Bilateral VI Research Articles

Prevalence and associated factors of visual impairment among adults at Debre Berhan town, North Shewa, Ethiopia

BackgroundVisual impairment refers to presenting distance visual acuity worse than 6/18 in the worst eye. It remains a global challenge that greatly affects the mobility, social participation and the quality of life of the people. This study was aimed to determine the prevalence and associated factors of visual impairment among adults aged ≥ 18 years.MethodsA community-based cross-sectional study was conducted at Debre Berhan town. Systematic random sampling method was employed to select the study participants from adult’s aged ≥18 years. Data was collected by interview with a pre-tested semi structured questionnaire. Both anterior and posterior segment ocular examinations were done by Optometrists and Ophthalmologist. After all ocular examinations adult’s aged ≥18 years with presenting Visual acuity of < 6/18 in the worst eye were considered as visually impaired. Multivariate logistic regression was used to identify the determinant factors and p value less than 0.05 was considered as statistically significant.ResultsA total of 416 participants were enrolled in the study with a 98.6% response rate. The prevalence of visual impairment among adults aged ≥ 18 years was 16.8% (95% CI, 13.5–20.2%). Among the overall prevalence of visually impaired adults 27 (6.49%) had bilateral VI and 43 (10.34%) had monocular VI. Aged > 64 years (AOR = 12.18, 95%CI: 4.47–33.20), illiterates AOR = 3.02, 95% CI: 1.36–6.72), previous eye trauma (AOR = 4.44, 95% CI: 1.64–12.04), family size > 5 (AOR: 4.44, 95% CI: 1.43–13.75) and family history of eye problem (AOR = 7.02, 95% CI: 1.95–25.22) had statistically significant association with visual impairment.ConclusionsPrevalence of visual impairment among adults was found to be a significant public health problem. Older age, illiterates, previous eye trauma, large family size and family history eye problem were positively associated with visual impairment.

Patterns and Predictors of Metastatic Spread to the Neck in Pediatric Thyroid Carcinoma.

Evaluate patterns and predictors of spread to the neck in pediatric metastatic differentiated thyroid carcinoma (DTC). Patients <18 years old undergoing thyroidectomy by a single surgeon from January 2015 to December 2019 were included. Neck sublevels were removed separately according to AJCC boundaries. Clinical outcomes included nerve injury, hypocalcemia, hematoma, and residual tumor. Forty-eight children underwent thyroid surgery. Thirty (63%) were for malignancy, 27 (90%) of which were DTC. Nineteen (70%) patients with DTC underwent 24 neck dissections; 19 central plus lateral and 5 central alone. The female to male ratio increased from 1:1 to 3:1 with age. Two children with lateral neck involvement had sub-centimeter primaries. Patients requiring neck dissection were more likely to have 1) diffuse sclerosing or tall cell variant, 2) T3 or T4 disease, 3) genetic mutation, 4) lymphatic invasion, 5) extracapsular extension, 6) positive resection margin. Levels IIA (79%), III (89%), IV (84%), VI (100%) were most commonly involved. Levels IB (16%), IIB (16%), VB (16%) were also involved, often without involvement of adjacent levels. Permanent injuries included one unilateral recurrent laryngeal nerve, one mild marginal mandibular nerve and one mild accessory nerve. Hypocalcemia was highest following neck dissection for malignant disease. One patient was re-operated for a mediastinal node. Most patients with N1 disease received radioactive iodine. Most patients have no evidence or indeterminate disease on long-term follow-up. Children with lateral nodal spread from DTC should be considered for neck dissection including Levels IB, IIA, IIB, III, IV, VB, bilateral VI. 4 Laryngoscope, 131:E1002-E1009, 2021.

