosympathetic paresis (OSP).

METHOD

Apraclonidine (0.5%) was administered to 31 eyes, nine with a diagnosis of Horner syndrome (HS), 22 with bilateral OSP caused by diabetes, and to 54 control eyes. All were confirmed with the cocaine test. The effects on pupil diameter and upper eyelid level were observed 1 hour later.

RESULTS

Apraclonidine caused a mean dilation of 2.04 mm (range 1--4.5) (p<0.001) in the pupils with OSP and it caused pupillary constriction in the control eyes with a mean change of -0.14 mm (range 0.5 to --1) (p<0.05). It caused reversal of anisocoria in all HS cases. Its effects on both pupil diameters and upper lid levels differed significantly between the groups (p<0.001). The mean elevation in the upper lid was 1.75 mm (range 1--4) in the OSP group (p<0.001) and 0.61 mm (range 0--3) in the control group (p<0.001).

CONCLUSION

The effect of the apraclonidine (0.5%) test on the pupil diameter was diagnostic for OSP and had at least the same sensitivity and specificity as the cocaine test for the diagnosis of OSP.

[Creutzfeldt-Jakob disease: a case that initiated with psychiatric symptoms]

Creutzfeldt-Jakob disease (CJD) is a rapidly progressive prion disease that causes deficits involving movement, cognition, and mental status. The clinical heterogeneity of the disease can make diagnosis difficult. Thorough neurologic, cognitive, and psychiatric examinations are necessary for observing its clinical features. In this case report we describe a 62-year-old male patient who was initially followed with a diagnosis of depression and later was diagnosed with CJD. The patient had a one-year history of anhedonia, loss of interest, social withdrawal, anxiety and decrease in speech and was given paroxetin 20 mg/day with a diagnosis of depression. During follow up, neurological symptoms including ataxia and rigidity became evident and dementia and akinetic mutism developed in a rapidly progressive course. Although electroencephalography (EEG) and magnetic resonance imaging (MRI) revealed nonspecific findings initially, typical findings for CJD were seen during the follow up. The positive 14-3-3 protein in CSF supported the diagnosis. The aim of this report is to emphasize the fact that CJD may present with different psychiatric symptoms and can be initially misdiagnosed. CJD should be considered in the differential diagnosis of patients who have focal neurological signs in addition to psychiatric symptoms. Repeated neurological examinations, EEG and cranial MRI may help in the diagnosis of these patients.

Mutations in a human ROBO gene disrupt hindbrain axon pathway crossing and morphogenesis

The mechanisms controlling axon guidance are of fundamental importance in understanding brain development. Growing corticospinal and somatosensory axons cross the midline in the medulla to reach their targets and thus form the basis of contralateral motor control and sensory input. The motor and sensory projections appeared uncrossed in patients with horizontal gaze palsy with progressive scoliosis (HGPPS). In patients affected with HGPPS, we identified mutations in the ROBO3 gene, which shares homology with roundabout genes important in axon guidance in developing Drosophila, zebrafish, and mouse. Like its murine homolog Rig1/Robo3, but unlike other Robo proteins, ROBO3 is required for hindbrain axon midline crossing.

Visual recovery patterns in children with Leber's hereditary optic neuropathy

Three patients with Leber's hereditary optic neuropathy (LHON) showed spontaneous improvement in visual acuities after months of legal blindness. Two male patients with bilateral subacute visual loss were 14 years of age at presentation. The first male patient had a mitochondrial DNA mutation at nucleotide position 11778. The second male patient was found to be negative for the designated primary mutations (11778, 14484, 3460) and two of the secondary mutations (15257, 9804). The third patient was a 20-year-old female who presented with bilateral optic atrophy. She had been diagnosed as LHON and was found positive for the 3460 mutation when she was 15. These patients' pattern of visual recovery by developing small islands of normal vision within a central scotoma is characteristic in such rare cases of LHON.

Optic neuropathy in primary antiphospholipid syndrome in childhood

Neurologic symptoms associated with antiphospholipid antibodies in children include thrombotic events, unilateral movement disorders, or migraine. We present a 7-year-old girl with bilateral optic neuropathy, cerebral white-matter lesions, and antiphospholipid IgM that responded to prednisone and tended to relapse when it was stopped. Remission was obtained under maintenance corticosteroid therapy, and the antiphospholipid antibodies disappeared. This case suggests a role for antiphospholipid antibodies in the pathogenesis of optic neuropathy in childhood.

Mitochondrial DNA analysis in the Turkish Leber's hereditary optic neuropathy population

PURPOSE

To define the prevalence of a panel of mitochondrial DNA (mtDNA) mutations associated with Leber's hereditary optic neuropathy (LHON) in the Turkish LHON population. LHON-associated mtDNA mutations have been found in LHON patients from around the world, but the Turkish LHON population has not been studied.

