Using AI Text-to-Image Generation to Create Novel Illustrations for Medical Education: Current Limitations as Illustrated by Hypothyroidism and Horner Syndrome

Our research letter investigates the potential, as well as the current limitations, of widely available text-to-image tools in generating images for medical education. We focused on illustrations of important physical signs in the face (for which confidentiality issues in conventional patient photograph use may be a particular concern) that medics should know about, and we used facial images of hypothyroidism and Horner syndrome as examples.

Static anisocoria in cats and dogs with naturally occurring tick paralysis (Ixodes holocyclus)

OBJECTIVE

To characterise the novel occurrence and neuro-ophthalmological features of static anisocoria in cats and dogs with tick paralysis (TP) (Ixodes holocyclus) due to a single tick located remote from the head and neck.

DESIGN

Observational case series with retrospective analysis.

METHODS

Medical records were reviewed from 69 cats and 169 dogs treated for TP from a suburban veterinary hospital in Newcastle, New South Whales, between September 2005 and October 2021.

RESULTS

Anisocoria was observed in 2/18 (11.1%) cats and 3/30 (10.0%) dogs with a single tick located remote from the head and neck. These proportions were not different when compared within species to 4 of 28 (14.3%) cats and 16 of 98 (16.3%) dogs with aniscocoria with a single tick located on the head and neck region (P = 1 and 0.56 respectively). Anisocoria arose from pupillary efferent dysfunction and included unilateral oculoparasympathetic dysfunction (internal ophthalmoplegia) in one dog, unilateral oculosympathetic dysfunction (Horner's syndrome) in one cat and one dog, and a combination of bilateral, but asymmetric, oculosympathetic and oculoparasympathetic dysfunction in one cat and one dog.

CONCLUSION

It is proposed that anisocoria in cases of TP with a tick located remote from the head and neck is due to an intrinsic latent asymmetry in the safety factor for pupillary efferent function that is unmasked by a systemically distributed holocyclotoxin inhibiting neural transmission within this system, and this is the prevailing pathomechanism, rather than a direct local effect, underscoring anisocoria with a tick located on the head or neck.

Segmental Zoster Paresis Accompanied by Horner's Syndrome

We herein report a 90-year-old immunocompromised woman who developed right upper limb weakness and right ptosis with a miotic pupil 1 week after oral therapy for zoster on the right T2 dermatome. The right pupil was dilated with instillation of 1% apraclonidine, indicating Horner's syndrome. The patient was treated with intravenous acyclovir and methylprednisolone. Focal weakness related to zoster, generally known as segmental zoster paresis, improved over five months, but Horner's syndrome remained. We suggest that aggressive intravenous treatment should be considered for rare cases of zoster that occur with a combination of these two neurological conditions.

Horner syndrome as an unusual presentation of cervical radiculomyelopathy associated with cervical disc herniation: A case report

INTRODUCTION AND IMPORTANCE

Horner syndrome, an oculo-sympathetic pathway disorder, is a very rare manifestation of cervical spine pathologies which usually present with either axial neck pain, radiculopathy, or myelopathy symptoms (or combinations of these). It is more-likely to happen in the upper cervical level involvement.

CASE PRESENTATION

A 44-year-old male presented with a complaint of right eyelid drop two months before admission. The symptom was accompanied by radicular neck pain and weakness of the right upper extremity (M4) since 1 month earlier. An MRI revealed a cervical herniated disc at the C5-6 spine level.

CLINICAL DISCUSSION

The patient underwent open discectomy followed by cervical disc replacement. Symptoms were significantly improved following surgery.

CONCLUSION

In the presence of cervical symptoms, a focused evaluation of Horner syndrome can be done, and symptom resolution can be expected after the appropriate treatment. Otherwise, a thorough examination must be obtained to find the pathology along the tract of the oculo-sympathetic pathway and prevent irreversible neurological disturbance.

Pseudo-Lyre Sign

To study the causes of the Pseudo- Lyre sign which is radiologically demonstrated in tumours other than the carotid body tumour. The study is based on an unusual case of neurofibroma of the cervical sympathetic chain presenting as a pulsatile mass in the carotid triangle in a 34 years female. Radiological investigation pointed to a diagnosis of a carotid body tumour because of typical splaying of the internal and external arteries causing the Lyre sign. At surgery, the tumour which was arising from the cervical sympathetic chain (CSC) was excised with minimum blood loss and histopathology confirmed it to be neurofibroma. This, we presume is the first ever report of a neurofibroma of the cervical sympathetic chain causing Lyre sign which we have referred to as Pseudo-Lyre sign. The various investigations which help in diagnosing the cause of Pseudo-Lyre sign have been discussed. All tumours causing Lyre sign on radio-imaging are not carotid body tumours. Other masses mostly neurogenic can demonstrate this sign and an attempt should be made preoperatively to confirm the diagnosis.

Lessons of the month: Giant cell arteritis with Horner's syndrome and vertebral dissection

We present a case of an 82-year-old woman presenting with left-sided Horner's syndrome and stroke. She also had a 6-week history of intermittent dizziness, reduced appetite, lethargy, muscle stiffness and weight loss. Examination revealed left temporal artery and left posterior auricular artery tenderness. Her ESR showed 62 mm/hr and imaging showed left vertebral artery dissection. Temporal artery biopsy was positive.The case highlights a rare presentation of giant cell arteritis with Horner's syndrome and left vertebral artery dissection. High clinical suspicion is required to prevent delay in diagnosis and treatment.

