Homer's Syndrome Research Articles

Spontaneous Arterial Dissection—Risk Factors And Clinical Features: Study Of 70 Cases And Review Of Literature

Dissection refers to a serious condition that begin as a tear or rupture in the inner layers of large vessel wall. Tear allows the blood to surges through the layers, leads to intramural hematoma or an aneurysmal dilatation, either of which can be a source of thromboembolism. Ischemic symptoms in surrounding structures are more often secondary to embolism. Dissections are labeled spontaneous in the absence of major blunt or penetrating trauma. The incidence rates for spontaneous carotid artery dissection have been reported to be 2.5 to 3 per 100,000 population. The average annual incidence for vertebral artery dissection were calculated to be 1 to 1.5 per 100,000. Typical clinical features seen with dissection include unilateral headache, ipsilateral Homer's syndrome, oculosympathetic palsy, prominent neck and facial pain, retinal ischemia, and symptoms of focal brain ischemia due to the site of dissection. The reason of dissection occurrence is still unknown but numerous factors e.g. connective tissue disorders, hyperhomocystinemia, fibromuscular dysplasia, recent infection, etc. may underlie spontaneous or minor trauma dissections. Patients with Spontaneous dissection are more susceptible to developing to stroke and its morbidity and mortality. In this retrospective study, we evaluate the clinical features, risk factors, treatment and outcome of spontaneous dissection in 70 patients (31 female and 39 male), referred to Namazi hospital between September 2012 and September 2016. The diagnosis of arterial dissection was established by qualified physicians according to radiological and clinical features. Patients with traumatic dissection and a history of major or minor head and neck injury were excluded. Subjects were observed for multiple risk factors such as age dependent risk factors, family history of venous thrombosis, history of trauma, coagulopathies, infectious diseases, systemic disorders, arterio-venous malformations and autoimmune diseases. We also investigated for any history of OCP administration in female patients. The collected data was evaluated using SPSS 16. Chi-square test were performed for the comparison of qualitative variables. And p<0.05 was considered as the level of significance in two-tailed tests. Statistical analysis of our data found a significant correlation between hypertension and occurrence of spontaneous arterial dissection. The findings confirm that hypertension, OCP administration and smoking can increase the risk of CVST significantly.

Thoracic sympathectomy by Natural Orifice Trans Umbilical Surgery （NOTUS） for woman patients with palmar hyperhidrosis

Objective To investigate the clinical value of transumbilical endoscopic thoracic sympa- thectomy on women patients with palmar hyperhidrosis. Methods A total of 25 consecutive women patients with palmar hyperhidrosis underwent transumblical thoracic sympathectomy with ultra-thin endoscope. The operative data, including duration of operation, intra-operative and postoperative complications were recor- ded. Results The procedure was performed successfully in all 25 patients with a mean operative time of 64 min（58-113 min）. No umbilical hernia, diaphragmatic hernia, Homer＇s syndrome or hemothorax were observed. Minor pneumothorax was found in postoperative chest X-ray in 3 patients, all of which were com- pletely resolved with conservative treatment. All patients recovered to their normal life at 1 week after dis- charge. The scar was small and hidden in umbilical with no visible incisions. After a follow-up of 4 to 12 months, all patients＇ hands sweating symptoms completely disappeared, axillary sweat symptoms completely resolved in 6 patients, significantly improved in 4 and mildly improved in 1. Conclusion Trans- umbilical thoracic sympathectomy with ultrathin flexible endoscope is a safe and effective option for women patients with severe palmar hyperhidrosis, which provides excellent cosmetic outcomes. Key words: Hyperhidrosis ; Endoscopic surgery; Ultrathin gastroscope

A Rare Cause of Arm and Shoulder Pain in an Eight-Year-Old Girl: Pancoast's Syndrome Secondary to Lobar Pneumonia

Dear Editor, Pancoast's syndrome consists of pain in the arm and shoulder, atrophy of hand muscles, and Homer's syndrome [1]. The initial symptom of Pancoast's syndrome generally is pain in the shoulder. In some patients, only partial characteristics could be observed. It occurs mainly in patients with a superior pulmonary sulcus tumor invading the lower brachial plexus roots and the cervicothoracic sympathetic chain. However, infectious causes of Pancoast's syndrome have been reported in the literature. Here, we report a case of Pancoast's syndrome secondary to lobar pneumonia caused by Klebsiella pneumoniae in an 8-year-old Uygur girl who developed typical pain in her arm and shoulder. An 8-year-old Uygur girl with a 5-day history of intermittent fever, 3-day of productive cough, 2-day of right shoulder and scapula pain, and dyspnea was admitted to a pediatric ward in Shufu County People's Hospital. The right shoulder pain was exacerbated while the arm is being lifted and would radiate to the right upper arm. She reported no other neurological symptoms. She could sleep only in semi-reclining position because of dyspnea at night. Physical examination was as follows: She was febrile. Body weight was 20 …

