Isolated anisocoria from an endodermal cyst of the third cranial nerve mimicking an Adie's tonic pupil

We present only the second reported case in the literature of a neuroenteric cyst involving the third cranial nerve. Our case is highlighted by the initial presentation of an isolated anisocoria, initially believed to represent an Adie's tonic pupil as interpreted by pharmacologic testing. False-positive results may occur with the dilute pilocarpine test.     

Obstructive hydrocephalus due to a third ventricular neuroepithelial cyst

Cysts occupying the third ventricle are rare lesions and may appear as an unusual cause of obstructive hydrocephalus. Various types of lesions occur in this location, and they generally have an arachnoidal, endodermal, or neuroepithelial origin. The authors present a case of acute hydrocephalus following minor trauma in a child due to cerebrospinal fluid outflow obstruction by a third ventricular cyst. Definitive diagnosis of this cystic lesion was possible only with contrast ventriculography and not routine computed tomography or magnetic resonance imaging. The investigation, treatment, and pathological findings are discussed.     

Extubation failure due to phrenic nerve injury

A 26 week gestation infant had an increasingly elevated right hemidiaphragm following drainage of bilateral pleural effusions and failed extubation on numerous occasions. Electric stimulation of the phrenic nerves revealed absent activity on the right, indicating phrenic nerve injury from chest tube drain insertion. Diaphragmatic plication was performed and the infant successfully extubated four days later.     

The third ventricle in hydrocephalus due to basal cistern block

One hundred and two cases of hydrocephalus due to basal cistern block were studied by ventriculography and encephalography. The third ventricle shows anterior displacement and there are varying degrees of impression upon the infundibular recess produced by a dilated inter-peduncular cistern. The block in the basal cisterns may occur at any level between the exit foramina of the fourth ventricle and the level of the tentorium. Loculation of cerebrospinal fluid in a basal cistern is seen with moderate frequency. —The cerebrospinal fluid protein levels in basal cistern block, which were usually moderately or markedly elevated, did not distinguish these cases from those with aqueduct stenosis. Nearly 20 per cent of the basal cistern block cases also had aqueduct stenosis. — The aetiology of the block in the basal cisterns is usually either haemorrhage (due to anoxia or trauma) or infection. Either of these causes the formation of obstructive adhesions in the subarachnoid space.     

Juvenile myelomonocytic leukemia presenting with facial nerve paresis: a unique presentation

Juvenile myelomonocytic leukemia (JMML) is a distinct myeloproliferative malignancy of early childhood with a varied clinical presentation that may include failure to thrive, malaise, fever, bleeding, pallor, lymphadenopathy, and hepatosplenomegaly. Skin, pulmonary, and gastrointestinal involvement have also been reported. There are no reports of central nervous system (CNS) involvement at diagnosis of this disease. This is a report of a 21-month old boy who had a right facial paresis at presentation. A brain mass was demonstrated on magnetic resonance imaging and cerebrospinal fluid analysis confirmed CNS leukemic infiltration. We report the presence of CNS infiltration as a part of the natural course of JMML and provide a review of the literature.     

Acute obstructive hydrocephalus due to a large posterior third ventricle choroid plexus cyst

We present the case of a child in whom acute hydrocephalus developed secondary to obstruction of the foramen of Monro by a choroid plexus cyst. The patient was seen in the emergency department with fevers, acute onset of headaches, and lethargy. Computed tomography demonstrated dilated lateral and third ventricles with a relatively normal-sized fourth ventricle. An external ventricular drain was placed. Despite decompression of the lateral ventricles, follow-up magnetic resonance imaging demonstrated a dilated third ventricle with a possible thin-walled mass extending from the foramen of Monro into the posterior portion of the third ventricle. The patient subsequently underwent endoscopic fenestration of the cyst with endoscopic third ventriculostomy. Although two other cases of symptomatic choroid plexus cysts of the third ventricle have been previously reported in children, our paper highlights the possibility of endoscopic cyst fenestration together with a third ventriculostomy as a treatment option in cases where the cyst extends into the posterior third ventricle. Despite adequate decompression, we were concerned that due to CSF pulsations the remnant cyst wall could result in acute aqueduct obstruction and subsequent hydrocephalus.     

