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Anisocoria as initial manifestation of multiple sclerosis. Use of 3 tesla magnetic resonance imaging
Anisocoria como manifestación inicial de esclerosis múltiple. Utilidad de la resonancia magnética nuclear de 3 teslas
A. Cerveróa,
, A. López-de-Eguiletaa, Á. Cano-Abascalb, M.J. Sedano-Tousb, M. Drake-Pérezc, A. Casadoa
Corresponding author
a Departamento de Oftalmología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
b Departamento de Neurología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
c Departamento de Radiología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
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Use of 3 tesla magnetic resonance imaging" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1998 "Ancho" => 2917 "Tamanyo" => 542758 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Manifestaciones oculares. A) Anisocoria en condiciones fotópicas. B) Constricción de la pupila del OD después de la administración de pilocarpina al 1%. C) Ptosis del párpado derecho y limitación de aducción, supraducción e infraducción del OD.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Cerveró, A. López-de-Eguileta, Á. Cano-Abascal, M.J. 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Use of 3 tesla magnetic resonance imaging" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "192" "paginaFinal" => "195" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Cerveró, A. López-de-Eguileta, Á. Cano-Abascal, M.J. Sedano-Tous, M. Drake-Pérez, A. Casado" "autores" => array:6 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Cerveró" "email" => array:1 [ 0 => "casadorojo@hotmail.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "López-de-Eguileta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Á." "apellidos" => "Cano-Abascal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M.J." "apellidos" => "Sedano-Tous" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "Drake-Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "A." "apellidos" => "Casado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Departamento de Oftalmología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Neurología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Radiología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anisocoria como manifestación inicial de esclerosis múltiple. Utilidad de la resonancia magnética nuclear de 3 teslas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1199 "Ancho" => 1750 "Tamanyo" => 294876 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">ocular expressions. A) Anisocoria in photopic conditions. B) Constriction of RE pupil after administrating 1% pilocarpine. C) right eyelid ptosis and RE limitation of adduction, supraduction and infraduction.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Multiple sclerosis is a chronic disease of the central nervous system caused by self-immune demyelinization that produces the loss of neurological functions. It is characterized by inflammatory attacks against myelin and progressive axonal degeneration that in time produces disseminated lesions.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Multiple sclerosis gives rise to multiple signs. A case of multiple sclerosis is presented having the first clinic expression of anisocoria and subsequently 3rd cranial nerve pair paresis.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinic case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">Female, 21, without relevant personal antecedents, who visited the Emergency Dept. due to blurred vision in the right eye (RE) with evolution of 48 h and anisocoria in the past 24 h.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Examination evidenced anisocoria in photopic conditions in RE at the expense of areactive midriasis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) without relative afferent pupil defect and slight palpebral ptosis. The patient did not refer previous traumatism or pharmacological dilatation. Visual acuity was 20/20 (Snellen) in both eyes, and ocular motility and ocular fundus examinations were normal. Optical coherence tomography examination, which included the retina nerve fiber layer (RNFL), macula and ganglion cell layer, did not show alterations. The pilocarpine test was conducted without identifying pupil constriction 30 min after administering 0.125% pilocarpine. However, miosis was observed in the RE after the administration of 1% pilocarpine (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). No other anomalies were observed in the neurological examination. With the presumptive diagnostic of 3rd right side cranial pair neuropathy with possible compressive etiology, the patient was admitted and a cranial angio-CT and nuclear magnetic resonance (NMR) were requested to identify compressive vascular alterations without success.