SUN-474 An Unusual Case of Poorly Differentiated Thyroid Carcinoma with an Excellent Prognosis

Background: Poorly differentiated thyroid carcinoma (PDTC) is a rare and aggressive subtype with morphological/behavioral features between differentiated thyroid carcinoma (DTC) and anaplastic thyroid carcinoma (ATC). Clinical case: A 43-year-old female presented with 3 cm right thyroid mass noted on US neck. FNA biopsy showed undifferentiated carcinoma, large cell type. Additional immune-stains were suggestive of ATC. Pre-surgery non-stimulated thyroglobulin (NSTG) was 311 (RR 0–55 ng/dl). Pathology post-total thyroidectomy with bilateral level VI lymph node dissection showed a 3.2 x 2.5 x 2.5 cm carcinoma with vascular and capsular invasion. Most of the mass consisted of very atypical pleomorphic cells, mitosis was difficult to find. The tumor did not show the widely invasive-destructive pattern commonly seen in ATC. An adjacent differentiated component showed predominantly follicular pattern and was described as dedifferentiated follicular carcinoma. All lymph nodes were negative for metastatic disease. Post-surgery NSTG was <0.2 (RR <0.1ng/ml as athyreotic), stimulated TG was 2.22 with negative TG antibodies. Four months later, she received 193.5 mCi radioactive iodine (RAI) therapy. The post-therapy scan showed no Iodine-131 avid uptake in neck or distant metastasis. Neck imaging and TG levels done periodically showed no structural or biochemical evidence of recurrence. Currently the patient is cancer-free for 14 years since diagnosis with no need for additional therapies. Discussion: PDTC accounts for 1–15% of all thyroid cancers. Although PDTC is rare, it is a clinically significant histological diagnosis as it represents the main cause of death from non-anaplastic follicular cell-derived thyroid carcinoma. The Turin proposal published in 2007 suggested three criteria for the diagnosis of PDTC which included the pattern of growth and high-grade features. PDTC presents more frequently with locally invasive extra-thyroidal disease, metastasis to regional lymph nodes and distant organs compared to DTC. Despite the capacity to have RAI uptake, there has been no evidence of significant improvement in survival due to tumor heterogeneity in differentiation. Recent data suggest that age more than 45 years, tumor size more than 4cm, extra-thyroidal extension, higher pathological T stage, positive margins, and distant metastasis predict worse prognosis. Conclusion: Our patient showed an excellent response to therapy in spite of having PDTC with positive margins. We hypothesize that this could be likely due to young age at the time of diagnosis, early detection of tumor while it was localized in the thyroid without distant metastasis as well as heterogeneity in the tumor with differentiated cells that are responsive to RAI. We conclude that with early detection, timely surgery, and adjuvant therapy, excellent prognosis can be achieved in patients with PDTC.

Intrinsic Cerebro-Cerebellar Functional Connectivity Reveals the Function of Cerebellum VI in Reading-Related Skills.

The engagement of the cerebellum VI in reading was reported in both typically developing and dyslexic readers. However, it is still not clear how the cerebellum VI contributes to reading. Here we have examined the correlation of intrinsic cerebro-cerebellar functional connectivity with two critical reading-related skills—phonological awareness (PA) and rapid automatized naming (RAN)—with fMRI technology. Specifically, we tested the hypothesis that the cerebellum may contribute to reading either by phonological skills or by automatizing skills. We chose the left and right cerebellum VI as ROIs, and we calculated the intrinsic cerebro-cerebellar functional connectivity during a resting state. We further explored whether and how cerebro-cerebellar resting state functional connectivity (RSFC) is associated with individuals’ reading-related skills including PA and RAN. The results showed that the functional connectivity between the left supramarginal gyrus and bilateral cerebellum VI was related to RAN, and the connectivity between the left insula and right cerebellum VI was related to PA. However, the effect of PA did not survive after the RAN was regressed out. Control analyses further confirmed that it was the intrinsic cerebro-cerebellar functional connectivity rather than the local cerebellar functionality that associated with phonological awareness ability and rapid automatized naming ability. For the first time, the relationship between cerebro-cerebellar resting state functional connectivity and specific reading-related skills has been explored, and this has deepened our understanding of the way the cerebellum VI is involved in reading.