The evaluation of patient demographics, etiologies and apraclonidine test results in adult Horner's syndrome

PURPOSE

We aimed to demonstrate the patient demographics, etiologies and apraclonidine test results in adult Horner's syndrome.

METHODS

This retrospective study was performed by the analysis of medical data of patients who were given 0.5% apraclonidine test. Patients' past medical history, demographic data, etiologies, accompanying neurological findings and pharmacological test results were assessed.

RESULTS

Forty patients (21 females and 19 males) with a mean age of 50.3 ± 11.6 years were evaluated. Apraclonidine 0.5% test was positive in 37 patients (92.5%). An etiology could be identified in 20 patients (central [9 patients, 45%], preganglionic [9 patients, 45%] and postganglionic [2 patients, 10%]). Neurological findings accompanying Horner's syndrome were present in 8 patients.

CONCLUSION

Despite detailed investigations, in a significant number of patients with Horner's syndrome an underlying cause may not be detected. Among the identifiable lesions, central and preganglionic involvements are still the first leading causes of Horner's syndrome. In addition, apraclonidine test may not be positive in all patients and a negative response does not exclude Horner's syndrome.

The diagnostic yield of advanced imaging in dogs with Horner's syndrome presenting with and without additional clinical signs: A retrospective study of 120 cases (2000-2018)

PURPOSE

To evaluate the diagnostic yield of advanced imaging in dogs with Horner's syndrome (HS) both with and without additional clinical signs.

METHODS

Retrospective review of clinical records from a UK referral hospital (2000-2018). Cases were excluded if HS was trauma- or surgery-related and if no advanced imaging with MRI or CT was performed. Imaging findings were assessed as well as any additional investigations performed.

RESULTS

One hundred twenty cases met the inclusion criteria; 88 with additional clinical signs and 32 with isolated HS. MRI or CT of head and neck was performed in 115 cases and/or thoracic CT in eight cases. Causative lesions were identified in 98% (86/88) of cases with additional clinical signs and 3% (1/32) of cases with isolated HS. This was statistically significant (p < .001). Pharmacological localization using phenylephrine (0.1%-10%) was accurate in predicting the site of a causative lesion in 79% (19/24) of tested cases. Overall, 28% (33/120) of cases were idiopathic, of which 49% (16/33) were golden retrievers. When compared to the overall hospital population, and UK Kennel Club records, this confirmed a significant predisposition in this breed (p < .001). No associations between idiopathic HS and concurrent systemic disease were identified.

CONCLUSION

This is the first study to evaluate the diagnostic yield of advanced imaging in dogs with HS. Isolated HS is significantly more likely to be idiopathic than cases presenting with additional clinical signs; this could guide decision-making regarding further investigations performed in a clinical setting. Idiopathic HS is over-represented in the golden retriever.

Isolated Middle-Third Clavicle Fracture Causing Horner's Syndrome: A Case Report and Literature Review

The pathophysiology of Horner's syndrome arises due to compression or destruction of the oculosympathetic nerve pathway. Traumatic Horner's syndrome may indicate lethal neurovascular injury, such as brain stem lesion, cervical spine injury, or carotid artery dissection. The middle-third is the most common type of clavicle fracture. However, the association of the isolated middle-third clavicle fracture and Horner's syndrome is rare. We report the case of a 47 year-old woman who presented to our emergency department with acute trauma. Severe tenderness and limited mobility were observed in her left shoulder. On radiographic examination, a middle-third clavicle fracture was diagnosed. Ptosis and myosis were also noticed on further examination, and she was subsequently diagnosed with Horner's syndrome. A survey of the brain, cervical spine, carotid artery, and lung revealed no pathological findings. Surgery for the clavicle fracture was performed 2 days after the accident. The patient recovered from Horner's syndrome gradually over the 2 months following the surgery, and the syndrome completely resolved by the third month. To the best of our knowledge, this is the first report of traumatic Horner's syndrome caused by an isolated middle-third clavicle fracture. The improved outcome may be attributed to the surgical intervention for middle-third clavicle fracture, which may help release ganglion or neuronal compression.

Silent stellate ganglion paraganglioma masquerading as schwannoma: A surgical nightmare

A 28-year-old normotensive female presented with Horner's syndrome and paresthesia over the left side of the chest. Imaging study showed a large heterogeneous enhancing lesion in short-T1 inversion recovery sequence with flow voids in T2W sequence of magnetic resonance imaging. The lesion was located in the left-sided D1 and D2 regions extending into the neural foramina and apical part of the lung. During surgery, even minimal dissection of the tumor resulted in marked fluctuation in hemodynamic parameters, requiring temporary suspension of the surgery multiple times until hemodynamic parameters were brought under control by the anesthesiologist with drugs. The massive fluctuation in hemodynamic parameters in an unprepared and unanticipated scenario was a challenge for the anesthetist and surgeon. The tumor was radically excised with improvement of paresthesia in the immediate postoperative period, but Horner's syndrome persisted. After 18-months of follow–up, she was relieved of all symptoms including Horner's syndrome. Histopathological examination confirmed our suspicion as paraganglioma.