METHODS

Thirty-two Turkish patients were defined clinically as having LHON on the basis of painless, subacute, bilateral optic neuropathy and the exclusion of other causes of subacute optic neuropathy. mtDNA was extracted from blood of the 32 probands and assayed for a panel of primary and secondary LHON-associated mtDNA mutations by polymerase chain reaction (PCR)-based methods. We studied three well-known LHON-associated primary mutations (at nucleotide positions 11778, 3460 and 14484) and one common secondary mutation (at nucleotide 15257) in all 32 probands. In addition to these mutations, 18 of the 32 probands were tested for the Complex IV, COX III gene, LHON associated 9804 and 9438 mutations and secondary LHON mutations at nucleotide positions 3394, 4160, 4216, 4917, 5244, 7444, 7706, 13708, 13730 and 15812.

RESULTS

Among the 32 probands tested for four common LHON mutations, 3 carried the 14484 mutation, 1 carried the 11778 mutation, 1 carried the 3460 mutation and 1 carried the 15257 mutation. Among the 18 LHON patients who tested for additional mutations, 1 proband harboured the 9804 mutation and 4 carried the secondary mutations at nucleotide positions 4216, 4917 and 13708.

CONCLUSION

The results of mtDNA analysis of the Turkish LHON patients appear to be different from those of previous reports.

Granulomatous hypophysitis and bilateral optic neuropathy

A 53-year-old woman with symptoms of hypopituitarism and ophthalmoplegia was diagnosed as having idiopathic granulomatous hypophysitis and later developed bilateral optic neuritis. She responded well to steroid treatment. Granulomatous hypophysitis is a rare entity, and this is the first reported case associated with optic neuritis.

Isolated sixth nerve palsy from pontine infarct

Isolated sixth nerve palsy associated with pontine infarct is very rare due to close anatomic organization of the structures. A 62-year-old woman, who complained of diplopia, had a diagnosis of sixth nerve palsy. Ophthalmological examination revealed 30 PD left esotropia in primary position with limited abduction of the left eye. Neurologic examination was normal. MR showed a lacunar infarct in the pons consistent with a fascicular lesion. Cerebral angiography was normal. Pontine infarcts causing fascicular lesions should be kept in mind in isolated sixth nerve palsies.

Isolated inferior rectus palsy as a result of paramedian thalamopeduncular infarction

The authors present the cases of two patients with isolated inferior rectus muscle paresis presumed to be caused by paramedian thalamopeduncular infarction that involved supranuclear descending pathways, just before the inferior rectus subnucleus in one patient, and just before subnucleus or fascicular fibers in the other patient. Both patients had no other associated neurologic dysfunction. The lesions that cause isolated inferior rectus palsy in these patients are documented by magnetic resonance findings. Although vascular ischemic lesions as the cause of isolated inferior rectus palsy were reported previously, to the authors' knowledge, it has not been demonstrated radiologically.

Acute blindness and putaminal necrosis in methanol intoxication

PURPOSE

To review the neuro-ophthalmological and radiological findings of acute methyl alcohol intoxication.

METHOD

8 acute methyl alcohol intoxication cases were evaluated.

RESULTS

All patients were male and their ages varied between 21 and 55. At the initial examination, 6 to 12 days after methanol intake, visual acuity ranged from no light perception to counting fingers at 2 meters with no color perception. Bilateral dense central scotomas were detected in patients whose vision was slightly preserved. Pupillary light reactions were either absent or sluggish. In 4 cases, edema of the optic disk and the peripapillary nerve fiber layer was observed. Three months later, optic atrophy had developed. Five patients underwent magnetic resonance imaging. Bilateral putaminal hyperintense lesions on T2 weighted images were observed in 3 cases. Two patients died and autopsy permission could not be obtained. Follow-up examination 12 months later revealed optic atrophy in the other six cases, with no improvement in vision.

CONCLUSION

Methanol intoxication is detrimental to health, possibly resulting in blindness and occasionally death. In association with ocular signs and the other systemic and laboratory features, the ophthalmologist should be alert to the diagnosis of methanol intoxication in which visual loss may be the only symptom.

A bad eye and a sore lip

A 48-year-old woman developed painful visual loss in the left eye, meningismus, and painful oral ulcers. Magnetic resonance imaging of the brain with gadolinium demonstrated enhancement of the left optic nerve. Lumbar puncture showed a lymphocytic pleocytosis, and a biopsy specimen of one of the oral ulcerations was consistent with Behçet's disease. Epidemiologic factors and diagnostic criteria for Behçet's disease are discussed.

Alexia without agraphia in multiple sclerosis

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Horner's syndrome due to jugular venous ectasia

Horner's syndrome may be caused by a lesion anywhere along the three-neuron pathway from the hypothalamus to the eye. This syndrome has been reported secondary to numerous causes to date. In this paper, we describe an extremely rare case of Horner's syndrome due to jugular venous extasia demonstrated by computed tomography and intravenous digital subtraction angiography.