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">After being in the hospital 72 h, the patient exhibited ipsolateral upper eyelid ptosis with associated adduction, supraduction and infraduction limitation in the RE (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). These findings reinforced the hypotheses of right side cranial pair compromise and accordingly a 3 T NMR with the FIESTA sequence <span class="elsevierStyleItalic">(fast imaging employing steady-state acquisition)</span> was requested. The NMR showed enhancement of midbrain close to the right interpeduncular fossa corresponding to the area of exit of the 3rd cranial pair, as well as incipient compromise in the areas of entry of both trigeminal nerves (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Aneurysm was discarded as well as infectious, infiltration and tumor etiologies. Lumbar puncture and analytical studies, including serology, autoantibodies and oligoclonal bands in the cerebrospinal fluid produced normal results. The visual field was also studied without showing any alteration.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was diagnosed with right side 3rd cranial pair inflammatory neuropathy of unspecified origin. Three boluses of intravenous methylprednisolone (1 g) were administered, observing progressive improvement of symptoms, persistence of diplopia in supra- and levoversion as well as of left eye adduction limitation. Follow-ups by Ophthalmology and Neurology did not evidence changes. Two months later, diplopia was nonexistent for which reason botulinum toxin injection in the left lateral rectus muscle was discarded. Six months later an additional NMR was taken without finding changes.</p><p id="par0030" class="elsevierStylePara elsevierViewall">After remaining 18 months asymptomatic, the patient returned to the Emergency Dept. with diminished visual acuity in the RE (best corrected visual acuity of 20/28 Snellen) associated to slight pain during ocular movement in said eye and dyschromatopsia. In addition, she referred hypostesia feelings in the lower left limb and trunk in the past 2 weeks, associated to self-limited episodes of bilateral hemi-facial hypoesthesia. Ocular fundus examination was normal and optical coherence tomography did not reveal damages in the RNFL or in the ganglion cell layer. Neurological examination showed preserved sensitivity in face and upper limbs, slight hypopalestesia (diminished vibration sensitivity) in the right lower limb and right trunk, as well as slight hyperalgesia in the left lower limb and right trunk up to T4 level. Strength was preserved in the 4 limbs, reflexes were normal, no dysmetry could be observed and gait was normal.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was diagnosed with retrobulbar optic neuropathy and sensory alterations suggesting myelitis. A new cranial-spinal 1.5 T NMR was taken which showed over 20 infra- and supra-tentorial demyelinizing plates, as well as in the cervical and dorsal spinal column. Several of these showed enhancement after contrast administration. In addition, the NMR showed compromise of the right optic nerve, 3rd right side cranial pair and bilateral 5th cranial pair (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). Lumbar puncture showed the presence of 12 leukocytes and oligoclonal bands. Visual evoked potentials and electroretinogram produced normal results as well as analytics, including immunological profile and proteingram.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnostic was recurrent-remitting multiple sclerosis. Treatment was initiated with 5 boluses of methylprednisolone (1 g intravenous) with improvement of symptoms. Subsequently, maintenance treatment was established with fingolimod. No new symptoms of multiple sclerosis were observed in 20 months follow-up.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Multiple sclerosis is regarded as a simulating disease because it can present with different clinical expressions, including alteration of motor and sensory functions and visual, cognitive and mental disorders. As regards ophthalmological diseases, optic neuritis is the most frequent ocular expression. Other ocular findings include ocular motility dysfunction due to nystagmus, internuclear ophthalmoplegia and cranial nerve palsy, particularly the 6th and 4th cranial pairs.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Paresis of the 3rd cranial pair as a sign of MS presentation is infrequent. Overall, 8 articles documented 3rd cranial pair paresis as onset of MS.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–8</span></a> In the majority of cases, compromise was unilateral and though the literature also describes associations with bilateral optic nerve compromise and internuclear ophthalmoplegia. In 3 of said cases, 3rd cranial nerve compromise was associated to pupil compromise.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the present case, the first expression of multiple sclerosis was isolated anisocoria. In such a scenario it was difficult to suspect demyelinizing etiology, even more so with normal RNFL values. In some occasions, patients with multiple sclerosis without neuritis episodes can exhibit RNFL alterations.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> When the patient developed complete palsy of the 3rd cranial pair, 3 T NMR was requested and this enabled the identification of the inflammation plates in the fascicle of said cranial pair.