Contralateral pupillary dilatation and hemiparesis: Kernohan’s notch revisited

Intracranial mass lesions can lead to transtentorial uncal herniation, and pupillary asymmetry is a well-recognized sign of impending cerebral herniation. Impending uncal herniation can lead to ipsilateral, bilateral, or uncommonly the contralateral pupillary dilatation. We report a case of a 22-year old, who had contralateral pupillary dilatation due to expanding intracranial mass lesion and recovered well after neurosurgical intervention. This case illustrates contralateral pupillary dilatation (“false-localizing” sign) in a sub-group of patients, and if untreated and ICP continues to rise, this is followed by ipsilateral pupil dilatation.

False Localizing Sign

The Kernohan syndrome results from the compression of the cerebral peduncle against the tentorium cerebelli. This phenomenon represents a relevant clinical sign of transtentorial herniation due to an ipsilateral expansive lesion. We reported a case of a 50-year-old woman with a right temporal meningioma who developed a false localizing hemiparesis, which improved after microsurgical resection. This case emphasizes the mechanism and rarity of this pathology.

Vestibular Schwannoma with Contralateral Facial Nerve Palsy: A False Localizing Sign

Vestibular schwannomas are the most common cerebellopontine angle tumors. These tumors commonly present with ipsilateral dysfunction of acoustic, vestibular, trigeminal, and facial nerves. Vestibular schwannoma with involvement of contralateral facial nerve is very unusual, and whenever present, it is considered as a false localizing sign. It seems that displacement and distortion of the brainstem by the large mass lesion may lead to this atypical presentation. We report a case of vestibular schwannoma with contralateral abducens and facial nerve paresis.

Localized Girdle Sensation of Mid-Trunk (False Localizing Sign) in a Patient with Compressive Cervical Myelopathy

Patient with compressive cervical myelopathy sometimes present with localized girdle sensation in the mid trunk (called false localizing sign). This symptom often confuses physicians, but the clinical features and mechanism are still unclear. We present a male patient presented with localized girdle sensation in the middle trunk following fall. Later on diagnosis of compressive cervical myelopathy was made after MRI cervical spine.

A CASE OF PRIMARY INTRAMEDULLARY TUMOR

Primary spinal cord tumors are rare neoplasms that can lead to significant patient disability and mortality. Given their rarity, they are often misdiagnosed, especially in the early stages, when a high index of suspicion is required. In rare cases of spinal cord tumors there may be a discrepancy between the sensory level and the real site of the tumor. This phenomenon, called “false localizing sign” is rare but well known and, if unrecognized, may delay the appropriate diagnosis and treatment. The aim of this work is to present a clinical case with a false localizing low thoracic sensory level due to an upper thoracic grade II ependymoma.

Malignant Hypertensive Retinopathy in an Infant with Mid-Aortic Occlusion

Purpose. Case report describing an eight-month-old infant presenting with intermittent esotropia and irritability who was found to have malignant (grade 4) hypertensive retinopathy and mid-aortic syndrome. Methods. Visual acuity was 6/140 in the right eye and not recordable in the left eye. Blood pressure was as high as 230/120 mmHg. Fundoscopy revealed bilateral optic disc swelling, macular stars, and serous retinal detachment in the left eye, findings that are consistent with malignant (grade 4) hypertensive retinopathy. CT abdominal angiogram revealed a severe mid-aortic syndrome with occlusion of the abdominal aorta at T12. Results. The patient was treated with medical management of his hypertension, improving the subretinal exudate. Binocular visual acuity improved to 6/9.5 over 9 months. There was a persistent left relative afferent pupillary defect and moderate left esotropia. Conclusion. This is the first reported case of malignant hypertensive retinopathy in an infant with concomitant mid-aortic occlusion. The authors emphasize the need for an ophthalmological and pediatric examination in a child presenting with intermittent squint and irritability. The esotropia was found to be a false localizing sign of raised intracranial pressure secondary to the severe mid-aortic syndrome.