Faculty Bibliography

Neurologic manifestations of Lyme disease are common, often debilitating, and potentially treatable. We document a case of Borrelia infection of the nervous system manifesting as a reversible Horner's syndrome. The search for Lyme disease should be part of the evaluation of an isolated central or preganglionic Horner's syndrome or any unexplained pupillary abnormality.

We studied a family in which the proband had an acute chiasmal syndrome secondary to a cavernous angioma of the optic nerve and chiasm. A brain magnetic resonance imaging scan indicated additional asymptomatic intracerebral cavernous angioma, and several of the patient's relatives were found to have various central nervous system vascular malformations. Magnetic resonance imaging may distinguish, noninvasively, symptomatic and asymptomatic carriers of cavernous angiomas and further delineate their inheritance patterns. Asymptomatic cavernous angiomas of the central nervous system are best followed without intervention, whereas symptomatic patients should be treated on an individual basis, depending on the location of lesion and the risk of surgical removal.

A case of rhinocerebral mucormycosis evaluated by magnetic resonance (MR) imaging is presented, with inflammatory changes in the paranasal sinuses and orbit. Extension of the infection into the cavernous sinus, with cavernous sinus thrombosis and internal carotid artery narrowing, was well demonstrated on pre- and postgadolinium MR images. Infarctions in the anterior choroidal artery distribution suggested intracranial invasion of basal arteries, and watershed distribution infarctions attested to the tenuousness of flow through a narrowed cavernous carotid artery. Magnetic resonance effectively demonstrated the wide array of findings possible in rhinoorbitocerebral mucormycosis.

Twenty-seven cases of chronic isolated abduction deficit, seen in 25 years of neuro-ophthalmology consultation, were reviewed. "Isolated" was defined as the lack of any other neurologic or ophthalmologic findings for at least six months. Cases were further subdivided into the categories of true and pseudo-abducens paresis. The origin, diagnosis, and management of long-standing abducens palsies were determined. Cases of pontine glioma, chordoma, chondrosarcoma, and meningioma that presented as an isolated abducens palsy and remained undiagnosed for at least six months were reviewed.

Ocular motility manifestations of focal brainstem dysfunction were the initial clinical features in three patients with human immunodeficiency virus (HIV) infection. These included conjugate gaze palsy with ipsilateral facial paresis, bilateral abducens palsy and a gaze paresis, and homolateral internuclear ophthalmoplegia and abducens nerve paresis. Two patients had focal brainstem lesions as evidenced on neuroimaging. The third showed concurrent infection with Treponema pallidum.

Magnetic resonance imaging provides a method of visualizing multiple sclerosis plaques, but the age and activity of these plaques cannot be determined with routine magnetic resonance images. Gadolinium DTPA is a paramagnetic contrast agent that does not cross an intact blood-brain barrier. We studied 16 patients with multiple sclerosis, using magnetic resonance imaging, gadolinium-enhanced magnetic resonance imaging, and computed tomographic scans. Gadolinium enhancement of multiple sclerosis plaques correlated with the clinical activity of the disease and corresponded anatomically with the symptoms and signs. We conclude that gadolinium enhancement of magnetic resonance images is a promising tool in the investigation of multiple sclerosis lesions and that it may provide a method for objective follow-up in clinical trails

Magnetic resonance (MR) images--both nonenhanced and enhanced with gadolinium DTPA/dimeglumine (Gd)--were compared with high-iodine (88.1 g I) computed tomographic (HICT) scans in demonstrating lesions in 15 patients known to have multiple sclerosis (MS). T1-weighted, mixed (T1, proton density, and T2), and T2-weighted MR pulse sequences were used. More than 20 lesions in each of 14 patients were demonstrated by pre-Gd mixed images and T2WI. Nine patients had clinical symptoms of active disease. Gd-enhanced T1WI showed at least one lesion that appeared to correspond with newly reported symptoms or signs. In addition, three clinically stable patients showed enhancement. Enhancement was best seen on 3-minute T1WI. HICT scans showed enhancement in four of the nine patients with active disease and in none of five clinically stable patients. Gd-enhanced MR imaging appears to be more sensitive than HICT in the detection of the transient abnormalities of the blood-brain barrier that occur in patients with active MS and appears capable of distinguishing active lesions that may correspond to the anatomic regions responsible for abnormal clinical findings