[Association between hematopoietic stem cell transplantation and Parsonage Turner syndrome: coincidence or cause-effect relationship?]

Parsonage-Turner syndrome or idiopathic brachial neuritis is a total or partial inflammation of the brachial plexus, with a typical presentation as a sudden and very intense pain in the shoulder, followed by weakness and early amyotrophy. The etiology is still unknown, although an immune mediated mechanism is thought to be involved. Hematopoietic stem cell transplantation is a well-established treatment for hematological malignancies, but with a growing implication in the treatment of autoimmune diseases. The neurological side effects are probably underdiagnosed. The association of the Parsonage-Turner syndrome and the hematopoietic stem cell transplantation is scarce. We describe two clinical cases of idiopathic brachial plexopathy after hematopoietic stem cell transplantation. The reconstruction of the immune system after a transplant may be the trigger of a brachial plexopathy, but more studies are necessary for the etiology of this disease to be understood and to establish a cause-effect relation with the transplant.

[MR neurography reveals fascicular constriction of the median nerve in a patient with neuralgic amyotrophy]

Diagnosing neuralgic amyotrophy can be challenging in clinical practice. Here, we report the case of a 37-years old Japanese woman who suddenly developed neuropathic pain in the right upper limb after influenza vaccination. The pain, especially at night, was severe and unrelenting, which disturbed her sleep. However, X-ray and MRI did not reveal any fractures or muscle injuries, and brain MRI did not reveal any abnormalities. During neurological consultation, she was in a posture of flexion at the elbow and adduction at the shoulder. Manual muscle testing suggested weakness of the flexor pollicis longus, pronator quadratus, flexor carpi radialis (FCR), and pronator teres (PT), while the flexor digitorum profundus was intact. Medical history and neurological examination suggested neuralgic amyotrophy, particularly anterior interosseous nerve syndrome (AINS) with PT/FCR involvement. Innervation patterns on muscle MRI were compatible with the clinical findings. Conservative treatment with pain medication and oral corticosteroids relieved the pain to minimum discomfort, whereas weakness remained for approximately 3 months. For surgical exploration, lesions above the elbow and fascicles of the median nerve before branching to the PT/FCR were indicated on neurological examinations; thus, we performed high-resolution imaging to detect possible pathognomonic fascicular constrictions. While fascicular constrictions were not evident on ultrasonography, MR neurography indicated fascicular constriction proximal to the elbow joint line, of which the medial topographical regions of the median nerve were abnormally enlarged and showed marked hyperintensity on short-tau inversion recovery. In patients with AINS, when spontaneous regeneration cannot be expected, timely surgical exploration should be considered for a good outcome. In our case, MR neurography was a useful modality for assessing fascicular constrictions when the imaging protocols were appropriately optimized based on clinical assessment.

Neurological manifestation of HEV infection: still a rare disease entity?

Hepatitis E virus (HEV) infection is the most common form of viral hepatitis and is reported to cause neurological manifestation in up to 30% of diagnosed infections. We evaluated the medical reports of all patients (n = 29,994) who were discharged from the Department of Neurology of Ulm University between 01.01.2015 and 30.09.2022 to detect neurological manifestations of HEV. In addition, we retrospectively analyzed the serum samples of n = 99 patients representing different neurological diseases possibly related to HEV for anti-HEV-IgM and anti-HEV-IgG. At the time of discharge from hospital, the etiology of neurological symptoms in these patients was unclear. Overall, five cases of extrahepatic neurological manifestation of HEV (defined as anti-HEV-IgM and HEV-IgG positive) could be detected. An increase of both, anti-IgM- and anti-IgG-serum levels was significantly more common in neuralgic amyotrophy/plexus neuritis/radiculitis than in AIDP/CIDP (P = 0.01), meningitis/encephalitis (P = 0.02), idiopathic peripheral facial paralysis (P = 0.02) and tension headache (P = 0.02). In 15% (n = 15 out of 99) of retrospectively analyzed serum samples, conspicuous positive anti-HEV-IgG levels were detected. This finding was most common in AIDP/CIDP. In conclusion, results of this study indicate neurological manifestation of HEV to be a rare but still underestimated course of disease, occurring at any age and gender. Therefore, testing for HEV should be considered in patients with neurological symptoms of unknown origin, especially in those with neuralgic amyotrophy/plexus neuritis.

