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P0387 THE MASK – TWO CLINICAL REPORTS OF BILATERAL FACIAL PALSY
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Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
Case 2: A 44-year-old woman with history of 3 abortions (<10 weeks of gestation) was admitted for left hemiplegia. The ophthalmological examination showed a bilateral papilloedema. An angio-MRI and cerebral angiography confirmed a diagnosis of saggital sinus thrombosis. The anticardiolipin antibody (60UI Ig-G) and anti-B2 glycoprotéineI Ig G were positive. The outcome with anticoagulant treatement was good. Conclusion: These two cases demonstrate the importance of screening for antiphospholipid antibodies in patients presenting with cerebral venous sinus thrombosis. Keywords: cerebral venous sinus, antiphospholipid syndrome
P0387 THE MASK – TWO CLINICAL REPORTS OF BILATERAL FACIAL PALSY
Svetlana Hryshkina, Ussumane Embaló, Sérgio Silva, Fernando Friôis, Jorge Almeida. Hospital São João, Porto The authors present two clinical reports of bilateral facial palsy of different and unusual etiologies. 1. A 59 year-old male with hypertension was admitted with left sided facial palsy and dysarthria. The following day he developed severe right sided facial palsy, with dysarthria, dysphasia, tongue protrusion and palatal elevation. Cerebral computer tomography (CT) scan was normal. Cerebral spinal fluid (CSF) revealed only high protein- no others biochemical or cytological changes were found. Bacterial culture of CSF and serological tests for borrelia burgdorferii, syphilis, cytomegalovirus, herpes virus and enterovirus were negative. Electromyography showed abnormalities that suggested Guillain-Barré Syndrome. Treatment with polyvalent human immunoglobulin was started, with progressive neurological improvement. 2. A 51 year-old diabetic woman initially presented with constitutional symptoms and left sided facial palsy. One week later she developed right sided facial palsy as well. Cerebral CT scan was normal. CSF showed 1.76g/L of protein with 77 cells. Bacterial culture was negative, but borrelia burgdorferii was detected by polymerase chain reaction. She completed 27 days treatment with ceftriaxone. It was observed slight recovery with stable neurological status.
three hours of ischemic stroke. Indication for thrombolysis strongly depends on quick recognition of warning signs and immediate activation of emergency team. Therefore knowledge of stroke risk factors and warning signs is of utmost importance. Aims: Identify levels of knowledge of stroke risk factors and warning signs in medical patients. Methods: Randomly selected medical patients were interviewed while waiting for consultation. Participants were clinical and sociodemographically characterized, and asked to identify or recognize stroke risk factors and warning signs. Results: 100 patients were included, average age 60.7 years, similar proportion of male and female. Overhalf (65%) presented at least 4 cardiovascular risk factors, and the more prevalent were hypertension (66%), overweight or obesity (63,8%), psychological stress (61%) and sedentary life-style (61%). Among 10 stroke risk factors considered, 94% spontaneously identified or recognized at least 8 of them, mainly hypertension (98%), dyslipidemia (97%), smoking (95%), obesity (95%) and previous stroke (95%). Among 8 confounding conditions inquired, 75% only considered 3 or less to be related to stroke risk. Among 8 stroke warning signs inquired, most patients (62%) spontaneously identified or recognized all of them, mainly oral comissure deviation (99%), speech impairment (96%), hemiparesis/muscle weakness (95%) and confusion (95%). Concerning 7 confounding symptoms inquired, most patients only considered 3 or less to be present in stroke. Few patients spontaneously identified stroke risk factors and warning signs, nonetheless they were able to recognize. Concerning attitude when stroke is suspected, 96% would immediately ask for medical care and 80% would activate emergency team. Conclusions: Medical patients are reasonably aware of stroke risk factors and warning signs. However, some uncertainty still needs to be clarified with further patient education programs.
P0389 6-DAY HISTORY OF INTERMITTENT NEUROLOGICAL SYMPTOMS FOLLOWING ROAD TRAFFIC ACCIDENT: DIAGNOSIS OF VERTEBRAL ARTERY DISSECTION CAN BE MISSED
Harith Altemimi, James Brown, Tsetsegdemberel Bat-Ulzii. Queen Elizabeth Hospital, NHS
The mask
Bilateral facial palsy is unusual pathology, defined as contra lateral involvement within 30 days. The aetiology is rarely idiopathic (Bell’s palsy) and always represents a diagnostic challenge for clinicians. The more frequent causes of bilateral facial palsy are neuroborreliosis (Lyme Disease), GuillainBarré Syndrome, human immunodeficiency virus infection, and sarcoidosis. The authors will review and summarize the literature.