P49 Temporal arteritis with Homer's syndrome

P49 Temporal arteritis with Homer's syndrome

Effect of stellate ganglion block on cerebral vasospasm in patients undergoing intracranial aneurysm surgery

Objective To evaluate the effect of stellate ganglion block (SGB) on cerebral vasospasm in patients undergoing intracranial aneurysm surgery. Methods Forty ASA Ⅱ or Ⅲ patients aged 14-64 yr weighing 40-81 kg undergoing intracranial aneurysm clipping were randomly divided into 2 groups ( n = 20 each): group control (group C) and group SGB. Left SGB was performed with 0.25% ropivacaine 10 ml immediately after intubation. Successful block was verified by development of Homer syndrome within 15 min after block. Anesthesia was induced with midazolam, propofol, fentanyl and vecuronium and maintained with isoflurane inhalation and intermittent iv boluses of fcntanyl and vecuronium. The patients were intubated and mechanically ventilated. PETCO2 was maintained at 30-35 mm Hg. BIS was maintained at 50-60. Right internal jugular vein was cannulated and the catheter was threaded cranially until resistance was met for blood sampling. Blood samples were collected before skin incision (T1), before clipping of aneurysm (T2), at 30 min after clipping (T3 ), and at the end of surgery (T4) for determination of plasma concentrations of endothelin (ET), calcium gene-related peptide (CGRP) and S100B protein. Transcranial Doppler was used to measure the flow rate of blood in bilateral middle cerebral artery and extracranial carotid artery at 1 and 3 days after surgery. All patients were observed for incidence of brain ischemia during 1-7 days after surgery. Results Plasma ET and S100B protein concentrations were significantly decreased, while plasma CGRP concentration was significantly increased after clipping of aneurysm at T3 and T4 in group SGB as compared with group C. The incidence of cerebral vasospasm and brain ischemia was significantly lower in group SGB than in group C. Conclusion SGB performed before operation can significantly reduce the incidence of cerebral vasospasm after clipping of intracranial aneurysm by inhibiting the release of ET and promoting the release of CGRP. Key words: Nerve block; Stellate ganglion; Neurosurgical procedures; Vasopasm,intracranial

Surgical treatment of lymphatic malformation located in head and neck in children

To evaluate the surgical approaches and therapeutic effect of lymphatic malformations located in head and neck in children. Eleven cases of lymphatic malformations in the region of head and neck in children encountered between Jan. 1998 and Dec.2008 in Peking University First Hospital were retrospectively analyzed. Initial diagnosis was made based on the physical examination and then confirmed by MR and Enhanced CT imaging. Surgical therapy was used for patients with lymphatic malformation which exceeds 4 cm. The operative technique was as follows: mass resection and superficial parotidectomy (4 cases), mass resection and total parotidectomy (2 cases), mass resection with neck dissection (2 cases), mass resection with neck dissection and sternotomy (1 case), marginal mandibular branch of facial nerve dissection and mass resection (2 cases). Dissection outside the false capsule was applied during the operation and facial nerve was dissected from bole to terminal arborization. The mass was completely removed in all 11 cases without organ dysfunction and obvious disfigurement. The cure rate was 100%. Three cases suffered from a branch of facial nerve paralysis because of tension and 1 case had a Horner's syndrome after operation. One case needed a blood transfusion (150 ml) during the operation. All cases have been followed up with excellent results from 6 to 121 months, 32 months of the median, no mass recurrence. Dissection outside the false capsule of mass and dissection of facial nerve were applied in the surgical treatment of huge lymphatic malformations. These methods are effective in the preservation of function and avoidance of abnormality.

Infarto de la PICA, síndrome de Wallenberg; a propósito de un caso

Wallenberg syndrome is a group of symptoms caused by occlusion of the posterior-inferior cerebellar artery (PICA). Our patient presented with a clinical picture of nausea, vomiting, ataxia, and other cerebellar signs, such as Homer syndrome. A case is presented of a 67 year-old male who, due to his clinical symptoms and results of complementary tests, was diagnosed with Wallenberg syndrome. He was admitted to the Stroke Unit, where specialised nursing care was provided, including monitoring of vital signs and neurological function. The treatment for this condition is symptomatic, and observation is very important in order to detect possible complications and recurrences. In our clinical case, in spite of the intensive surveillance in the Stroke Unit, began vomiting which resulted in bronchoaspiration and required admittance to the Intensive Care Unit. It is for this reason we must underline the importance of the role of nursing in preventing possible complications.