COVID-19 Vaccine Related Cervical Radiculitis and Parsonage-Turner Syndrome: Case Report and Review of the Literature

Parsonage-Turner Syndrome, or neuralgic amyotrophy, is an acute-onset upper limb and shoulder girdle palsy that can occur in a post-viral, post-surgical or idiopathic setting. There have also been some reported cases of the syndrome occurring following vaccinations. The pathophysiology of neuralgic amyotrophy is not completely understood and many of the commonly used diagnostic imaging modalities we use to try and diagnose this syndrome are inaccurate and misleading. We present the case of a 40-year-old gentleman who presented with acute onset burning pain and fasciculations in his right upper extremity following vaccination with the second dose of the Pfizer-BioNTech COVID-19 vaccine. His symptoms progressed to weakness in isolated muscle groups with electromyographic evidence of decreased nerve conduction. MRI of the cervical spine demonstrated multilevel central and foraminal stenosis, suggesting a diagnosis of cervical radiculopathy. The patient underwent a C4-5/C5-6 and C6-7 laminoforaminotomy and tolerated the procedure well. Post-operatively, the patient has experienced gradual symptom improvement with residual right triceps and pectoralis muscle weakness as well as paresthesias of the right elbow and forearm. Parsonage-Turner Syndrome is a brachial plexus palsy that can affect one or multiple branches of the brachial plexus. It causes acute-onset pain and weakness, and the diagnosis can be difficult to make with the commonly used diagnostic imaging methods. We reviewed other case reports about neuralgic amyotrophy following vaccinations as well as the current literature on more accurate diagnostic imaging modalities that may help our diagnosis and understanding of the pathophysiology of this condition.

High-resolution MR neurography follow-up of SARS-CoV-2 vaccination-associated neuralgic amyotrophy

Little is known about the value of high-resolution follow-up imaging in patients with neuralgic amyotrophy (NA) and the question of the best treatment algorithm remains unclear. Three patients (one female, two male) with the clinical presentation of SARS-CoV-2-vaccination-associated NA underwent initial magnetic resonance neurography (MRN) imaging and follow-up examinations. All patients showed a marked clinical improvement, independent of treatment, including an almost full recovery of motor function over the course of 8-12 months which was accurately mirrored by imaging findings on MRN. MRN imaging is a valuable tool for monitoring the further clinical course of patients suffering from vaccination-associated NA.

[Neuralgic amyotrophy: a common cause of unilateral and bilateral diaphragmatic pareses]

There are several causes for unilateral or bilateral diaphragmatic paresis. The most common cause is an (intraoperative) injury to the phrenic nerve.However, in up to 20% of cases, no explanation can be found despite extensive workup. Neuralgic amyotrophy (NA, also known as Parsonage-Turner syndrome) is a common underdiagnosed multifocal autoimmune-inflammatory disease that predominantly affects proximal nerve segments of the upper extremities. Classic symptoms include acute onset of severe pain in the shoulder girdle with delayed onset of paresis of the shoulder and arm muscles. In at least 7% of cases, the phrenic nerve is also affected. Based on the annual incidence of NA of 1:1000, the entity as a cause of diaphragmatic dysfunction is probably not as uncommon as previously thought. However, clinical experience shows that this diagnosis is often not considered, and diaphragmatic paresis gets wrongly classified as idiopathic.This is particularly disastrous because in the early stage of NA, medical therapy with corticosteroids is mostly not considered and the possibility that surgical repair of the diaphragm may be performed prematurely, given that the condition may resolve spontaneously many months after symptom onset.The aim of the present article is to raise awareness of the entity of NA as a cause of diaphragmatic paresis and to establish a standardized approach to diagnosis and treatment.