Incidental intrathorcic schwannoma post upper respiratory tract infection associated with Horner's syndrome: A case report

Background

Schwannomas may remain asymptomatic, and may be discovered incidentally.

Case presentation

Here we describe a case of a young female complaining of upper respiratory tract symptoms who was incidentally found to have an intrathoracic neurogenic tumor consistent with schwannoma associated with Horner's syndrome. Biopsy of the tumor revealed S100, BCL-2 and CD 99+ compatible with schwannoma. Patient had brachial plexus exploration and dissection of thoracic inlet tumor resected through video assisted thoracoscopic surgery (VATS). Patient did exceptionally well afterwards with no documented Horner's symptoms.

Conclusion

Characterized as a rare case, this patient presented post viral infection and found to have a rare tumor. Successful surgical treatment alleviated her symptoms.

Horner's syndrome following single lung transplantation

Lung transplantation have significantly improved quality of life in patients with end stage respiratory failure, however use of lifelong immunosuppressive therapy and development of bronchiolitis obliterans reflects in a 5-year survival is less the 60%. Ophthalmic complications following lung transplantation are uncommon. Some cases of infectious and malignant ophthalmic complications have been described previously. Here we describe a case of Horner's syndrome following single lung transplantation.

Ectopic thymus as a cause of Horner's syndrome

Ectopy of the thymus is a rare anomaly arising during fetal development, where the thymus does not make a complete decent into the thoracic cavity where it should involute in adolescence. The most common complications of an ectopic thymus include tracheal or esophageal compression presenting in childhood. This is a report of a single case of ectopic cervical thymus identified in a 2-month-old infant presenting with Horner's syndrome. Thymic ectopy should be on the differential when performing a radiologic evaluation of a neck mass when imaging characteristics are similar to thymic tissue.

Neuro-Ophthalmology at the Bedside: A Clinical Guide

Neuro-ophthalmological signs and symptoms are common in the emergency department but are a frequent source of diagnostic uncertainties. However, neuro-ophthalmological signs often allow a precise neuro-topographical localization of the clinical problem. A practical concept is presented how to perform a neuro-ophthalmological examination at the bedside and to interpret key findings under the aspect of emergency medicine with limited resources.

A Rare Case of Possible Vacuolar Degeneration of Leprosy in Brain with Segmental Necrotizing Granulomatous Neuritis and Horner's Syndrome

Leprosy has a predilection for peripheral nerves, but rarely does it involve the central nervous system (CNS). There is a single study of CNS involvement in leprosy showing vacuolar changes of motor neurons in medulla oblongata and spinal cord in autopsy findings. Besides this, there has been only one case report providing direct histopathological and molecular evidence of CNS involvement by leprosy in a living patient. Segmental necrotizing granulomatous neuritis (SNGN) is a rare condition affecting the peripheral nerves in leprosy usually seen as a complication of tuberculoid (TT) and borderline tuberculoid (BT) leprosy. We report the case of a 23-year-old male patient, a case of Hansen's disease (BT) who developed CNS involvement in the form of partial Horner's syndrome (right) and SNGN while on treatment. Magnetic resonance imaging of the brain revealed T2 hyperintense lesion on the dorsal aspect of left pontomedullary junction, suggestive of vacuolar degeneration of leprosy. Histopathology of greater auricular nerve (right) revealed SNGN.

Atypical presentation of extraspinal neurofibroma presenting with acute-onset monoparesis and Horner's syndrome: Case report and review of literature

The clinical presentation of spinal or extraspinal neurofibroma is radiculopathy or myelopathy, pain, and motor weakness. Extraspinal neurofibroma presenting with acute-onset monoparesis and Horner's syndrome is very rare. We report the case of a 55-year-old female who presented with acute-onset monoparesis of the left upper limb along with left-side drooping of the eyelid. Imaging revealed C6–D2 extraspinal solitary mass lesion lateral to spinous process with bleed without intraspinal component. The patient underwent an anterior cervical approach and excision of the tumor. Final biopsy report was a neurofibroma. At 3-year follow-up, she recovered from motor weakness, and Horner's syndrome subsided. Extraspinal neurofibroma can present with acute bleed, and surgical outcome is superior in early intervention.

Horner's Syndrome due to Cervical Sympathetic Chain Schwannoma: A Rare Presentation and Review of Literature

Cervical sympathetic chain schwannoma (CSCS) is an extremely rare benign tumor, and it is a diagnostic challenge. We report a case of 45-year-old female who presented with a solitary right cervical swelling with clinical features of Horner's syndrome (HS). She was evaluated with computed tomography, magnetic resonance imaging, and angiography. Surgical excision of the lesion was performed, and the histological examination revealed the diagnosis of schwannoma. Herein, we review the presentation, imaging characteristics, and operative considerations of a patient with a large CSCS, presenting with HS.

Horner's Syndrome as Initial Manifestation of Possible Brachial Plexopathy Neurolymphomatosis

Introduction: Horner's syndrome is an established clinical finding unique to neoplastic brachial plexopathy.

Background: We present the case of a patient who developed Horner's syndrome as the first manifestation of neurolymphomatosis (NL) of the brachial plexus that did not have the usually associated bulky adenopathy/Pancoast syndrome phenotype.

