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A 68-year-old man presented with right eye pain and vertigo. Thereafter, he gradually leaned rightward, then laid down. He felt nausea and vomited. His right upper eyelid drooped and he felt dysethesia of the right hand. On neurological examination, ptosis of his right eye with slightly miotic right pupil, paresis of the right soft palate and hoarseness were noted. Arm deviation test demonstrated rightward deviation. He presented sensory ataxia of the right upper and lower extremities: finger nose test showed mild dysmetria of the right upper extremity, heel knee test demonstrated dysmetria of right lower extremity and these findings worsened when he closed his eyes. He showed mild bending of his bilateral ring and little fingers when he did rapid alternative movement. He leaned rightward when he sat and closed his eyes. Position sense of his right upper and lower extremities was decreased and sometimes he could not answer correctly when asked on which direction his finger pointed. Pinprick sensation was mildly decreased on the left side not including the face. Touch and vibration sense were normal. SEP findings on upper and lower extremity stimulation were normal. MRI of the brain showed T2 high intensity and partially T1 low intensity lesion at the right medulla (Figure). MR angiography showed no apparent lesion of major arteries such as dissection of the vertebral arteries. He complained and presented with hiccup initially. On MRI, the lesion was thought to involve the spinothalamic tract, medial lemniscus and inferior olivary nucleus. Ambiguus nucleus was in the lesion and solitary nucleus near the lesion. There is no report that seems to describe clinical features of a lesion like that in this case. Intermediate medullary infarction may present dissociated sensory disturbance like Brown-Sequard syndrome and position sensory disturbance without disturbance of vibration sense.
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PMID:[Intermediate medullary infarction: a case report]. 1609 22

Internal iliac artery aneurysms (IIAAs) are rare and their concealed location in the pelvis presents a diagnostic challenge. We report a case of a 79-year-old man who presented 12 years after an abdominal aortic aneurysm repair, with signs of prolapse, bleeding, hemorrhoids, and a deep vein thrombosis. His condition rapidly deteriorated, with the development of acute renal failure and obvious perianal and perineal ecchymoses, within a few days. Abdominal ultrasound and computed tomography showed a ruptured IIAA. His renal function returned to normal after surgical decompression of the aneurysm.
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PMID:Bleeding prolapsed hemorrhoids as a presentation of ruptured internal iliac artery aneurysm: report of a case. 1617 75

We report two children with post radiation midbrain damage causing severe neurological symptoms. A twelve-year-old boy with a four year history of hydrocephalus was diagnosed with tectal glioma, which endoscopic biopsy revealed to be low grade. He underwent gamma knife radiation surgery (central 24 Gy/peripheral 12 Gy). Two months later bilateral ptosis followed by total oculomotor palsy and drowsiness developed. Despite pulsed-steroid therapy the tumor size increased up to 4.6 times in volume. The tumor was totally removed and was diagnosed as an early delayed radiation reaction pathologically. His symptoms disappeared except for a slight upper gaze palsy. The second patient was a six-year-old girl with a medulloblastoma. Following total resection and a VP shunt she received conventional radiation therapy along with chemotherapy. After the final irradiation she became comatose (JCS II-2) and MRI revealed diffuse midbrain damage with acute aqueduct obstruction, which recovered in two weeks. Reports of irradiation injuries of the midbrain in childhood are rare but it should be considered as a possible cause of fulminant symptoms requiring emergency treatment. Because of midbrain anatomical complexity, midbrain radiation therapy requires great care, especially in children.
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PMID:[Fulminating midbrain irradiation injury of pediatric brain tumor]. 1624 69

We describe a family with lacrimo-auriculo-dento-digital syndrome (LADD). A 13-year-old boy had cup-shaped ears, deafness, unilateral choanal atresia, bilateral nasolacrimal duct obstruction, xerostomia, alacrima due to congenital absence of lacrimal glands, agenesis of salivary glands, chronic dacryocystitis, keratoconjunctivitis sicca, ptosis, nail dysplasia of the thumb, shortness of fifth toe, temporal bone abnormality and epilepsy. His younger sister had shortened middle phalanx of fifth digits. His middle sister had hypodontia, shortened distal phalanx of fifth digit, agenesis of salivary glands, mild hearing loss and exotropia. His older sister had left nasolacrimal duct obstruction and aplasia of both parotid glands. The oldest sister had hypodontia and divergent excess exotropia. His mother had hypodontia. These findings are consistent with LADD syndrome. An autosomal dominant pattern of inheritance with variable expressivity has been demonstrated. Renal and uro-genital anomalies have been noted variably.
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PMID:Characteristics of lacrimo-auriculo-dento-digital (LADD) syndrome: case report of a family and literature review. 1646 Aug 12