Cerebello-Cortical Alterations Linked to Cognitive and Social Problems in Patients With Spastic Paraplegia Type 7: A Preliminary Study.

Spastic paraplegia type 7 (SPG7), which represents one of the most common forms of autosomal recessive spastic paraplegia (MIM#607259), often manifests with a complicated phenotype, characterized by progressive spastic ataxia with evidence of cerebellar atrophy on brain MRI. Recent studies have documented the presence of peculiar dentate nucleus hyperintensities on T2-weighted images and frontal executive dysfunction in neuropsychological tests in SPG7 patients. Therefore, we decided to assess whether any particular MRI pattern might be specifically associated with SPG7 mutations and possibly correlated with patients' cognitive profiles. For this purpose, we evaluated six SPG7 patients, studying the cerebello-cortical network by MRI voxel-based morphometry and functional connectivity techniques, compared to 30 healthy control subjects. In parallel, we investigated the cognitive and social functioning of the SPG7 patients. Our results document specific cognitive alterations in language, verbal memory, and executive function in addition to an impairment of social task and emotional functions. The MRI scans showed a diffuse symmetric reduction in the cerebellar gray matter of the right lobule V, right Crus I, and bilateral lobule VI, together with a cerebral gray matter reduction in the lingual gyrus, precuneus, thalamus, and superior frontal gyrus. The evidence of an over-connectivity pattern between both the right and left cerebellar dentate nuclei and specific cerebral regions (the lateral occipital cortex, precuneus, left supramarginal gyrus, and left superior parietal lobule) confirms the presence of cerebello-cortical dysregulation in different networks involved in cognition and social functioning in SPG7 patients.

Cryptococcal meningitis and immune reconstitution inflammatory syndrome in a pediatric patient with HIV after switching to second line antiretroviral therapy: a case report

BackgroundCryptococcal meningitis (CCM) is a common and deadly disease among HIV-infected patients. Notable about CCM is its association with the immune reconstitution inflammatory syndrome (IRIS). Though it has been posited a switch from first to second-line antiretroviral therapy (ART) can induce CCM IRIS, a case presentation of CCM IRIS has not been published.Case presentationA 10-year-old, HIV-infected girl who initially presented with severe headache and new-onset seizures, with cerebrospinal fluid that returned antigen, India Ink, and culture positive for Cryptococcus neoformans. Notably, 8 weeks prior to seizures, she had switched from first line to second-line ART (abacavir-lamivudine-efavirenz to zidovudine-lamivudine-lopinavir/ritonavir) due to virologic failure, with a viral load of 224,000 copies/milliliter. At time of seizures and 8 weeks on second-line ART, her viral load had reduced to 262 copies/milliliter.Her hospital course was prolonged, as she had ongoing headaches and developed bilateral cranial nerve VI palsies despite clearance of Cryptococcus from cerebrospinal fluid on antifungal therapy and therapeutic lumbar punctures. However, symptoms stabilized, and she was discharged with oral fluconazole. Cranial nerve palsies resolved 10 weeks post discharge and she has remained disease free.ConclusionsWe describe a case of CCM IRIS in a 10-year-old HIV infected child after changing to second-line ART. This case provides evidence that screening for cryptococcal antigenaemia prior to switch from first-line to second-line ART could be an important measure to prevent cryptococcal disease.

Volumetric reduction of cerebellar lobules associated with memory decline across the adult lifespan.