Discussion: We discuss the clinical utility of Horner's syndrome with regards to brachial plexopathy of indeterminate etiology, as well as the utility of other diagnostic modalities in NL.

Concluding Remarks: NL, particularly of the brachial plexus, is particularly challenging to diagnose. MRI and CSF studies are often inconclusive. FDG-PET imaging can be difficult to get insurance to approve. The presence of Horner's syndrome in brachial plexopathy of indeterminate etiology, even in the absence of bulky adenopathy, should raise clinical suspicion of NL, possibly prompting such interventions as fascicular nerve biopsy.

Unilateral Straight Hair-A Symptom of Acquired Horner's Syndrome in a Neonate

A multicystic tumor of the right neck was detected in a girl at 29 weeks of gestation by fetal ultrasound and magnetic resonance imaging (MRI). The baby was delivered by cesarean section at week 37 of gestation. The newborn adapted well, with minimal compromise of breathing and drinking. Postnatal ultrasound and MRI revealed a cervical lymphangioma measuring 60.5 × 60.6 × 41.2 mm. We performed subtotal resection of the tumor when the girl was 34 days. As a complication of surgical resection, the girl developed ipsilateral Horner's syndrome. In the postoperative period, her curled hair turned straight at the side of the head affected by Horner's syndrome. At the age of 2.5 years, ultrasonic imaging revealed the presence of three cysts measuring 3 mm in diameter each. Horner's syndrome had improved, and the texture of the girl's hair had become curly again on both sides.

[Horner's syndrome as presentation of pulmonary tuberculosis]

Horner's syndrome results from a blockage of the sympathetic innervation to the eye at any point along its trajectory. It presents various etiologies, and it is a very unusual form of presentation of pulmonary tuberculosis. We describe the case of a patient with a Horner syndrome secondary to involvement of the pulmonary apex due to tuberculosis.

"Collateral Damage:" Horner's Syndrome Following Excision of a Cervical Vagal Schwannoma

Horner's syndrome is characterized by triad of blepharoptosis, miosis, and anhydrosis on the lateral part of the face. Incidence of iatrogenic Horner syndrome resulting from neck surgeries has been reported between 10% to 18.5%. Iatrogenic Horner syndrome resulting from excision of cervical vagal nerve schwannoma is uncommon, and has rarely been mentioned in literature. We report a rare case of iatrogenic preganglionic Horner's syndrome resulting from excision of a cervical vagal schwannoma. An 18 years old female presented with the complaints of sudden drooping of right upper lid associated with reduced sweating on right side of face for the past 3 months. There was history of excision of a right cervical vagal schwannoma. Ocular examination revealed mild ptosis, miosis with anisocoria more in scotopic illumination. Photographs of the patient prior to surgery showed no evidence of ptosis. Preoperative Magnetic resonance imaging revealed a mass suggesting a vagal nerve schwanomma. A diagnosis of iatrogenic preganglionic Horner's syndrome was made and the patient was kept under follow up. Horner's syndrome is an uncommon sequelae of cervical vagal schwannoma excision that results from injury of the cervical sympathetic chain intraoperatively and hence should be discussed with the patient during pre-operative counseling.

Metastatic squamous cell carcinoma to the superior cervical ganglion mimicking a retropharyngeal lymph node

BACKGROUND

Metastasis of squamous cell carcinoma (SCC) to the superior cervical ganglion (SCG) has never been reported. Its anatomic location may easily be mistaken for a retropharyngeal lymph node. We present the first case of SCC metastasis to the SCG.

METHODS

We report a case of a 69year-old never smoking male, who presented with right retropharyngeal PETCT-avid disease following chemoradiation for squamous cell carcinoma of the tonsil. He was brought to the operating room for resection, intraoperative radiation and reconstruction.

RESULTS

Intraoperatively, visualization and frozen section confirmed squamous cell carcinoma located in the superior cervical ganglion. The ganglion was resected, intraoperative radiation was given and the patient was reconstructed with a radial forearm free flap. Postoperatively, the patient displayed features of a Horner's syndrome.

CONCLUSIONS

The superior cervical ganglion may be mistaken for a retropharyngeal lymph node. Although extremely rare, these entities may be differentiated on the basis of radiological studies.

Apraclonidine in the treatment of ptosis

Transient ptosis is a known complication of botulinum toxin (BoNT) injection due to inadvertent migration of toxin into the levator palpebrae superioris muscle. Currently there is no treatment available for BoNT induced ptosis. Apraclonidine hydrochloride is a topical ophthalmic solution with selective alpha-2 and weak alpha-1 receptor agonist activity that has the ability to elevate the eye lid. Apraclonidine has been used as a diagnostic test in Horner's syndrome. We evaluated the effects apraclonidine in a cohort of BoNT induced ptosis and a patient with Horner syndrome. Each patient was administered 2 drops of apraclonidine 0.5% solution to the eye with the ptosis and was re-examined 20-30min later. All 6 patients showed improvement in ptosis. There was also improvement in ptosis in a patient with Horner's syndrome. Apraclonidine is not only useful as a diagnostic test in Horner's syndrome, but may be an effective and safe treatment for BoNT-induced ptosis.