</p><p id="par0055" class="elsevierStylePara elsevierViewall">A tesla (T) is a magnetic induction unit equivalent to 20,000 times the magnetic field of the Earth. NMR resolution is measured according to the teslas they exhibit. Lower resolution NMR have 0.2 T and are still being used because it enables open measurements. The NMR devices being used in usual clinical practice have 1.5 T. The 3 T equipment is not so frequent although it offers faster time, greater comfort, improved quality in diffusion techniques as well as improved contrast. Even less frequently, some 7 T equipment are already in the market, as well as 9.4 T NMR which has already been approved after testing in humans. In the present case, we requested the FIESTA sequence in the 3 T NMR (also available for 1.5 T NMR) because it enables the visualization of cranial nerves at the base of the skull and the differentiation of tumoral injuries from inflammatory and demyelinization lesions.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Accordingly, it could be concluded that in the presence of areactive midriasis that responds to the 1% pilocarpine test it is essential to discard compressive courses such as aneurysm (generally in the posterior communicating artery) by means of angio-TC, NMR and arteriography.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> However it should be noted that 3 T NMR with the FIESTA sequence enables the observer to discard small lesions in the nucleus or the intra-midbrain tract of the 3rd cranial nerve.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interests</span><p id="par0065" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1328697" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1224528" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1328696" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1224529" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinic case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-11-25" "fechaAceptado" => "2020-01-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1224528" "palabras" => array:3 [ 0 => "Anisocoria" 1 => "Third cranial nerve" 2 => "Multiple sclerosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1224529" "palabras" => array:3 [ 0 => "Anisocoria" 1 => "Tercer par craneal" 2 => "Esclerosis múltiple" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A 21-year-old woman seen in this clinic with non-reactive mydriasis in the right eye that contracted with 1% pilocarpine. Cranial angio-CT and 1.5 T magnetic resonance imaging (MRI) did not detect any disease. Given a subsequent limitation of adduction, supraduction, and infarction of the right eye, a 3 T MRI was requested. This showed a lesion of the midbrain at the exit of the 3rd cranial nerve. After improvement, no new episodes were observed until 18 months later, when the patient presented with probable optic neuritis and systemic symptoms. At this time the 1.5 T MRI detected infratentorial and supratentorial demyelinating plaques. A subsequent lumbar puncture and clinic outcome confirmed the diagnosis of relapsing-remitting multiple sclerosis.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Mujer de 21 años que presenta midriasis arreactiva en ojo derecho que contrae con el test de pilocarpina al 1%. La angio-TC craneal y la resonancia magnética nuclear (RMN) de 1,5 T no detectaron anomalías. Ante una posterior limitación de la aducción, supraducción e infraducción de dicho ojo, se solicitó una RMN de 3 T, que evidenció una lesión del mesencéfalo en la salida del tercer par craneal. Tras mejoría, no tuvo nuevos episodios hasta 18 meses después, cuando acudió con una probable neuritis óptica y síntomas sistémicos. En este momento la RMN de 1,5 T detectó placas desmielinizantes infratentoriales y supratentoriales. La punción lumbar posterior y la evolución clínica confirmaron el diagnóstico de esclerosis múltiple recurrente-remitente.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cerveró A, López-de-Eguileta A, Cano-Abascal Á, Sedano-Tous MJ, Drake-Pérez M, Casado A. Anisocoria como manifestación inicial de esclerosis múltiple. Utilidad de la resonancia magnética nuclear de 3 teslas. Arch Soc Esp Oftalmol. 2020;95:192–195.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1199 "Ancho" => 1750 "Tamanyo" => 294876 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">ocular expressions. A) Anisocoria in photopic conditions. B) Constriction of RE pupil after administrating 1% pilocarpine. C) right eyelid ptosis and RE limitation of adduction, supraduction and infraduction.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1023 "Ancho" => 1500 "Tamanyo" => 215571 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">cerebral lesion shown in magnetic resonance. A) 3 tesla magnetic resonance with FIESTA sequence evidencing the presence of enhancement in the anterior medial region of the right cerebral peduncle adjacent to the exit of the ipsilateral 3rd cranial pair (arrow). B) Cranio-medullary magnetic resonance with demyelinizing plates (supratentorial, infratentorial and in the right medulla).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ocular motor manifestations of multiple sclerosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. Nerrant" 1 => "C. 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