The human cerebellum plays an essential role in motor control, is involved in cognitive function and helps to regulate emotional responses. However, little is known about the relationship between cerebellar lobules and age-related memory decline. We aimed to investigate volume alterations in cerebellar lobules at different ages and assess their correlations with reduced memory recall abilities. A sample of 275 individuals were divided into the following four groups: 20-35 years (young), 36-50 years (early-middle age), 51-65 years (late-middle age), and 66-89 years (old). Volumes of the cerebellar lobules were obtained using volBrain software. Analysis of covariance and post hoc analysis were used to analyze group differences in cerebellar lobular volumes, and multiple comparisons were performed using the Bonferroni method. Spearman correlation was used to investigate the relationship between lobular volumes and memory recall scores. In this study, we found that older adults had smaller cerebellar volumes than the other subjects. Volumetric decreases in size were noted in bilateral lobule VI and lobule crus I. Moreover, the volumes of bilateral lobule crus I, lobule VI, and right lobule IV were significantly associated with memory recall scores. In the present study, we found that some lobules of the cerebellum appear more predisposed to age-related changes than other lobules. These findings provide further evidence that specific regions of the cerebellum could be used to assess the risk of memory decline across the adult lifespan.

Altered cerebro-cerebellum resting-state functional connectivity in HIV-infected male patients

In addition to the role of planning and executing movement, the cerebellum greatly contributes to cognitive process. Numerous studies have reported structural and functional abnormalities in the cerebellum for HIV-infected patients, but little is known about the altered functional connectivity of particular cerebellar subregions and the cerebrum. Therefore, this study aimed to explore the resting-state functional connectivity (rsFC) changes of the cerebellum and further analyze the relationship between the rsFC changes and the neuropsychological evaluation. The experiment involved 26 HIV-infected men with asymptomatic neurocognitive impairment (ANI) and 28 healthy controls (HC). We selected bilateral hemispheric lobule VI and lobule IX as seed regions and mapped the whole-brain rsFC for each subregion. Results revealed that right lobule VI showed significant increased rsFC with the anterior cingulate cortex (ACC) in HIV-infected subjects. In addition, the correlation analysis on HIV-infected subjects illustrated the increased rsFC was negatively correlated with the attention/working memory score. Moreover, significantly increased cerebellar rsFCs were also observed in HIV-infected patients related to right inferior frontal gyrus (IFG) and right superior medial gyrus (SMG) while decreased rsFC was just found between right lobule VI and the left hippocampus (HIP). These findings suggested that, abnormalities of cerebro-cerebellar functional connectivity might be associated with cognitive dysfunction in HIV-infected men, particularly working memory impairment. It could also be the underlying mechanism of ANI, providing further evidence for early injury in the neural substrate of HIV-infected patients.

Altered brain function in persistent postural perceptual dizziness: A study on resting state functional connectivity

This study used resting state functional magnetic resonance imaging (rsfMRI) to investigate whole brain networks in patients with persistent postural perceptual dizziness (PPPD). We compared rsfMRI data from 38 patients with PPPD and 38 healthy controls using whole brain and region of interest analyses. We examined correlations among connectivity and clinical variables and tested the ability of a machine learning algorithm to classify subjects using rsfMRI results. Patients with PPPD showed: (a) increased connectivity of subcallosal cortex with left superior lateral occipital cortex and left middle frontal gyrus, (b) decreased connectivity of left hippocampus with bilateral central opercular cortices, left posterior opercular cortex, right insular cortex and cerebellum, and (c) decreased connectivity between right nucleus accumbens and anterior left temporal fusiform cortex. After controlling for anxiety and depression as covariates, patients with PPPD still showed decreased connectivity between left hippocampus and right inferior frontal gyrus, bilateral temporal lobes, bilateral insular cortices, bilateral central opercular cortex, left parietal opercular cortex, bilateral occipital lobes and cerebellum (bilateral lobules VI and V, and left I-IV). Dizziness handicap, anxiety, and depression correlated with connectivity in clinically meaningful brain regions. The machine learning algorithm correctly classified patients and controls with a sensitivity of 78.4%, specificity of 76.9%, and area under the curve=0.88 using 11 connectivity parameters. Patients with PPPD showed reduced connectivity among the areas involved in multisensory vestibular processing and spatial cognition, but increased connectivity in networks linking visual and emotional processing. Connectivity patterns may become an imaging biomarker of PPPD.

Isolated abducens nerve palsy associated with subarachnoid hemorrhage: a localizing sign of ruptured posterior inferior cerebellar artery aneurysms.