Parsonage-Turner syndrome following monkeypox infection and vaccination

Beginning in May 2022, monkeypox infection and vaccination rates dramatically increased due to a worldwide outbreak. This case highlights magnetic resonance (MR) neurography findings in an individual who developed Parsonage-Turner syndrome (PTS) 5 days after monkeypox symptom onset and 12 days after receiving the JYNNEOS vaccination. MR neurography of the patient's left suprascapular nerve demonstrated intrinsic hourglass-like constrictions, a characteristic finding of peripheral nerves involved in PTS. Other viral infections and vaccinations are well-documented triggers of PTS, an underrecognized peripheral neuropathy that is thought to be immune-mediated and results in severe upper extremity pain and weakness. The close temporal relationship between monkeypox infection and vaccination, and PTS onset, in this case, suggests a causal relationship and marks the first known report of peripheral neuropathy associated with monkeypox.

Ultrasound Diagnostic and Physiotherapy Approach for a Patient with Parsonage-Turner Syndrome-A Case Report

Parsonage-Turner syndrome (PTS) is a rare neurological disorder that causes major diagnostic problems. This paper presents a case report of a patient with PTS and proposes a new physiotherapy program.

CASE DESCRIPTION

a 23-year-old man presents a sudden severe pain of his right arm. The man is consulted by several doctors and physiotherapists. Three magnetic resonance imagings (MRI), a nerve conduction study (NCS), and needle electromyography (EMG) are performed. After 6 months, based on medical history, physical examination and ultrasound imaging (UI), the physiotherapist suggests PTS, which is confirmed by a neurologist.

INTERVENTION

due to the lack of physiotherapy treatment standards in PTS, we apply neurodynamic techniques.

OUTCOMES

neurodynamic techniques are effective in reducing pain and paraesthesia, improving sensation, and reducing nerve swelling (assessed by UI), as well as improving manual dexterity and overall health status.

CONCLUSIONS

the patient with PTS is challenging for making an accurate diagnosis. This study shows an important role for UI, which shows changes in the musculocutaneous nerve, despite the lack of abnormalities in the MRI, NCS, and EMG, and helps in making an accurate diagnosis. This report also confirms that physiotherapy based on neurodynamic techniques may have beneficial effects in PTS.

Diaphragmatic Dysfunction due to Neuralgic Amyotrophy After SARS-CoV-2 Vaccination: A Case Report

Neuralgic amyotrophy is an idiopathic neuropathy characterized by acute-onset pain, typically in the upper extremity or shoulder, followed by weakness of the associated muscles. Phrenic nerve involvement is rare. We report a 63-year-old man who presented with dyspnea and right shoulder pain after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. His chest radiograph showed an elevated right hemidiaphragm that was absent before vaccination. A pulmonary function test showed a restrictive pattern with a significant reduction (40%) in forced vital capacity in the supine position. Diaphragm ultrasonography revealed a reduction in both diaphragmatic excursion and a thickening fraction of the right hemidiaphragm. Electrophysiological studies suggested a right upper brachial plexopathy. Considering the temporal relationship between the vaccination and absence of other causes, SARS-CoV-2 vaccination was thought to be the reason for neuralgic amyotrophy with diaphragmatic dysfunction. As there was no evidence of hypoventilation or sleep disturbance that may require noninvasive ventilation, the patient was followed with conservative treatment with analgesics. During 8 months of follow-up, his shoulder pain was relieved significantly but dyspnea improved only slightly. Neuralgic amyotrophy is an under-diagnosed etiology of diaphragmatic dysfunction and should be considered in patients with dyspnea and shoulder pain.