P0388 KNOWLEDGE OF STROKE RISK FACTORS AND WARNING SIGNS IN MEDICAL PATIENTS
Gonçalo Cardoso, Ana Sofia Duque, Patrícia Freitas, Joana Cabete, Joana Silvestre, Vítor Batalha, Luís Campos. Medicine Department Iv, São Francisco Xavier Hospital, Western Lisbon Hospital Centre Background: Stroke is an important cause of death and disability. Benefit of thrombolytic therapy has been proved in selected patients, within the first
Introduction: Vertebral artery dissection is a well-recognised cause of stroke in young patients accounting for 4% of ischaemic strokes in those less than 45. It can occur spontaneously but is typically associated with a trivial history of neck trauma. Symptoms include neck pain, occipital headache, visual disturbances, weakness, clumsiness and numbness. Signs are associated with the area of the resulting ischaemia, but principally affect the distribution of the Posterior Inferior Cerebellar Artery (PICA). In the majority of cases, neurological symptoms evolve rapidly. Case report: A 58-year-old male who was admitted via the Emergency Department following a road traffic collision. A history of sciatica and Ménière’s disease was noted. On admission, no spinal tenderness or headache was present, and no focal neurological symptoms were elicited. The patient was investigated by the Surgical team for possible renal contusion. Radiological investigations revealed only a resolving right lower lobe consolidation, a trace amount of fluid around the right kidney. In the days following admission, the patient was found to have fluctuating weakness in the lower limbs, together with decreased sensation of right lower limb. This was attributed at the time to his history of sciatica. An orthopaedic review found no decreased power in the lower limbs, though a lumbar radiograph showed degenerative changes of the vertebrae. On the 3rd day post-admission the patient developed visual blurring and sensory symptoms involving right face and right hand, together with worsening unsteadiness. A CT head was requested and found to be normal. Six days post-admission, a neurological review confirmed a right-sided Horner’s sign and rotational nystagmus. An urgent MRI head and MRI angiogram were performed. They showed complete absence of blood flow in the right vertebral artery (fig. 1), and a region of T2 hyper-intensity in the right side of medulla indicating acute infarct (fig. 2). This was consistent with a diagnosis of right vertebral artery dissection with associated thrombosis, and the patient was commenced on antiplatelet (aspirin) and anticoagulant (low molecular weight heparin, followed by warfarin) therapy for 3 months. The patient was admitted to the Stroke Unit for intensive supportive treatments, including physiotherapy and occupational therapy. Over the course of the next 10 days, the patient made a good recovery with only slight
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
Case 2: A 44-year-old woman with history of 3 abortions (<10 weeks of gestation) was admitted for left hemiplegia. The ophthalmological examination showed a bilateral papilloedema. An angio-MRI and cerebral angiography confirmed a diagnosis of saggital sinus thrombosis. The anticardiolipin antibody (60UI Ig-G) and anti-B2 glycoprotéineI Ig G were positive. The outcome with anticoagulant treatement was good. Conclusion: These two cases demonstrate the importance of screening for antiphospholipid antibodies in patients presenting with cerebral venous sinus thrombosis. Keywords: cerebral venous sinus, antiphospholipid syndrome
P0387 THE MASK – TWO CLINICAL REPORTS OF BILATERAL FACIAL PALSY
Svetlana Hryshkina, Ussumane Embaló, Sérgio Silva, Fernando Friôis, Jorge Almeida. Hospital São João, Porto The authors present two clinical reports of bilateral facial palsy of different and unusual etiologies. 1. A 59 year-old male with hypertension was admitted with left sided facial palsy and dysarthria. The following day he developed severe right sided facial palsy, with dysarthria, dysphasia, tongue protrusion and palatal elevation. Cerebral computer tomography (CT) scan was normal. Cerebral spinal fluid (CSF) revealed only high protein- no others biochemical or cytological changes were found. Bacterial culture of CSF and serological tests for borrelia burgdorferii, syphilis, cytomegalovirus, herpes virus and enterovirus were negative. Electromyography showed abnormalities that suggested Guillain-Barré Syndrome. Treatment with polyvalent human immunoglobulin was started, with progressive neurological improvement. 2. A 51 year-old diabetic woman initially presented with constitutional symptoms and left sided facial palsy. One week later she developed right sided facial palsy as well. Cerebral CT scan was normal. CSF showed 1.76g/L of protein with 77 cells. Bacterial culture was negative, but borrelia burgdorferii was detected by polymerase chain reaction. She completed 27 days treatment with ceftriaxone. It was observed slight recovery with stable neurological status.