We report a 68-year-old male who had orbital trauma from a bicycle accident. His vision was initially normal but deteriorated over 8 days to complete blindness. After 13 days, when he first consulted a physician, clinical investigation revealed total ophthalmoplegia, ptosis, and chemosis. Computed tomographic scan showed fractures of the medial orbital wall, orbital floor, and posterior ethmoid with dislocation into the orbital apex near the optic nerve. The patient was sent to our department for optic nerve decompression. Clinical examination showed induration and an already healed infraorbital entry wound suggesting an orbital foreign body, which was confirmed by ultrasound. Renewed analysis of CT scans in different window settings could clearly demonstrate a wooden foreign body in the lower eyelid. Additionally, a diffuse inflammation in the orbital apex was diagnosed. The foreign body was removed and decompression of the orbita and optic nerve was performed. Antibiotics and corticosteroids were administered i.v. Unfortunately, no visual improvement could be achieved.
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PMID:[Secondary amaurosis after infraorbital injury with a wooden foreign body]. 1660 92

We report a 64-years old man who had myasthenia gravis (MG) appearing after surgical removal of thymoma. His thymoma was not removed completely due to adhesion with other organs. Histopathologicaly, the thymoma was an invasive and predominantly epithelial type. CD45RO positive cells increased in the thymus. After five months of thymectomy, he received radiation therapy because the remaining tumor grew up slightly. The radiation was effective, and the recurrence of tumor has never been detected after that. However, nine months after the surgery, he noticed ptosis and double vision, and he was diagnosed as MG because of positive serum anti-AchR antibody and positive Tensilon test. He received oral prednisolone, and he has kept a good condition. Previous reports have shown that an extensive thymectomy tends to reduce the incidence of post-operative MG. In our case, the remaining thymoma might increase the risk of MG. And the removed thymus might contain an unknown regulatory factor that could inhibit a development of MG. The risk factor for development of post-operative MG should be investigated in future.
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PMID:[A case of myasthenia gravis appearing after thymomectomy: with histopathological investigation]. 1691 Apr 71

A 42-year-old man presented with a three-day history of progressive bilateral blurred vision, photophobia and headaches. There was no history of trauma. He was emmetropic with visual acuity of 6/60 (pinhole 6/24) in both eyes, no ptosis and full range of eye movements. His pupils were in fixed mydriasis. The pupils were unreactive to light or accommodation. His optic discs and fundi were normal. Pilocarpine failed to constrict his pupils. Initially, he strongly denied using any topical ocular medications but later remembered that 10 days previously his eyes had felt 'gritty' and his wife had instilled their son's old atropine penalisation drops into both his eyes. His signs and symptoms had resolved over the next two days.
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PMID:A case of accidental mydriasis. 1731 76

Case reports of traumatic aortic regurgitation caused by detached commissures are rare. We report a case of a 56-year-old man involved in a traffic accident. During his hospitalization for subdural hematoma and pulmonary contusion, he began to suffer from heart failure. He was operated on under diagnosis of severe aortic regurgitaion. The commissure between the left and the noncoronary cusps was largely detached from the aortic wall, which was easily estimated to be the cause of the prediagnosed left cusp prolapse. His aortic valve was replaced, and his postoperative course was uneventful.
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PMID:Traumatic aortic regurgitation caused by a detached commissure. 1744 71

Arthur Keith (1866-1955) was a renowned anatomist who published 529 contributions emphasizing the interaction between structure, function, and patient care. His only practice was 4 years as a family doctor, although he later trained to be a surgeon. Ten of his many articles related to hernia; two (1906, 1924) dealt with etiology. In these he rejected Russell's congenital saccular theory of abdominal herniation, since the latter's assertions regarding peritoneal diverticula were not supported by embryological research. Instead, Keith became the first to hypothesize that defects in the belly wall of adults were brought about by pathological damage to fasciae, aponeuroses and tendons, secondary to systemic connective tissue disease abetted by aging. The pelvis was similarly afflicted, leading to vaginal prolapse, the most common hernia among women. Diverticula were likely to sprout from a weakened alimentary tract. He stated that prevention was a serious consideration. The surgical establishment, overburdened by dogmas accumulated from 5,000 years of being solely responsible for the care of patients with herniae, ignored his hypothesis for decades. However, recent research in herniology has made him a prophet.
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PMID:Arthur Keith, the anatomist who envisioned herniosis. 1825 5

We report a case of severe mitral regurgitation due to partial rupture of an anterior papillary muscle. A 63-year-old man was admitted to a hospital with heart failure. He was treated with diuretic agents effectively. Echocardiography demonstrated severe mitral regurgitation with prolapse of posterior leaflet and small mass-like structure on the prolapsed segment that was diagnosed the thickened leaflet. Coronary angiography revealed total occlusion of left anterior descending artery (LAD) filled with good collateral from right posterior descending artery and severe diffuse stenosis of circumflex artery (Cx). The patient underwent surgery on the 33rd day after admission with heart failure. At surgery, we recognized rupture of one of the heads of anterior papillary muscle that was entangled in chordae of the prolapsed segment. Mitral valve repair and coronary revascularization to LAD and Cx was successfully performed. His postoperative course was uneventful, and he was discharged on the 28th postoperative day.
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PMID:[Mitral valve repair with concomitant coronary bypass for partial rupture of an anterior papillary muscle]. 1807 82


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