Parsonage-Turner Syndrome Following COVID-19 Vaccination: MR Neurography

Vaccination is one of the several known triggers of Parsonage-Turner syndrome (PTS). This case series describes two individuals with clinical presentations of PTS whose symptoms began 13 hours and 18 days following receipt of the Pfizer-BioNTech BNT162b2 and Moderna mRNA-1273 COVID-19 vaccine, respectively. The diagnosis of PTS was confirmed by using both electrodiagnostic testing and 3.0-T MR neurography. Although research is needed to understand the association between PTS and COVID-19 vaccination, MR neurography may be used to help confirm suspected cases of PTS as COVID-19 vaccines continue to be distributed worldwide.

Parsonage-Turner Syndrome After SARS-CoV-2 BNT162b2 Vaccine: A Case Report

CASE

Parsonage-Turner syndrome, also known as brachial neuritis or neuralgic amyotrophy, is characterized by sudden-onset pain and subsequent weakness of the shoulder. Known precipitating factors include viral and bacterial infections and certain immunizations. Isolated cases after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported. We report the case of a 66-year-old woman with right shoulder dysfunction and medial scapular winging after immunization with the SARS-CoV-2 BNT162b2 vaccine (Pfizer).

CONCLUSION

After physical therapy, the patient resumed her normal activities of daily living. Findings from this case represent the first known documentation of Parsonage-Turner syndrome after SARS-CoV-2 BNT162b2 vaccination.

Parsonage-Turner Syndrome Following Typhoid Vaccination

Parsonage-Turner syndrome is a rare neurological disease of varying etiology characterized by severe shoulder pain, muscle weakness, and atrophy. Mechanisms are unclear, but are thought to be genetic and immune-mediated reactions. Rarely, Parsonage-Turner syndrome occurs as a side effect of vaccination. A 20-year-old male who worked as a soldier visited the military hospital because of shoulder pain after vaccination against typhoid and was diagnosed with Parsonage-Turner syndrome based on electromyography and joint magnetic resonance imaging. Pain was controlled with a nerve block. Intravenous immunoglobulin was administered for improvement of neurologic symptoms. This case suggests that Parsonage-Turner syndrome should be considered as a side effect of vaccination. To the best of our knowledge, this is the first report of Parsonage-Turner syndrome following vaccination in Korea.

Development of Parsonage-Turner Syndrome After Interscalene Brachial Plexus Block Including 10-Year Follow-up: A Case Report

CASE

A 22-year-old female patient demonstrated physical examination findings of Parsonage-Turner syndrome (PTS) 5 days after left shoulder arthroscopic surgery with interscalene brachial plexus block. The diagnosis was confirmed with electrodiagnostic testing 2 weeks after surgery. Symptoms resolved spontaneously within 2 years with full return-to-preinjury sport and job activity. These outcomes were maintained at the 10-year follow-up.

CONCLUSIONS

PTS should be considered in the differential diagnoses for any postsurgical neurological variations after upper extremity surgery under regional anesthesia.

Parsonage-turner syndrome associated with SARS-CoV2 (COVID-19) infection

Parsonage-Turner Syndrome (PTS), also known as idiopathic brachial plexopathy or neuralgic amyotrophy, is an uncommon condition characterized by acute onset of shoulder pain, most commonly unilateral, which may progress to neurologic deficits such as weakness and paresthesias (Feinberg and Radecki, 2010 [1]). Although the etiology and pathophysiology of PTS remains unclear, the syndrome has been reported in the postoperative, postinfectious, and post-vaccination settings, with recent viral illness reported as the most common associated risk factor (Beghi et al., 1985 [2]). Various viral, bacterial, and fungal infections have been reported to precede PTS, however, currently there are no reported cases of PTS in the setting of recent infection with SARS-CoV2 (COVID-19). We present a case of a 17 year old female patient with no significant past medical or surgical history who presented with several weeks of severe joint pain in the setting of a recent viral illness (SARS-CoV2, COVID-19). MRI of the left shoulder showed uniform increased T2 signal of the supraspinatus, infraspinatus, teres minor, teres major, and trapezius muscles, consistent with PTS. Bone marrow biopsy results excluded malignancy and hypereosinophilic syndrome as other possible etiologies. Additional rheumatologic work-up was also negative, suggesting the etiology of PTS in this patient to be related to recent infection with SARS-CoV2 (COVID-19). Radiologists should be aware of this possible etiology of shoulder pain as the number of cases of SARS-CoV2 (COVID-19) continues to rise worldwide.