three hours of ischemic stroke. Indication for thrombolysis strongly depends on quick recognition of warning signs and immediate activation of emergency team. Therefore knowledge of stroke risk factors and warning signs is of utmost importance. Aims: Identify levels of knowledge of stroke risk factors and warning signs in medical patients. Methods: Randomly selected medical patients were interviewed while waiting for consultation. Participants were clinical and sociodemographically characterized, and asked to identify or recognize stroke risk factors and warning signs. Results: 100 patients were included, average age 60.7 years, similar proportion of male and female. Overhalf (65%) presented at least 4 cardiovascular risk factors, and the more prevalent were hypertension (66%), overweight or obesity (63,8%), psychological stress (61%) and sedentary life-style (61%). Among 10 stroke risk factors considered, 94% spontaneously identified or recognized at least 8 of them, mainly hypertension (98%), dyslipidemia (97%), smoking (95%), obesity (95%) and previous stroke (95%). Among 8 confounding conditions inquired, 75% only considered 3 or less to be related to stroke risk. Among 8 stroke warning signs inquired, most patients (62%) spontaneously identified or recognized all of them, mainly oral comissure deviation (99%), speech impairment (96%), hemiparesis/muscle weakness (95%) and confusion (95%). Concerning 7 confounding symptoms inquired, most patients only considered 3 or less to be present in stroke. Few patients spontaneously identified stroke risk factors and warning signs, nonetheless they were able to recognize. Concerning attitude when stroke is suspected, 96% would immediately ask for medical care and 80% would activate emergency team. Conclusions: Medical patients are reasonably aware of stroke risk factors and warning signs. However, some uncertainty still needs to be clarified with further patient education programs.
P0389 6-DAY HISTORY OF INTERMITTENT NEUROLOGICAL SYMPTOMS FOLLOWING ROAD TRAFFIC ACCIDENT: DIAGNOSIS OF VERTEBRAL ARTERY DISSECTION CAN BE MISSED
Harith Altemimi, James Brown, Tsetsegdemberel Bat-Ulzii. Queen Elizabeth Hospital, NHS
The mask
Bilateral facial palsy is unusual pathology, defined as contra lateral involvement within 30 days. The aetiology is rarely idiopathic (Bell’s palsy) and always represents a diagnostic challenge for clinicians. The more frequent causes of bilateral facial palsy are neuroborreliosis (Lyme Disease), GuillainBarré Syndrome, human immunodeficiency virus infection, and sarcoidosis. The authors will review and summarize the literature.
P0388 KNOWLEDGE OF STROKE RISK FACTORS AND WARNING SIGNS IN MEDICAL PATIENTS
Gonçalo Cardoso, Ana Sofia Duque, Patrícia Freitas, Joana Cabete, Joana Silvestre, Vítor Batalha, Luís Campos. Medicine Department Iv, São Francisco Xavier Hospital, Western Lisbon Hospital Centre Background: Stroke is an important cause of death and disability. Benefit of thrombolytic therapy has been proved in selected patients, within the first
Introduction: Vertebral artery dissection is a well-recognised cause of stroke in young patients accounting for 4% of ischaemic strokes in those less than 45. It can occur spontaneously but is typically associated with a trivial history of neck trauma. Symptoms include neck pain, occipital headache, visual disturbances, weakness, clumsiness and numbness. Signs are associated with the area of the resulting ischaemia, but principally affect the distribution of the Posterior Inferior Cerebellar Artery (PICA). In the majority of cases, neurological symptoms evolve rapidly. Case report: A 58-year-old male who was admitted via the Emergency Department following a road traffic collision. A history of sciatica and Ménière’s disease was noted. On admission, no spinal tenderness or headache was present, and no focal neurological symptoms were elicited. The patient was investigated by the Surgical team for possible renal contusion. Radiological investigations revealed only a resolving right lower lobe consolidation, a trace amount of fluid around the right kidney. In the days following admission, the patient was found to have fluctuating weakness in the lower limbs, together with decreased sensation of right lower limb. This was attributed at the time to his history of sciatica. An orthopaedic review found no decreased power in the lower limbs, though a lumbar radiograph showed degenerative changes of the vertebrae. On the 3rd day post-admission the patient developed visual blurring and sensory symptoms involving right face and right hand, together with worsening unsteadiness. A CT head was requested and found to be normal. Six days post-admission, a neurological review confirmed a right-sided Horner’s sign and rotational nystagmus. An urgent MRI head and MRI angiogram were performed. They showed complete absence of blood flow in the right vertebral artery (fig. 1), and a region of T2 hyper-intensity in the right side of medulla indicating acute infarct (fig. 2). This was consistent with a diagnosis of right vertebral artery dissection with associated thrombosis, and the patient was commenced on antiplatelet (aspirin) and anticoagulant (low molecular weight heparin, followed by warfarin) therapy for 3 months. The patient was admitted to the Stroke Unit for intensive supportive treatments, including physiotherapy and occupational therapy. Over the course of the next 10 days, the patient made a good recovery with only slight