Left parapharyngeal ectopic goitre associated with eutopic thyroid and postoperative Horner's syndrome

INTRODUCTION

The authors report a case of left parapharyngeal ectopic goitre, in which resection was followed by postoperative Horner's syndrome, and describe the difficult management of this entity.

CASE REPORT

A 25-year-old woman presented with upper oesophageal dysphagia and a well-demarcated left parapharyngeal mass displacing the great vessels laterally and posteriorly. The mass was resected via an exploratory neck incision. Histological examination of the operative specimen revealed hyperplastic thyroid parenchyma. The postoperative work-up revealed a eutopic and euthyroid thyroid gland. The postoperative course was marked by Horner's syndrome that persisted at 1-year follow-up.

DISCUSSION

Parapharyngeal ectopic thyroid coexisting with a functional thyroid is extremely rare. Parapharyngeal masses are usually derived from the parotid gland and nerves. Surgery of the parapharyngeal space can cause injury to the sympathetic trunk, responsible for Horner's syndrome, as in our patient.

CONCLUSION

Ectopic thyroid should be considered as a possible diagnosis of a parapharyngeal mass. Although rare, Horner's syndrome is a dreaded complication of surgery of the parapharyngeal space.

Horner's syndrome in traumatic first rib fracture without carotid injury; review of anatomy and pathophysiology

Case report of a 51 year old man involved in a motor vehicle accident presenting with multiple thoracic wall injury, including bilateral first rib fractures. He slowly developed a right sided Horner's syndrome due to a right paravertebral haematoma. The initial imaging did not display any carotid injury, however the developing right paravertebral haematoma was not initially reported. We review the anatomy and pathophysiology of this well-known but rare condition to show how first rib fractures should raise suspicion of Horner's syndrome irrespective of the presence or absence of any underlying blunt carotid injury.

Horner's syndrome in cervico-dorsal tuberculosis: A rare case report

Tuberculosis is a disease that affects any part of body and presents with varied complications. A case of cervico-dorsal tuberculosis is described here presenting with quadriparesis and Horner's syndrome. Horner's syndrome as a complication of cervico-dorsal tuberculosis has not been reported yet in literature.

Post-thyroidectomy iatrogenic Horner's syndrome with heterochromia

Purpose

To present a case of iatrogenic Horner's syndrome seen together with the heterochromia in the post-thyroidectomy period.

Methods

A 23-year-old female patient was admitted to our clinic with complaints of low vision in the eye and difference in eye color that developed over the past two years. In the left eye, myosis and minimal ptosis (∼1 mm) was detected, and the color of the iris was lighter than the right eye.

Results

The pre-diagnosis of left iatrogenic Horner's syndrome was finalized after 0.5% topical apraclonidine test.

Conclusion

Heterochromia can be observed in iatrogenic Horner's syndrome.

Significant Differences in Sympathetic Nerve Fiber Density Among the Facial Skin Nerves: A Histologic Study Using Human Cadaveric Specimens

Sympathetic nerve fibers in the skin nerves are connected with vasomotor, thermoregulatory, sensory input modulatory, and immunologic events; however, to our knowledge, no histological information is available for skin nerves in the human face. Using specimens from 17 donated cadavers (mean age, 86 years), we measured a sectional area of tyrosine hydroxylase (TH)-positive fibers in (1) the frontal nerve (V1), (2) the infraorbital nerve (V2), (3) the mental nerve (V3), (4) the greater auricular nerve (C2), (5) the auriculotemporal nerve (ATN), and (6) the zygomatic branch of the facial nerve (VII). The V1, V2, and V3 were obtained at their entrances to the subcutaneous tissue from the bony canal or notch. The V1, C2, ATN, and/or VII usually contained abundant TH-positive fibers (almost 3%-8% of the nerve sectional area), whereas the V2 and V3 consistently carried few TH-positive fibers (<1%). The difference between these two groups was quite significant (P < 0.001). Thus, from the superior cervical ganglion, the sympathetic nerve fibers reached the forehead through the frontal nerve trunk, whereas artery-bounded fibers came to the cheek, nose, and mouth. The sympathetic palsy caused by trigeminal nerve involvement is mainly characterized by the symptoms seen in the distribution of the ophthalmic division of the trigeminal nerve, such as in Horner's syndrome. It suggests that the forehead and the other facial areas are representative parts of those different sympathetic innervations that could be useful for evaluating the sympathetic function of the face in various diseases. Anat Rec, 299:1054-1059, 2016. © 2016 Wiley Periodicals, Inc.

[Harlequin phenomenon associated with neurological abnormalities: A case report]

BACKGROUND

Harlequin phenomenon consists of facial flush and erythrosis with unilateral sweating and pallor, associated with contralateral anhidrosis. We present the case of a child in whom the syndrome was associated with Horner's syndrome, epilepsy, mental and psychomotor retardation.

PATIENTS AND METHODS

A 9-year-old boy presented with right unilateral hemifacial erythema on effort, with normal colouring and Horner's syndrome on the left side of the face. His medical history revealed generalized myoclonic epilepsy, psychomotor delay and mental retardation. No underlying anomalies were identified. Harlequin phenomenon was diagnosed.