OBJECTIVE Compressive cranial nerve syndromes can be useful bedside clues to the diagnosis of an enlarging intracranial aneurysm and can also guide subsequent evaluation, as with an acute oculomotor nerve (cranial nerve [CN] III) palsy that is presumed to be a posterior communicating artery aneurysm and a surgical emergency until proven otherwise. The CN VI has a short cisternal segment from the pontomedullary sulcus to Dorello's canal, remote from most PICA aneurysms but in the hemodynamic pathway of a rupturing PICA aneurysm that projects toward Dorello's canal. The authors describe a cranial nerve syndrome for posterior inferior cerebellar artery (PICA) aneurysms that associates subarachnoid hemorrhage (SAH) and an isolated abducens nerve (CN VI) palsy. METHODS Clinical and radiological data from 106 surgical patients with PICA aneurysms (66 ruptured and 40 unruptured) were retrospectively reviewed. Data from a group of 174 patients with other aneurysmal SAH (aSAH) were analyzed in a similar manner to control for nonspecific effects of SAH. Univariate statistical analysis compared incidence and risk factors associated with CN VI palsy in subarachnoid hemorrhage. RESULTS Overall, 13 (4.6%) of 280 patients had CN VI palsy at presentation, and all of them had ruptured aneurysms (representing 13 [5.4%] of the 240 cases of ruptured aneurysms). CN VI palsies were observed in 12 patients with ruptured PICA aneurysms (12/66 [18.1%]) and 1 patient with other aSAH (1/174 [0.1%], p < 0.0001). PICA aneurysm location in ruptured aneurysms was an independent predictor for CN VI palsy on multivariate analysis (p = 0.001). PICA aneurysm size was not significantly different in patients with or without CN VI palsy (average size 4.4 mm and 5.2 mm, respectively). Within the PICA aneurysm cohort, modified Fisher grade (p = 0.011) and presence of a thick cisternal SAH (modified Fisher Grades 3 and 4) (p = 0.003) were predictors of CN VI palsy. In all patients with ruptured PICA aneurysms and CN VI palsy, dome projection and presumed direction of rupture were directed toward the ipsilateral and/or contralateral Dorello's canal, in agreement with laterality of the CN palsy. In patients with bilateral CN VI palsies, a medial projection with extensive subarachnoid blood was observed near bilateral canals. CONCLUSIONS This study establishes a localizing connection between an isolated CN VI palsy, SAH, and an underlying ruptured PICA aneurysm. CN VI palsy is an important clinical sign in aSAH and when present on initial clinical presentation may be assumed to be due to ruptured PICA aneurysms until proven otherwise. The deficit may be ipsilateral, contralateral, or bilateral and is determined by the direction of the aneurysm dome projection and extent of subarachnoid bleeding toward Dorello's canal, rather than by direct compression.

Cerebellar contributions to biological motion perception in autism and typical development.

Growing evidence suggests that posterior cerebellar lobe contributes to social perception in healthy adults. However, they know little about how this process varies across age and with development. Using cross-sectional fMRI data, they examined cerebellar response to biological (BIO) versus scrambled (SCRAM) motion within typically developing (TD) and autism spectrum disorder (ASD) samples (age 4-30 years old), characterizing cerebellar response and BIO > SCRAM-selective effective connectivity, as well as associations with age and social ability. TD individuals recruited regions throughout cerebellar posterior lobe during BIO > SCRAM, especially bilateral lobule VI, and demonstrated connectivity with right posterior superior temporal sulcus (RpSTS) in left VI, Crus I/II, and VIIIb. ASD individuals showed BIO > SCRAM activity in left VI and left Crus I/II, and bilateral connectivity with RpSTS in Crus I/II and VIIIb/IX. No between-group differences emerged in well-matched subsamples. Among TD individuals, older age predicted greater BIO > SCRAM response in left VIIb and left VIIIa/b, but reduced connectivity between RpSTS and widespread regions of the right cerebellum. In ASD, older age predicted greater response in left Crus I and bilateral Crus II, but decreased effective connectivity with RpSTS in bilateral Crus I/II. In ASD, increased BIO > SCRAM signal in left VI/Crus I and right Crus II, VIIb, and dentate predicted lower social symptomaticity; increased effective connectivity with RpSTS in right Crus I/II and bilateral VI and I-V predicted greater symptomaticity. These data suggest that posterior cerebellum contributes to the neurodevelopment of social perception in both basic and clinical populations. Hum Brain Mapp 38:1914-1932, 2017. © 2017 Wiley Periodicals, Inc.