Development of Parsonage-Turner Syndrome After Heat Stroke in Firefighters: A Report of 2 Cases

CASE

Two firefighters developed Parsonage-Turner syndrome (PTS) shortly after sustaining episodes of heat stroke. Patient 1 was a 40-year-old man who presented with shoulder pain and supraspinatus and infraspinatus weakness. Patient 2 was a 35-year-old man who presented with shoulder pain and absent external rotation strength. Both had electrodiagnostic testing and magnetic resonance imaging findings consistent with PTS. Both demonstrated partial but incomplete recovery at 1- and 2.5-year follow-ups, respectively.

CONCLUSIONS

PTS should remain on the differential diagnosis for any patient presenting with sudden onset shoulder pain and neurological deficits after an episode of heat-related illness.

Neuralgic amyotrophy. An update

A century after the first description of neuralgic amyotrophy (NA), its pathophysiology remains unknown. An inflammatory (auto)immune pathophysiology is presumed, with mechanical or infectious precipitating conditions, which triggers attacks. Clinically, NA is an acute and painful unique or multiple mononeuropathy that causes palsy, amyotrophy and sensory loss in an asymmetric and patchy distribution. It involves the upper brachial plexus rather than the other parts but also may involve the cervical plexus, lumbosacral plexus and cranial nerves. The impairment can be restricted to one fascicule of one nerve, plexus or root; limited to a few ones; or extensive, involving both upper limbs. Its evolution is usually monophasic and auto-limited and never leads to generalized polyneuropathy. Electrodiagnostically, NA is characterized by severe axonal damage. The recovery is usually good after 6 months to 3 years in 80% of cases. Persistent disability is present in 20% of idiopathic NA cases and is more frequent in hereditary NA, with frequent recurrences, more frequent bilateral impairment, and more atypical distribution (cervical plexus, lumbosacral plexus or cranial nerves) than with idiopathic NA. Hereditary NA is mainly linked to a mutation in the gene of the Septin-9 protein. When the patient is seen early after disease onset, treatment with corticosteroids for 2 weeks seems to shorten the pain duration and the delayed recovery. With diagnosis during the palsy period, treatment is based on pharmacologic and non-pharmacologic therapies according to the complaints of the patient.

Onset of complications following cervical manipulation due to malpractice in osteopathic treatment: a case report

The aim of this study is to correlate cervical disc herniation with manipulation performed by a non-physician osteopath on a patient complaining of neck pain. The authors report a case in which a woman - treated with osteopathic spinal manipulation - developed cervical-brachial neuralgia following the cervical disc herniation. The patient then underwent surgery and was followed by physiotherapists. A clinical condition characterized by limitation of neck mobility, with pain and sensory deficit in the right arm and II-III fingers, still persists. The patient consulted the authors to establish whether cervical disc herniation could be attributed to manipulation. Adverse events or side effects of spinal manipulative therapy are relatively common and usually benign. Most of these side effects are mild or moderate, but sometimes they can be severe. Cervical manipulation can provoke complications less often than thoracic or lumbar manipulation. Furthermore, many diseases can be absolutely and relatively contraindicated to osteopathic treatment. Therefore, the knowledge of a patient's clinical conditions is essential before starting a manipulative treatment; otherwise the osteopath could be accused of malpractice. It is the authors' opinion that a cause-effect relationship exists between the manipulative treatment and the development of disc herniation.