DISCUSSION

Despite its stereotypical clinical features, Harlequin phenomenon is a poorly known disease. However, clinicians must be aware of it in order to determine the diagnosis and investigate for causes and any associated abnormalities. The underlying mechanism is an autonomic neuropathy affecting the sympathetic vasodilator neurons. To our knowledge, there have been no previous reports of Harlequin phenomenon in association with Horner syndrome, psychomotor delay and mental retardation.

Horner's Syndrome after Scalene Block and Carotid Dissection

BACKGROUND

Horner's syndrome refers to the clinical triad of ptosis, miosis, and anhidrosis resulting from disruption of the ocular and facial sympathetic pathways. A myriad of etiologies can lead to Horner's syndrome; awareness of the underlying anatomy can assist physicians in identifying potential causes and initiating appropriate care.

CASE REPORT

Two patients presented to our Nashville-area hospital in 2014. Patient 1 was a 26-year-old man who noticed facial asymmetry one day after an outpatient orthopedic procedure. His symptoms were attributed to his posterior interscalene anesthesia device; with deactivation of this device, the symptoms rapidly resolved. Patient 2 was a 42-year-old man who presented to our emergency department with persistent headache and ptosis over several weeks. Computed tomography angiography revealed ipsilateral carotid dissection and the patient was admitted for further management. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The pathologies underlying Horner's syndrome are exceedingly diverse. Although classic teaching often focuses on neoplastic causes, and more specifically Pancoast tumors, neoplasms are discovered only in a small minority of Horner's syndrome cases. Other etiologies include trauma, cervical artery dissection, and infarction. With a better understanding of the pertinent anatomy and array of possible etiologies, emergency physicians may have more success in identifying and treating the causes of Horner's syndrome.

Brown-Séquard syndrome without vascular injury associated with Horner's syndrome after a stab injury to the neck

CASE DESCRIPTION

This case reviews the acute care and rehabilitation course of a 44-year-old right-handed woman after an assault with a pocketknife. She suffered multiple stab wounds including penetrating injury to the left side of her neck. Physical examination revealed left hemiplegia (motor score = 57), impaired pinprick sensation on the right caudal to the C5 dermatome, impaired joint position sense on the left, and left ptosis and miosis. Initially she was unable to stand without maximum assistance. MR imaging revealed transection of the left hemicord at the C5 level without cord hemorrhage. CTA of the neck was negative for vascular injury. She completed 18 days of acute inpatient rehabilitation. She used forearm crutches for ambulation at time of discharge. Prior to discharge the patient provided written permission for a case report.

DISCUSSION

Stab wounds are the most common cause of traumatic Brown-Séquard syndrome. Horner's syndrome is common in spinal cord lesions occurring in the cervical or thoracic region, however the combination of Horner's and Brown-Séquard syndromes is less commonly reported. In this case report, we review recommendations regarding initial imaging following cervical stab wounds, discuss anatomy and associated neurological findings in Brown-Séquard and Horner's syndromes, and review the expected temporal course of motor recovery.

CONCLUSIONS

Facilitating motor recovery and optimizing function after Brown-Séquard spinal cord injury are important roles for the rehabilitation team. Imaging is necessary to rule out cord hemorrhage or vascular injury and to clinically correlate cord damage with physical examination findings and expected functional impairments. Documenting associated anisocoria and explaining this finding to the patient is an important element of spinal cord injury education. Commonly, patients with Brown-Séquard injuries demonstrate remarkable motor recovery and regain voluntary motor strength and functional ambulation.

First Rib Fracture Resulting in Horner's Syndrome

BACKGROUND

First rib fractures and traumatic Horner's syndrome are both quite rare, which can make it difficult to properly diagnose the combination of these 2 conditions in the emergency department. These conditions may be associated with severe medical emergencies, such as ongoing carotid dissection.

CASE REPORT

We present the case of a 33-year-old man who sustained fractures to his right second, third, and fourth ribs and a delay in the diagnosis of left Horner's syndrome after he was involved in a traffic accident. Left Horner's syndrome was caused by a left transverse fracture of the first rib. This fracture was not detected on chest radiographs and required a 3-dimensional reconstructed neck computed tomography scan for detection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In the diagnosis of carotid artery dissection, conventional angiography is the criterion standard but is considered invasive. CTA is less invasive, time-saving, and can show more anatomic structures in the neck in addition to the carotid arteries. It is a good screening diagnostic modality in the traumatology department. Although the treatments for Horner's syndrome and first rib fracture are conservative, the early diagnosis of both conditions can resolve the anxiety and uncertainty experienced by both doctors and patients.

Repeated Transient Wallenberg's Syndrome: Probable Association with Ipsilateral Vertebral Artery Hypoplasia and Aortic Valve Disease

BACKGROUND

Here we report a rare case of repeated transient Wallenberg's syndrome and discuss its mechanism.

METHODS

Case report and literature review.

RESULTS

A 57-year-old man was admitted for 1.5-month repeated transient Wallenberg's syndrome, including right-sided Horner's syndrome, lower limb weakness, and paresthesia on the right side of the body and face. His symptom appeared mostly during physical activity. Symptoms occurred nearly everyday and lasted from 5 minutes to 30 minutes. His cranial magnetic resonance imaging (MRI) including diffusion-weighted MRI imaging was normal, and his cervical contrast-enhanced magnetic resonance angiography reflected right vertebral artery hypoplasia. Twenty-four-hour electrocardiogram and electroencephalography showed no abnormalities. Echocardiography showed aortic valve calcification with moderate aortic stenosis, moderate aortic insufficiency, and dilated aorta. Dual-antiplatelets or warfarin (international normalized ratio reached 2.07) were not effective to reduce the attacks.