Partial third nerve palsy after Measles Mumps Rubella vaccination

Background

Measles Mumps Rubella (MMR) vaccination is known to cause some serious adverse events, such as fever, rash, gland inflammation and neurologic disorders. These include third and sixth cranial nerve palsies.

Results

The case reported describes a partial recurrent oculomotor palsy associated with systemic symptoms following MMR vaccination in a healthy young child. The oculomotor palsy did not recover completely during the follow-up.

Conclusions

Most of the times, measles, mumps and rubella cause mild illness and discomfort; but can also have serious or fatal sequelae. MMR vaccination has been proved to be safe and to reduce significantly the number of reported infections due to these viruses. However, significant adverse events can occur and paediatricians and public health operators should be aware of this aspect.     

Ocular fixation to nasal periosteum with a superior oblique tendon in patients with third nerve palsy

PURPOSE: To report a new surgical approach that uses ocular fixation to the nasal periosteum with superior oblique tendon for patients with complete third nerve palsy. METHODS: Prospective study of 15 patients with complete third nerve palsy who underwent surgery using a superior oblique tenectomy and ocular fixation to the nasal periosteum with the superior oblique tendon fragment. RESULTS: Eleven (73%) patients achieved good ocular alignment, 1 (7%) patient had a cosmetically acceptable result, and 3 (20%) patients had a cosmetically unacceptable result. Five (30%) patients had preoperative diplopia; all achieved resolution of their double vision in the primary position of gaze after surgery. Two patients without preoperative diplopia did not achieve good alignment and had diplopia postoperatively. Follow-up ranged from 8-41 months (mean: 19 months). No operative complications occurred. CONCLUSION: Ocular fixation to the nasal periosteum with superior oblique tendon is a safe, effective, and technically undemanding option for the surgical management of patients with complete third nerve palsy.     

Drop hand in a 12-year-old girl: Radial nerve at peril due to knitting

Reported here is a 12-year-old girl who suffered numbness and weakness in her right hand. She was diagnosed to have a right-sided radial nerve injury proximal to the supinator muscle. To the best knowledge of the authors, this is the first report of a child with radial nerve entrapment due to intense knitting.     

Ultrasound-guided femoral nerve block for pain control in an infant with a femur fracture due to nonaccidental trauma

A 3-month-old infant girl was transferred to our emergency department (ED) with a subtrochanteric femoral neck fracture due to nonaccidental trauma. She received multiple doses of parenteral analgesics both before arrival and in our ED. We performed an ultrasound-guided femoral nerve block using 2.0 mL of 0.25% bupivicaine (approximately 1.25 mg/kg) before placing the patient in a Pavlik harness. Successful pain control was achieved within 15 minutes of the procedure allowing pain-free manipulation of the affected extremity. The patient required only a single dose of parenteral narcotics during the ensuing 18 hours. To our knowledge, this is the first report of an ultrasound-guided femoral nerve block used in the ED for pain control in a pediatric patient.     

Response of the foetal pupil to vibro-acoustic stimulation: a foetal attention test

Background

The iris regulates the intensity of light that stimulates the retina. The pupils dilate also in response to mental activities as sign of attention. We hypothesized that the response of the foetal pupil to vibro-acoustic stimulation (VAS) reflects foetal attention.

Aims

To determine whether the changes in the foetal pupil produced by vibroacoustic stimulation is a sign of foetal attention.

Study design

We studied sonographically the pupils and iris of 151 foetuses between 27 and 41 weeks of gestation, using maximum ultrasonic zoom.

Subjects

160 human foetuses between the 27th and the 41st week of gestation.

Outcome measures

The diameters of the pupil and iris were compared before and after VAS.

Results

At baseline, the pupils were miotic. We observed a response to VAS, manifest as a prominent pupillary dilatation in all foetuses. At all gestational ages, the percent increase in pupillary diameter was ≥ 57% (mean 87%; range: 57-135%).

Conclusions

VAS dilated the foetal pupil. Sonographic assessment of the foetal pupil provided important insights in the development of foetal neurological functions.     

Hypertension due to Angiodysplasia

Renovascular hypertension is non essential hypertension, wherein anatomically evident arterial occlusive disease and increased blood pressures are related as cause and effect. The hypertension is due to renal ischemia. Angiodysplasia is an uncommon angiopathy associated with heterogeneous histological changes that may affect the carotid circulation and the visceral and peripheral arteries.