Alexia without either agraphia or hemianopia in temporal lobe lesion due to herpes simplex encephalitis

We report a case of alexia without either agraphia or hemianopia following herpes simplex encephalitis. The patient had a temporal lobe lesion with involvement of the occipitotemporal gyrus. This is an unusual cause of alexia without agraphia. The location of the lesion supports the view that transcallosal fibers from the right hemisphere to the left angular gyrus course inferior to the posterior horn of the left lateral ventricle and pass close to the left occipitotemporal gyrus.

Macular subretinal neovascular membrane associated with pseudotumor cerebri

We report on the development of juxtapapillary subretinal neovascular membrane and permanent severe visual loss in a patient with pseudotumor cerebri. The patient was managed by a lumboperitoneal shunt. After surgery, despite resolving papilledema and intracranial pressure control, the membrane had enlarged rapidly to involve the foveal avascular zone, and resulted in rapid visual loss. The membrane slowly regressed, and was replaced by fibrous tissue at the ninth month, causing permanent severe visual loss.

Intermittent diplopia in chordoma

The symptoms and findings of three patients with clivus chordomas who had episodes of intermittent diplopia are presented. The causes of intermittent diplopia are reviewed, and the possible mechanisms of this symptom in chordomas are discussed.

Late visual recovery after intravenous methylprednisolone treatment of Purtscher's retinopathy

A 25-year-old man involved in a minor traffic accident subsequently had a Purtscher's-type retinopathy and lost visual acuity (20/800). After treatment with intravenous methylprednisolone at a dose of 1 g/day, his visual acuity improved to 20/70 three days later and to 20/50 one week later. The exudates and hemorrhages gradually disappeared. However, a localized central scotoma and afferent pupillary defect still persisted. We review previous reports on the retinal pathophysiology of Purtscher retinopathy and discuss the potential benefit of treatment with high-dose intravenous corticosteroids.

Pseudotumor cerebri secondary to dural sinus thrombosis in neurosarcoidosis

Pseudotumor cerebri as a presenting manifestation of neurosarcoidosis is rare. This case reported herein had pseudotumor cerebri secondary to dural sinus thrombosis as a presenting feature of neurosarcoidosis without known systemic sarcoidosis. Proper systemic steroid therapy resulted in ocular and systemic recovery. Neurosarcoidosis should be considered in the differential diagnosis of pseudotumor cerebri in patients with unusual neurological findings.

The peripheral course of the axons innervating the medial rectus muscle within the subarachnoid portion of the oculomotor nerve

There is clinical evidence of topographic localisation of fibres within the oculomotor nerve. It is generally accepted that the pupillomotor fibres have a localised course within the dorsomedial periphery of the subarachnoid portion. However, the precise course of the individual groups of axons innervating each muscle has not been examined in detail. In this study the course of the axons innervating the medial rectus muscle was investigated in the subarachnoid portion of the oculomotor nerve of the rat. The medial rectus muscle was injected with horseradish peroxidase until it was fully infiltrated. The subarachnoid portion of the oculomotor nerve was removed and sectioned longitudinally in the sagittal plane. Sections were reacted with tetramethylbenzidine as a chromogen. Labelled axons were found to be localised in the ventral part of the subarachnoid portion of the nerve.

Familial Behçet's disease

OBJECTIVES

To highlight the frequency, clinical features and histocompatibility antigen types of the familial form of Behçet's disease.

METHODS

Twenty-seven cases with familial Behçet's disease in 12 families were evaluated according to clinical features, sites of involvement, HLA-A and HLA-B typing. A review of the literature is presented.

RESULTS

The frequency of familial form of Behçet's disease was found to be 8.7% among 137 patients studied. Vascular involvement was 7.4% (2/27) in the familial group while it was 28.8% (36/125) in patients without the familial form of the disease (p < 0.01). HLA-B51(5) and HLA-A2 were positive in 68% and 75% in 16 familial cases studied, respectively.

CONCLUSIONS

Familial Behçet's disease, which constitutes a small group of patients with Behçet's disease, may represent a clinically heterogeneous subtype of this entity. Although lower frequency of vascular complications was observed in this study, it is not possible to indicate the precise frequency of vascular and ocular complications of the familial form of Behçet's disease. The frequencies of HLA-A2 and HLA-B51(5) positivity are higher than the previously reported non-Behçet's controls from Turkey.

High myopia causing bilateral abduction deficiency

We present two cases of degenerative myopia with abduction deficiency. Three mechanisms can explain the defect in the abduction: (a) the size of the long globe filling the space of the orbits, (b) the tightness of the medial recti due to long axis of the globe, and (c) longstanding esotropia becoming decompensated later in life. We believe that high myopia is not a well-known cause of abduction deficiency, and it should be considered in the differential diagnosis.

Eales disease with internuclear ophthalmoplegia

Eales disease is an idiopathic type of retinal perivasculitis characterized by recurrent retinal and vitreous hemorrhages. Neurologic involvement is rare. We report the case of a patient with Eales disease who had internuclear ophthalmoplegia thought to be a neurologic manifestation of this disease.