CONCLUSIONS

Hemodynamic instability due to valve disease combined with right vertebral artery hypoplasia could lead to transient Wallenberg's syndrome. Antithrombotics are often ineffective for this kind of patients and the best therapy for them could be to cure their valve disease. Repeated transient Wallenberg's syndrome is rare and that caused by ipsilateral vertebral artery hypoplasia and severe valve disease has not been reported up till now to our knowledge, so it will widen the knowledge on etiologies of transient ischemic attacks and provide information and reference to cardiologists and neurologists in diagnosis and treatment for patients with similar clinical manifestations.

Horner's syndrome subsequent to minimally invasive video-assisted thyroidectomy in two patients

Horner's syndrome (HS), characterized by a combination of ptosis and miosis, is an uncommon complication of thyroid surgery, particularly in minimally invasive thyroid surgery. Two cases of HS were observed secondary to minimally invasive video-assisted thyroidectomy in the Department of Thyroid Breast Surgery of Zhejiang Provincial People's Hospital between August 2012 and July 2014. The two patients developed miosis and ptosis following total thyroidectomy; all symptoms had resolved at 1 and 11 months subsequent to surgery, respectively. HS has currently been reported secondary to numerous types of minimally invasive thyroid procedures. The literature was reviewed to identify cases of this iatrogenic complication secondary to each type of thyroidectomy and the possible injury mechanisms underlying the syndrome were summarized in the present study. In addition, factors that were associated with minimally invasive thyroidectomy, such as the limited endoscopic vision during the procedure, the retraction effect and the occurrence of thermal damage from the use of the harmonic scalpel, were emphasized. The present study concluded that close attention is required during minimally invasive thyroid surgery in order to avoid HS as a complication of the procedure.

Concurrent Horner's and Harlequin syndromes

Horner's syndrome and Harlequin syndrome are both caused by disruptions to the sympathetic supply to the face. They have a varied aetiology, including intraneural dysfunction, extra- or intraneural compression, and idiopathic as well as iatrogenic causes. Horner's syndrome can occur as a rare complication of thyroid surgery and the Harlequin sign has only been documented as a complication of cervical surgery in a handful of paediatric patients. We present a patient who developed both conditions subsequent to excision of a papillary carcinoma with a neck dissection. We illustrate the anatomical basis for this presentation and highlight the need for its appreciation. This is of particular interest as it impacts on several specialities operating in the cervical and thoracic fields.

Visual Hallucinations in a Patient with Horner's Syndrome Secondary to Internal Carotid Dissection

A 67-year-old female presented with post-ganglionic Horner's syndrome. In addition to the classical symptoms of Horner's syndrome, the patient reported experiencing frightening complex visual and auditory hallucinations on two different occasions. Magnetic resonance angiography of the cerebrum, neck and upper thorax revealed internal carotid dissection. The symptoms and hallucinatory experiences resolved soon after antiplatelet therapy was commenced. We propose peduncular hallucinosis as the underlying mechanism.

Horner's syndrome and weakness of upper limb after epidural anaesthesia for caesarean section

Horner's syndrome is not rare during labour epidural analgesia or in pregnant patients receiving epidural anaesthesia for caesarean section as thought previously. It occurs due to blockade of sympathetic fibres supplying the eye and face area. Most of the times it is a benign and self-limiting condition; however, it may become a serious systemic manifestation. We present a case where patient had weakness of upper-limb and Horner's syndrome of same side with visual disturbances. These symptoms were transient and resolved spontaneously without any treatment.

Rapidly enlarging neck masses of the thyroid with Horner's syndrome: a concise clinical review

BACKGROUND

Horner's syndrome (HS) presenting with a neck mass is a rare but challenging clinical scenario which may be caused by malignant thyroid disease.

METHODS

A concise review of the literature (PubMED database; 1990-2013) on the clinical management of neck masses with HS. An example case is also discussed.

RESULTS

1.3% of HS is caused by thyroid pathology. Thyroid pathology is the commonest cause of a neck mass associated with HS: the majority are caused by benign pathology; with carcinoma and lymphoma accounting for the remainder. Anaplastic thyroid carcinoma (ATC), thyroid lymphoma (TL) and thyroid sarcoma (TS) typically present with rapidly enlarging anterior neck masses in the elderly and are difficult to distinguish clinically. Although fine needle aspirate cytology (FNAC) is the diagnostic tool of choice for thyroid masses, core or incisional biopsy may be necessary when FNAC is inconclusive.

CONCLUSION

Differentiation between ATC, TL and TS is imperative as their treatment and prognoses differ greatly. Where feasible a combination of surgical debulking, radiotherapy and chemotherapy is the treatment of choice in ATC. Advanced cases benefit from 2 monthly endoscopic surveillance ± tracheostomy, stenting or Nd-YAG laser therapy. Aggressive oncological resection alone is recommended in TS. Treatment regimes in thyroid lymphoma (typically chemotherapy ± radiotherapy) differ for histological sub-types. 5-year failure-free survival is 90% in TL compared with a mean survival of 6-8 months in ATC and 10 months in TS.