Intraneural perineurioma of unilateral radial and median nerves manifesting with long-standing focal amyotrophy in a 14-year-old-boy

Intraneural perineuriomas are rare tumors of the peripheral nerves with unique immunohistochemical findings. In this report, we highlight the clinical and imaging findings of an adolescent male with histologically proven intraneural perineurioma involving multiple nerves. The salient features included a clinically progressive course, imaging evidence of involvement of long segments of multiple nerves, enlargement of individual fascicles within the affected nerves, and intense contrast enhancement of the enlarged fascicles. The identification of enlarged fascicles with intense contrast enhancement within the affected and distended nerve segments may aid in distinguishing intraneural perineurioma from other tumors affecting the peripheral nerves.

[Pathogenesis and treatment of brachial plexus neuritis]

Neuralgic amyotrophy (NA, also known as Parsonage-Turner syndrome) is a distinct peripheral nervous system (PNS) disorder, characterized by sudden attacks of severe neuropathic pain usually in the shoulder and/or arm. The neuralgia commonly disappears after a few days to weeks, and consequently patchy paresis with amyotrophy appears. The available evidence suggests that NA is essentially idiopathic immune-mediated neuritis of the brachial plexus, and also has a complex pathogenesis that includes an underlying predisposition, susceptibility to dysfunction of some PNS structure, and a trigger for the attacks, such as viral infection, vaccination, trauma, surgery, and strenuous exercise. Genetic factors also contribute to the pathogenesis of NA, and thus, this disorder occurs in both idiopathic and hereditary forms, but hereditary one is considered to be 10 times less common than idiopathic one. NA has been considered to be self-limiting, benign disorder showing good recovery without specific treatments. However, recent studies have indicated that the long-term prognosis of NA is less favorable than has been assumed. In 2009, a Cochrane review identified one open label, retrospective series, the results of which suggested that administration of corticosteroids in the acute phase of NA could shorten the duration of painful symptoms and also accelerate recovery in some patients. We recently have reported that intravenous immunoglobulin (IVIg) with methylpredonisolone pulse therapy is effective for motor impairment of NA.

[Radial nerve palsy as a presenting feature of neuralgic amyotrophy]

A 28-year-old man noticed weakness in his left arm when he woke up. He was diagnosed as left radial nerve palsy and managed conservatively at a local hospital. A few days later, severe pain of the brachium appeared. Although severe pain improved in a year, dysesthesia and muscle atrophy remained. On admission, muscle weakness and atrophy were found in muscles innervated predominantly by the left radial nerve. In addition, needle-electromyography and computed tomography revealed the involvement of muscles innervated by the left suprascapular, long thoracic and axillary nerves, and we diagnosed the patient as neuralgic amyotrophy. Neuralgic amyotrophy should be kept in mind in diagnosing acute onset, painful radial palsy.

[Cervicobrachialgia - an update under special consideration of the surgical management]

The classic cervicobrachialgia results acutely from cervical nerve root compression by disc herniation or subacutely by radicular compression after progressive spondylotic changes of the cervical spine. The clinical presentation includes local and radiating pain syndromes that can be accompanied by sensorimotor deficits. Besides the medical history and a targeted clinical examination, supplementary radiographic means should be undertaken to confirm diagnosis. If no urgent surgical indication exists, conservative therapy should be initiated. However, with varying results of conservative and surgical therapy, chronic impairment can occur.

Isolated shoulder palsy due to infarction of the cortical branch of the middle cerebral artery

A 71-year-old man with hyperlipidemia abruptly developed left-sided isolated shoulder palsy. Cranial magnetic resonance imaging demonstrated infarction of the cortical branch of the right middle cerebral artery (MCA). In the primary motor cortex, there is broad somatotopic representation of various body parts in a particular arrangement, and the area corresponding to the shoulder is very small. Consequently, there have been only 3 reported cases of isolated shoulder palsy due to cerebral infarction, and its vascular supply remains uncertain. The present case indicates that the corresponding area to the shoulder receives its blood from the cortical branch of the MCA.

[Uncommon cervicobrachial neuralgia: about 17 cases]

BACKGROUND

Cervicobrachial neuralgia (CBN) is frequent in out patient clinic as well in general medicine as in rheumatology. Even though cervical disc degeneration and osteophytosis constitute the most frequent etiology of such a trouble, the practitioner must be aware of much more serious underlying cause.