Intraoperative Neuromonitoring in Selective Neck Dissection for Thyroid Cancer: SND (IIa–Vb) with Wu Gaosong's Procedure

Introduction: Thyroid carcinoma is the most common endocrine malignancy and the ninth common malignancy in the United State, about 80% of thyroid carcinoma is papillary thyroid cancer.1,2 The prognosis of most cases is excellent but local invasion, lymph node, or distant metastasis may happen in some cases.3 The lateral neck compartmental lymph node dissection should be performed for patients with biopsy-proven metastatic lateral cervical lymphadenopathy.4 Nowadays, the standard extent of neck dissection includes the lymph nodes at levels II, III, IV, and V. The dissection of levels IIb and Va should be based on an evident clinical metastasis on preoperative ultrasonography and nodal fine needle aspiration (FNA) cytology. Lymphadenectomy in patients with nodal metastasis lowered incidence of recurrence and improved survival.5,6 However, complications might occur when patients selected unskilled or inexperienced surgeons. Potential complications from lateral neck dissection include chyle leak, hypoparathyroidism, injury to the internal jugular vein or carotid artery, and injury to nerves such as accessory nerve, sympathetic cervical plexus, and phrenic nerve.7 Prof. Wu, the chief surgeon in this video and also the chief surgeon in the educational video of thyroid surgery in China, is a high-volume thyroid surgeon who has performed more than 1000 thyroid operations annually. The philosophies behind thyroidectomy with Wu Gaosong's procedure and central compartment lymph nodes dissection with Wu Gaosong's procedure have been published.8,9 In this video, we show selective neck dissection (SND) for thyroid cancer: SND (IIa–Vb) with Wu Gaosong's procedure. Materials and Methods: The patient is a 57-year-old woman who was suffering from papillary thyroid carcinoma and underwent total thyroidectomy with bilateral level VI dissection 1 year ago. The recent ultrasonography reported left lateral neck nodal metastases and FNA cytology proved the metastases of papillary thyroid carcinoma. The patient had no symptoms at all and physical examination found no positive result. We performed a SND with Wu Gaosong's procedure. The sternocleidomastoid muscle, the external jugular vein, the internal jugular vein, the phrenic nerve, the accessory nerve, the cutaneous nerve, and the thoracic duct were preserved effectively. The dissection was restricted strictly within the “facial envelope,” which wrapped the lateral lymph nodes and comprised five boundaries, including the investing fascia laterally and anteriorly, the prevertebral fascia posteriorly, the carotid sheath medially, the digastric muscle superiorly, and the clavicle inferiorly. The lower jugular groups were connected loosely with carotid sheath and prevertebral fascia, and we used a peanut to dissect the fatty tissue in this area. Nerve monitoring (NIM-Response 3.0 System, Medtronic) was used in this case to help us identify various nerves in the lateral neck. One milli ampere electrical current was used to stimulate the target nerve. Results: Postoperative pathology analysis revealed 6/31 nodal metastases. The patient is discharged without any complication 5 days after operation. Conclusions: Nerve monitoring might have potential to be used in the lateral neck dissection and the procedure helps to decrease the incidence of potential complications during lateral neck dissection. No competing financial interests exist. Runtime of video: 7 mins 52 secs