Transient unilateral brachial plexopathy and partial Horner's syndrome following spinal anesthesia for cesarean section

A healthy 21-year-old primigravida presented for elective cesarean section. At 45 min after intrathecal (IT) injection of bupivacaine, morphine and fentanyl she developed dysphagia, right sided facial droop, ptosis and ulnar nerve weakness. This constellation of signs and symptoms resolved 2 h later. Based on the time course and laterality of her symptoms, as well as the pharmacologic properties of spinal opioids, we believe her symptoms can be attributed to the IT administration of fentanyl.

Trigeminal autonomic headaches caused by a multinodular goiter--a case report

BACKGROUND

Though thyroid growths are considered to be a frequent cause of Horner's syndrome, concurrent headache attacks are not commonly seen.

CASE

A 63-year-old woman presented with severe, daily occurring, unilateral headache attacks with ipsilateral Horner's syndrome. Magnetic resonance imaging arteriography showed a multinodular goiter displacing the left common carotid artery.

CONCLUSION

This case exemplifies the combination of headache attacks and Horner's syndrome due to mechanical pressure of an enlarged thyroid, mimicking the symptoms both of carotid dissection as well as trigeminal autonomic cephalgias like paroxysmal hemicrania.

Sympathetic neuropathy and dysphagia following doxycycline sclerotherapy

This case report demonstrates neurologic sequela following treatment with doxycycline sclerotherapy. A six-week-old child presented with respiratory distress from a macrocystic lymphatic malformation, extending from the skull base to the anterior mediastinum. Following doxycycline sclerotherapy, the airway symptoms resolved; however, the child developed silent aspiration and Horner's syndrome. Two months following treatment the patient resumed oral diet and at one year post-intervention there has been no recurrence of symptoms, with only mild ptosis remaining. While neuropathies following doxycycline sclerotherapy have been described, aspiration has never been documented. This case demonstrates a single patient's clinical course and resolution of their neuropathies.

[Incomplete Horner's syndrome as a presenting sign of fourth ventricle ependymoma]

CASE REPORT

The case of 44 year old male patient with palpebral ptosis and trigeminal neuralgia as presenting sign of fourth ventricle ependymoma is reported. After surgical treatment, the patient developed a residual paresis of the sixth cranial nerve.

DISCUSSION

Horner's syndrome occurs due to an alteration of the sympathetic innervations of the eye and adnexa. Some tumours may be the cause, in our case an ependymoma of the fourth ventricle, which onset exceptionally with blepharoptosis and involvement of the ophthalmic division of trigeminal nerve, due to the proximity of these nerve fibres at the brainstem.

Pourfour Du Petit syndrome after interscalene block

Interscalene block is commonly associated with reversible ipsilateral phrenic nerve block, recurrent laryngeal nerve block, and cervical sympathetic plexus block, presenting as Horner's syndrome. We report a very rare Pourfour Du Petit syndrome which has a clinical presentation opposite to that of Horner's syndrome in a 24-year-old male who was given interscalene block for open reduction and internal fixation of fracture upper third shaft of left humerus.

[Irreversible Horner's syndrome after bilateral thoracoscopic sympathectomy]

CASE REPORT

A 19 year-old boy who developed a right Horner's syndrome after a bilateral sympathectomy as a treatment for palmoplantar hyperhidrosis.

DISCUSSION

Horner's syndrome is defined by the occurrence of miosis, ptosis and enophthalmos as a result of involvement of sympathetic innervation. This is quite rare, but identification is very important because it may also be an ominous sign secondary to a neoplasm, neurological diseases, or surgery of the sympathetic chain, as in our case.

Post-Ganglionic Horner's Syndrome: An Unusual Presentation of Non-Hodgkin Lymphoma

In this paper, we present the rare case of a patient with cervical lymphadenopathy diagnosed as a T-cell-rich B-cell non-Hodgkin lymphoma that manifested Horner's syndrome due to a post-ganglionic sympathetic neuron lesion caused by the tumor.

Horner's syndrome with abducens nerve palsy

A 68-year-old male patient presented with a week of sudden diplopia. He had been diagnosed with nasopharyngeal cancer 8 months prior and had undergone chemotherapy with radiotherapy. Eight-prism diopter right esotropia in the primary position and a remarkable limitation in abduction in his right eye were observed. Other pupillary disorders and lid drooping were not found. After three weeks, the marginal reflex distance 1 was 3 mm in the right eye and 5 mm in the left eye. The pupil diameter was 2.5 mm in the right eye, and 3 mm in the left eye under room illumination. Under darkened conditions, the pupil diameter was 3.5 mm in the right eye, and 5 mm in the left eye. After topical application of 0.5% apraclonidine, improvement in the right ptosis and reversal pupillary dilatation were observed. On brain magnetic resonance imaging, enhanced lesions on the right cavernous sinus, both sphenoidal sinuses, and skull base suggested the invasion of nasopharyngeal cancer. Lesions on the cavernous sinus need to be considered in cases of abducens nerve palsy and ipsilateral Horner's syndrome.