Introduction: Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is an ophthalmologic condition of likely immune origin. Typically, it presents as a chorioretinitis with bilateral visual disturbance and characteristic funduscopic lesions of the retinal pigment epithelium. APMPPE has been associated with several systemic and neurological complications, including cerebrovascular diseases. Case Report: A 58-year-old woman presented with sudden right hemiparesis and dysarthria, with magnetic resonance imaging evidence of an acute ischemic lesion in the left pons. Five days later, she developed contralateral hemiparesis and evolved into a locked-in syndrome. A new lesion located at the right pontomedullary junction was detected by magnetic resonance imaging. The patient developed a visual deterioration that had started 1 week before admission. An ophthalmologic evaluation showed visual acuity loss (20/200 in both eyes) and characteristic yellow-white lesions in the posterior pole of both eyes. Laboratory analyses were remarkable for positive antinuclear antibodies, an elevated erythrocyte sedimentation rate, and C-reactive protein. The cerebrospinal fluid showed elevated protein levels, lymphocytic pleocytosis, and normal glucose levels. The fundoscopy findings together with recurrent strokes led to the diagnosis of APMPPE and appropriate immunomodulatory treatment with corticosteroids and azathioprine was started. Conclusions: This case illustrates the importance of careful evaluation and high clinical suspicion for this entity when dealing with patients with new-onset headache or stroke associated with visual impairment. Proper ophthalmologic evaluation is important so that adequate therapy is established.
Deep cerebral venous thrombosis is an uncommon condition, which usually produces headache, altered consciousness, and ocular movement abnormality. Parkinsonism occasionally occurs when there is basal ganglia involvement.We report a case of a 78-year-old male who presented with a rapidly progressive parkinsonism with poor response to dopaminergic therapy. The patient had bilateral and symmetrical hypokinesia, rigidity, and marked gait impairment with festination. Brain MRI showed bilateral thalamic hyperintensity on T2-weighted and FLAIR sequences, with right thalamic and intraventricular hemorrhage due to straight sinus thrombosis. Angiography revealed an arteriovenous malformation in the quadrigeminal cistern with afferent supply from the posterior cerebral arteries, as well as partial thrombosis of the vein of Galen and half of the straight sinus. No predisposing factor for thrombosis was found. Given the location and size of the malformation, and the substantial amount of thalamic and intraventricular hemorrhage, conservative management was decided, with slow but progressive gait improvement.The presence of deep cerebral venous thrombosis should be suspected in cases of rapidly progressive parkinsonism with cognitive decline. As in this case, thrombosis may be secondary to a deep arteriovenous malformation, a very rare occurrence that may require specific therapy.
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