P15.01 Anti-Ri syndrome presenting with bilateral CN VI palsy and jaw dystonia

P15.01 Anti-Ri syndrome presenting with bilateral CN VI palsy and jaw dystonia

Extra-luminal sigmoid sinus granulation tissue resulting in otitic hydrocephalus

Summary A four-year-old male presented to the emergency department with bilateral cranial nerve VI palsy following a failed outpatient course of antibiotics for acute mastoiditis. Imaging revealed a right sigmoid sinus flow defect. Urgent mastoidectomy with removal of the right sigmoid sinus osseous plate was performed. Intraoperatively, extensive granulation tissue was encountered compressing the sinus. The cranial nerve deficit resolved overnight, and follow-up imaging revealed restoration of venous outflow. As a result, the flow void was determined to be a result of compression of the sinus rather than thrombosis, and a prolonged course of systemic anticoagulation was avoided.

Sixth Nerve Palsy in Paediatric Intracranial Hypertension

ABSTRACTThe purpose of this study was to report the incidence and describe the characteristics of sixth cranial nerve (CN VI) palsy in paediatric patients with intracranial hypertension (IH). A retrospective chart review of central Ohio children diagnosed with IH over the 3-year period from 2010 to 2013 was conducted. IH without identifiable cause was defined as idiopathic intracranial hypertension (IIH), whereas IH with identifiable pathologic aetiology was deemed secondary intracranial hypertension (SIH). A subset of patients with CN VI palsy was identified. Data collected included patient age, gender, past medical history, aetiology of SIH, ophthalmic examination, lumbar puncture results, neuroimaging results, and response to treatment. Seventy-eight children with intracranial hypertension were included in the study. Nine (11.5%) children (four males, five females; median age 14, range: 3–18) were found to have a unilateral (n = 2) or bilateral (n = 7) CN VI palsy. Five children had IIH; the remaining four had SIH from cerebral venous sinus thrombosis (n = 2) and infection (n = 2). The mean lumbar puncture opening pressure for the nine patients with CN VI palsy was 40 cm H2O (range: 21–65 cm H2O). Papilloedema was present in 8/9 (89%) patients. One patient required a lumboperitoneal shunt, and two others required optic nerve sheath fenestrations in addition to medical management. All cases of CN VI palsy resolved with treatment. In our primary service area, the incidence of CN VI palsy is approximately 12% among paediatric IH patients. The majority of cases with CN VI palsy presented with papilloedema and all cases resolved with treatment of intracranial hypertension.

Temporal dynamics of visual working memory

The involvement of the human cerebellum in working memory has been well established in the last decade. However, the cerebro-cerebellar network for visual working memory is not as well defined. Our previous fMRI study showed superior and inferior cerebellar activations during a block design visual working memory task, but specific cerebellar contributions to cognitive processes in encoding, maintenance and retrieval have not yet been established. The current study examined cerebellar contributions to each of the components of visual working memory and presence of cerebellar hemispheric laterality was investigated. 40 young adults performed a Sternberg visual working memory task during fMRI scanning using a parametric paradigm. The contrast between high and low memory load during each phase was examined. We found that the most prominent activation was observed in vermal lobule VIIIb and bilateral lobule VI during encoding. Using a quantitative laterality index, we found that left-lateralized activation of lobule VIIIa was present in the encoding phase. In the maintenance phase, there was bilateral lobule VI and right-lateralized lobule VIIb activity. Changes in activation in right lobule VIIIa were present during the retrieval phase. The current results provide evidence that superior and inferior cerebellum contributes to visual working memory, with a tendency for left-lateralized activations in the inferior cerebellum during encoding and right-lateralized lobule VIIb activations during maintenance. The results of the study are in agreement with Baddeley's multi-component working memory model, but also suggest that stored visual representations are additionally supported by maintenance mechanisms that may employ verbal coding.