Diagnosis and surgical treatment of cervical lymphangioma

To discuss the methods of surgical treatment and their timing choices of cervical lymphangioma. A retrospective review of 53 patients with cervicofacial lymphangioma were treated surgically from July 1990 to December 2008. The age at operation was from 6.5 months to 41 years old (median age was 2 years old and 3 months). Eighteen (34.0%) lesions were located in the suprahyoid region and 35 (66.0%) lesions in the infrahyoid region. The diameter of lesion ranged from 3.3 to 8.2 cm (average: 4.4 cm). Neck mass was the sole symptom for 77.4% (41/53) cases. Nine patients presented with life-threatening complications including intracystic hemorrhage in 2 cases/times, infection and rapid increase in tumor size in 5 cases/times, dysphagia in 2 cases/times and respiratory obstruction in 4 cases/times. Color Doppler ultrasound was used to diagnose all patients pre-operatively. Computed tomography (CT) was used in 11 cases and magnetic resonance imaging (MRI) in 21 cases for differential diagnosis. The patients were treated by complete resection in 34 cases and subtotal resection in 8 cases. But partial resection in 11 (20.8%) cases developed a residual or recurrent lesion within 9 months to 5 years post-operation, including 7 cases in suprahyoid region and 4 cases in infrahyoid region. The rate of residual or recurrent lesions was significantly higher in the suprahyoid region (7/18) than that in the infrahyoid region (4/35) (chi(2) test, P < 0.05). The peri-operative complications were paralyses of mandibular branch of facial nerve, Horner's syndrome, secondary hemorrhage, fluid collection at resection site, local infection and parotid fistula in 1 case respectively. Respiratory distress caused by edema of tongue was present in 2 cases. All of them were cured conservatively. The pathological diagnosis was confirmed as capillary lymphangioma in 19 cases and cystic lymphangioma in 34 cases. The localization and extent of cervical lymphangioma are the most important determining factors for a successful surgical resection. Although complete excision is the ideal treatment for cervicofacial lymphangioma, this should not be attempted if lesions are too large and neighboring structures liable to injury. The surgeons should be aware of the limitations and potential surgical complications in certain instances.

Treatment of symptomatic intracranial atheromatous stenosis with the Gateway balloon and Wingspan stent system: short and medium term results

Objective To assess the safety, feasibility and short-mid term effectiveness of the Wingspan stent in the treatment of high-grade symptomatic intracranial atheromatous stenosis. Methods Sixty-three patients with symptomatic intracranial atheromatons stenosis (≥ 70%) were treated with the Gateway balloon-Wingspan stent system. The pre-and post-treatment improvement of symptoms, severity of stenosis, successful rate of treatment, complications were evaluated. Physician-reported follow-up in all 63 patients lasted an average period of 9. 3 months. The X2 test was used for statisties. Results Sixty-three lesions involved the intracranial internal carotid artery (n = 12), middle cerebral artery (n = 22), V4 segment vertebral artery (n = 15), basilar artery (n = 14). Sixty-two lesions were successfully treated with the deployment of the self-expanding Wingspan stent with residual stenosis ≤ 30%. One case failed because of intracranial hemorrhage during the operation. The successful rate of stenting is 98.0% (62/63). The mean stenosis was (82. 3 ± 9. 2) % before treatment, and it improved to (23.0 ± 11.2) % after stent placement. During the follow-up period, 1 patient died of postprocedural hyper-perfusion, one had ischemic stroke after procedure, one presented Homer syndrome at the 11th day, one had iachemic stroke at the 5th month after the procedure, while the other patients had significantly improved. The frequency of ≥50% restenosis on follow-up angiography or computed tomography was 10% (1/10). Conclusions Angioplasty and stenting for high-grade symptomatic intracranial artery stenosis with the Gateway-Wingspan stent system are safe and effective with high rate of technical success, but moderately high rate of residual stenosis and restenosis exist. With the improvement of operation skill and stent system, a better outcome in the future could be achieved. Key words: Vertebasilar insufficiency; Intracranial arteriosclerosis; Angioplasty; Stent

Effects of left stellate ganglion block on cardiac function in patients undergoing coronary artery bypass grafting