AIM

To investigate the epidemiology, clinical features, aetiologies and paraclinical characteristics of uncommon CBN.

METHODS

Retrospective chart review about 17 cases of uncommon CBN among the 84 cases of CBN hospitalized at the rheumatology department of the Charles Nicolle Hospital during a 16-years-period [1990-2005].

RESULTS

There were 11 men and 6 women with a mean age of 63 years [33y-81y]. All patients presented a CBN since in average five months [2 months- 24 months]. Neck stiffness was noted in 60% of cases and a neurological impairment in 47% of cases. X-ray radiographs of cervical spine were normal in five cases. In the remaining cases, they showed lytic images (six cases), disk space narrowing with vertebral erosions (two cases) and vertebral fracture (three cases). Further investigations concluded that the CBN was due to a Pancoast'syndrome in five cases, an infectious spondylitis in three cases, cervical bone metastasis in two cases, a syringomyelia in two cases, a neuroma in one case, a thoracic outlet syndrome in one case and an erosive spondylarthropathy in a patient presenting chronic renal failure managed by hemodialysis.

CONCLUSION

In comparison with common CBN, our patients presenting symptomatic CBN were characterised by an inflammatory and refractory pain. The more frequent recourse to modern imaging is justified.

Pediatric monomelic amyotrophy: evidence for poliomyelitis in vulnerable populations

Pediatric monomelic amyotrophy may present a diagnostic challenge. This is particularly true for immigrant or adopted children who have little or no available medical history. We present clinical and electrophysiological data from 11 children with monomelic amyotrophy who had electrophysiological evidence of a unilateral or profoundly asymmetric motor neuronopathy. The cause of amyotrophy in each case is most consistent with prior: (1) wildtype poliovirus myelitis; (2) "polio-like" virus myelitis, or (3) vaccine associated paralytic poliomyelitis.

[Collet-Sicard syndrome after carotid artery dissection]

Collet-Sicard syndrome is a rare condition, defined as unilateral palsy of the last four cranial nerves. It differs from Villaret syndrome because of absence of sympathetic involvement. Collet-Sicard syndrome is most often caused by skull tumors, carotid artery dissections or head and neck trauma. We report the case of a 57-year-old man who presented palsy of the left lower cranial nerves IX-XII linked to carotid artery dissection after trivial neck injury.

[Idiopathic brachial neuritis following general anesthesia]

A 25-year-old woman complained of intense pain in her left shoulder several hours after augmentation mammaplasty under general anesthetic; pain was followed by marked sensory and motor deficit in the same arm. A diagnosis of idiopathic brachial neuritis was made after the main causes of intraoperative nerve damage had been ruled out. The shoulder pain resolved after 3 weeks but the sensory and motor deficit remained unchanged. An electrophysiological study performed at 4 weeks revealed abnormalities suggestive of edema or inflammation and an absence of signs of denervation. These findings and the favorable clinical course confirmed the diagnosis of idiopathic brachial neuritis. After 3 months, only mild weakness and numbness in the deltoid region persisted. Although most postoperative neuropathies are iatrogenic, idiopathic brachial neuritis should be included in the differential diagnosis when no evident cause is found. This syndrome is rare but may appear spontaneously after any type of surgery or anesthetic technique; the prognosis is good. Diagnosis, which can be based on symptoms, imaging and electrophysiological studies, is important both for clinical management and for establishing medical and legal liability.

[Differential diagnosis of neuralgic amyotrophy and vertebral artery dissection]

In most cases the definite diagnosis of neuralgic amyotrophy is not possible, so it is based on the typical course of symptoms after other diagnoses have been excluded. We report an otherwise healthy woman who presented with symptoms typical of neuralgic amyotrophy. However we could diagnose a vertebral artery dissection that probably caused the symptoms by compression of the cervical roots. The differential diagnosis of neuralgic amyotrophy and vertebral artery dissection is discussed.