The pescatorial sixth

A 56-year-old man with diabetes presented with acute diplopia and signs of bilateral complete abduction deficits. Diffuse areflexia was his only other sign at presentation. Within a few days, he developed complete ophthalmoplegia and ataxia, consistent with a clinical diagnosis of Miller-Fisher syndrome, and repeated history revealed a possible gastroenteritis 3 weeks prior. This case illustrates an “ophthalmoplegia without ataxia” variant of this classic autoimmune condition, which should be considered in patients presenting with bilateral VI nerve palsies.

A Case Report of ‘Pseudo Tumor Cerebri’

Pseudo tumor cerebri is a clinical entity of uncertain etiology characterized by intracranial hypertension. The syndrome classically manifests with headaches and visual changes in women with obesity. This case is being presented for the following points: raised ICT, bilateral CN VI palsy, bilateral papilledema (left > right), neck rigidity present without Kernig’s and Brudginski signs. Keeping the history, Neurological findings, investigative results, point to the possibility of raised intracranial pressure with CN VI involvement. The final clinical diagnosis, to the above syndrome, points out to ‘Pseudo-tumor cerebri’.

Strabismus and diplopia in a patient with acute myeloid leukemia.

Patient: Male, 64Final Diagnosis: Acute myeloid leukemia (AML)Symptoms: —Medication: —Clinical Procedure: —Specialty: —Objective:Unusual clinical courseBackground:Central nervous system (CNS) involvement is a sporadic presenting finding in patients with acute myeloid leukemia (AML) both at diagnosis and at relapse. Moreover patients with CNS localization are often asymptomatic, while sometimes show meningeal signs and symptoms or, extremely rarely, signs of cranial nerve impairment.Case Report:Here we report on a patient with refractory AML who suddenly developed strabismus and diplopia. Both neurological and ophtalmologic examinations were suggestive of a bilateral VI cranial nerve palsy. Noteworthy, both a cranial CT and MRI were substantially normal, while a rachicentesis was performed and cerebrospinal fluid examination was clearly suggestive of a meningeal involvement by AML.Conclusions:This is to our knowledge the first reported case in which the clinical picture of meningeal localization in an AML patient was dominated by an isolated abducens cranial nerve impairment. Moreover it highlights as unexplained strabismus and diplopia can be considered as a potential sign of CNS involvement, even if conventional imaging is negative.

Reoperative Experience with Papillary Thyroid Cancer

Intense postoperative monitoring has resulted in increasing detection of patients with recurrent papillary thyroid cancer (PTC). Our goals included quantifying successful reoperation, and analyzing surgical complications and reasons for relapse. From 1999 to 2008, a total of 410 patients underwent reoperation for PTC relapse. We analyzed post-reoperative disease outcomes, reasons for relapse, and complications. Bilateral reoperative thyroidectomy was performed in 13 (3%) patients; lobectomy, 34 (8%); central neck (VI) soft tissue local recurrence excision, 47 (11.5%); bilateral VI node dissection, 107 (26%); unilateral VI dissection, 112 (27%); levels II-V dissection, 93 (23%); levels III-V, 86 (21%); lateral single- or two-compartment dissection, 51 (12%); and node picking, 20 (5%) of level VI and 53 (13%) lateral neck. Complications occurred in 6%; including hypoparathyroidism, 3%; unintentional recurrent laryngeal nerve (RLN) paralysis, 3%; phrenic nerve injury, 0.5%; spinal accessory nerve injury, 0.5%; and chyle leak in 1.6%. Of 380 (93%) patients with follow-up (mean 5.2years); 274 (72%) patients are alive with no structural evidence of disease, 38% developed disease relapse (mean 2.1years), 42 (11%) died from PTC, and 55 (14%) are alive with disease. The reason for relapse was a false negative pre-reoperative ultrasound (US) in 18 (5%), nodal recurrence in the operative field in 37 (10%), a combination of these two reasons in 10 (3%), and disease virulence (local or systemic recurrence) in 81 (21%). Although 72% of patients were rendered structurally disease free after reoperation, nearly 40% suffered additional relapse. Improved surgical technique or preoperative localization might positively affect 15-20%; at least 20% reflect the biologic aggressiveness of the disease.