Objective To investigate the effects of left stellate ganglion block (SGB) on the cardiac function in patients undergoing coronary artery bypass grafting (CABG). Methods Thirty-eight ASA Ⅱ or Ⅲ patients of both sexes aged 42-64 yr undergoing CABG were randomly divided into 2 groups ( n = 19 each) : control group (C) and SGB group. The patients were premedicated with intransuscular midazolam 5 mg, morphine 10 mg, premethazine 25 nag and penehyclidine 1 mg. Radial artery was cannulated. Swan-Ganz catheter was placed via right internal jugular vein. SGB was performed via anterior approach. 1% fidocaine 10 ml was injected. Successful block was verified by development of Homer syndrome. EGG, SpO2, MAP, HR, cardiac output (CO), CVP, mean pulmonary arterial pressure (MPAP) and pulmonary artery wedge pressare (PAWP) were monitored during anesthesia. Cardiac index (CI), stroke index (SI), systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), and left and right ventricular stroke work index (LVSWI, RVSWI) were calculated. CO, HR, MAP, CVP, MPAP, PAWP, EI, SI, SVR, PVR, LVSWI, and RVSWI were recorded before SGB (T0) and 5, 10 and 15 min after SGB (T1-3). Results CO and CI at T1,2, RVSWI at T2 were significantly higher while CVP at T1-3 and PAWP at T3 were significantly lower in SGB group than in control group. RVSWI was significantly increased as compared with the baseline at To in SGB group. Conclusion Left SGB can increase cardiac output and improve cardiac function in patients undergoing CABG. Key words: Nerve block; Stellate ganglion; Heart function tests; Coronary artery bypass

迷走神経咽頭枝由来と疑われた頸部神経鞘腫例

We report a rare case of schwannoma arising from the pharyngeal branch of the vagus nerve. An 18-year-old woman presented with an egg-sized nontender upper cervical swelling. Computed tomography and magnetic resonance imaging (MRI) revealed a well-defined tumor measuring 50mm in its major axis in the left carotid space. The tumor was moderately enhanced, and showed hypointensity and isointensity on T1- and T2-weighted MRI, respectively. Otorhinolaryngological findings were otherwise normal. A schwannoma was most likely suspected, and she underwent transcervical resection of the tumor. A cordlike strand connected to the cephalad end of the tumor was severed, while both the vagus and hypoglossal nerves were identified and preserved. The histopathological diagnose is schwannoma. After surgery, the patient manifested a curtain sign toward the unaffected side without showing vocal cord palsy or Homer's syndrome, indicating that the tumor had arisen from the pharyngeal branch of the vagus nerve. Clinical characteristics of schwannomas in the carotid space were reviewed.

Ｆｉｒｓｔ Ｂｉｔｅ Ｓｙｎｄｒｏｍｅ２症例と発症機序

Two cases of first bite syndrome (FBS) were reported as a complication after surgery for parapharyngeal tumor. FBS is the development of pain in the parotid area associated with the first bite of food, especially the first meal of the day. In one case, pleomorphic adenoma of the left parotid gland extended into the parapharyngeal space. During resection, dissection around the external carotid artery was performed to mobilize the parotid tail and part of the parotid gland tissue was preserved. In the other case, acinic cell carcinoma of the left parapahryngeal space was resected. During resection, the external carotid artery was cut and most of the parotid gland was preserved. In both cases, sympathetic innervation of the parotid gland through the sympathetic plexus around the external carotid artery was lost without Homer's syndrome. It is possible that sympathectomy of the residual parotid gland is responsible for the development of FBS.

Endoscopic transthoracic electrocautery of the sympathetic chain for palmar and axillary hyperhidrosis

Endoscopic transthoracic electrocautery of the sympathetic chain has been the preferred treatment for palmar or axillary hyperhidrosis in this unit since 1980. A retrospective study was carried out of the first 112 patients with case material derived from a postal questionnaire, chart review and outpatient assessment. Eighty-five patients undergoing bilateral transthoracic electrocautery who replied to the questionnaire (76 per cent response rate) form the basis of this study. There were 65 females and 20 males with a mean age of 24.3 years (range 15-40 years). The hands alone were affected in 20 patients (24 per cent), the axillae alone in 17 (20 per cent) and both areas in 48 (56 per cent). Mean hospital stay was 3.1 days (range 1-7 days). Outcome was assessed by 92 per cent of patients immediately after operation as 'very much improved' or 'moderately improved', and this assessment persisted in 85 per cent after a mean follow-up of 43 months (range 3-95 months). Cosmetic results were rated as satisfactory by 95 per cent. Apart from pain after operation, morbidity was limited to transient Horner's syndrome in three patients, surgical emphysema in three, and pneumothorax requiring a chest drain in one. A repeat procedure was needed in one patient because of an inadequate first operation. Some compensatory hyperhidrosis occurred in 54 (64 per cent) patients. As a minimally invasive procedure, endoscopic transthoracic electrocautery should be considered the treatment of choice for palmar and axillary hyperhidrosis.

Abstracts

Abstracts

Isolated cervical esophageal duplication: a rarity

Duplication of alimentary canal is a well-known entity seen commonly in the abdomen and the thorax. Esophageal duplications are the second most common ones after the ideal duplications, but those in the neck are rarer—only 8 cases have been seen earlier. Cervical esophageal duplication in its isolated form causing torticollis and other chronic pressure symptoms has not been reported previously. Here, the authors present a 3-year-old male patient who had cystic duplication of the esophagus in the neck associated with the cervical vertebral defect and Homer syndrome. The authors hereby discuss the various embryological theories of etiopathogenesis of this malformation in brief.

Abducens Nerve Palsy and Homer Syndrome Due to Metastatic Tumor in the Cavernous Sinus

A 41-year-old man was diagnosed as having primary parotid carcinoma on the right side. After radical parotidectomy, radiation therapy and systemic chemotherapy, the primary parotid carcinoma was completely remitted. Two years later, right abducens nerve palsy and Horner syndrome appeared. Neuroimaging demonstrated a gadolinium-enhanced lesion in the posterior portion of the right cavernous sinus, and metastasis of parotid carcinoma was suspected. After radiosurgery and systemic chemotherapy, the intracavernous lesion disappeared. This is the first case of combination of abducens nerve palsy and ipsilateral Horner syndrome due to metastasis from parotid carcinoma to the cavernous sinus.

Vagal Paraganglioma Arising in the Parapharyngeal Space : A Case Report

A rare case of paraganglioma arising in the vagus is reported. A 36-year-old woman complained of neck swelling. She underwent CT, MRI and angiography and was diagnosed as hypervascular tumor occupying the right parapharyngeal space. This tumor was totally removed using a mandibular swing approach. Prior to tumor removal, feeding artery was ligated, and relatively little bleeding (244 ml) was noted for such a case. After the surgery, she developed difficulty in swallowing, hoarseness and Homer's syndrome. She underwent additional surgeries: cricopharyngeal myotomy, laryngeal elevation and arytenoid roatation. Except these problems, the postoperative course was uneventful and she was free from disease for 12 months.

Imaging Neuroblastoma in Children

Neuroblastoma is a common solid tumor of childhood that can involve the abdomen, thorax, pelvis, or the head and neck. The clinical manifestations are dependent on the widespread distribution of neural crest tissue and the length of the sympathetic chain involvement. Abdominal pain and hypertension may occur as a result of renal vasculature compression; respiratory distress may be evident in thoracic tumors; and Homer's syndrome or heterochromia of the iris may manifest from neuroblastoma of the head and neck. In addition, symptoms of cord compression and back pain may result from spinal cord compromise due to epidural invasion. Metastatic involvement of the liver, skin, periorbital regions, or bone may cause hepatomegaly, skin nodules, proptosis, or bone marrow failure, respectively. Clinical findings along with tumor metastasis may be studied by various imaging modalities to assess the nature and extent of the tumor. Diagnostic tests include plain radiography, ultrasonography, CT scanning, and MR imaging. Bone marrow studies, bone scans, and scintigraphy with 131I-metaiodobenzylmandelic may be utilized for metastatic evaluation. By using these imaging studies to detect the nature and behavior of neuroblastoma, early intervention may indeed improve patient survival.

Two cases of reiterated Horner’s syndrome after lumbar epidural block

We describe two young men with low back pain, who were given repeat lumbar epidural blocks for treatment of pain. They both developed reiterated unilateral Homer's syndrome. Computer tomography and myelography of the lumbar spine prior to the intervention showed signs of suspect disc herniation and sequelae after previous surgery.

Traumatic Carotid Artery Dissection Causing Blindness

A case of delayed postoperative visual loss due to bilateral traumatic carotid artery dissection is presented. In patients with a major craniofacial injury due to a high-speed motor vehicle accident, we suggest that carotid artery duplex ultrasonography be used in the initial evaluation for possible carotid artery dissection. Magnetic resonance imaging of the head and neck with magnetic resonance angiography should be performed subsequently if indicated. Early diagnosis and initiation of therapy can minimize complications.