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Eight-and-a-half syndrome as manifestation of acute disseminated adenovirus encephalomyelitis
Síndrome del ocho y medio como manifestación de enfermedad desmielinizante aguda por adenovirus
S. Fathi Nieto
, E. García-Soler, R. Butrón Ruiz, J. Orts Llácer, M. Aguilar González, H. Barranco González
Corresponding author
Departamento de Oftalmología, Hospital Universitario La Fe, Valencia, Spain
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Fathi Nieto, E. García-Soler, R. Butrón Ruiz, J. Orts Llácer, M. Aguilar González, H. Barranco González" "autores" => array:6 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Fathi Nieto" "email" => array:1 [ 0 => "gsolerenrique@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "E." "apellidos" => "García-Soler" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Butrón Ruiz" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Orts Llácer" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Aguilar González" ] 5 => array:2 [ "nombre" => "H." "apellidos" => "Barranco González" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Oftalmología, Hospital Universitario La Fe, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome del ocho y medio como manifestación de enfermedad desmielinizante aguda por adenovirus" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 924 "Ancho" => 1674 "Tamanyo" => 156897 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Brain MRI. (A) Cross section in T2 sequence; the green arrow points to a hyperintense lesion in the floor of the fourth ventricle with cranial direction towards the medial longitudinal fascicle. (B) Same lesion in coronal T2 FLAIR sequence.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acute disseminated encephalomyelitis (ADE) is a demyelinating disease of the central nervous system (CNS) that affects children between the ages of 5 and 8 years,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> with an average age of 7.1 years.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">It should be suspected in pediatric patients mainly when, after a history of infectious disease or previous vaccination in the last 2–4 weeks, they manifest clinical symptoms of encephalitis with headache, fever, nausea, vomiting and varied neurological focality reflecting multifocal CNS involvement.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">It is more frequent in winter and spring, with a slight male predisposition.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Diagnosis is based on clinical history, neurological symptoms and the findings visible on brain and spinal cord magnetic resonance imaging (MRI),<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> the imaging test of choice when this entity is suspected. MRI shows multiple hyper-reflective lesions with poorly defined margins on T2 and FLAIR sequences, affecting the central and subcortical white matter; the grey matter-white matter junction of both hemispheres, cerebellum, brainstem and spinal cord, and the grey matter of the thalamus and basal ganglia.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> It is recommended to complete the study with a complete blood test with serology and antibodies and a lumbar puncture, which is normal in 20%–30% of cases, the rest being non-specific but reflecting inflammation data.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The first line of treatment is based on the use of corticosteroids in megabolic boluses for 5 days, followed by a tapering regime for 4–6 weeks. Refractory or severe cases are combined with immunoglobulins 2 g/kg for 2–5 days. In cases refractory to previous treatment or sudden onset cases, it has been combined with plasmapheresis<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> and even with hypothermia and decompressive craniotomy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The prognosis of the disease is favourable, resolving in most cases without sequelae.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case</span><p id="par0035" class="elsevierStylePara elsevierViewall">Male, aged 8, who consulted the emergency department of the pediatric ophthalmology department of our centre for diplopia in dextroversion and abnormal eye movements with onset that same day. He had no relevant personal history or recent vaccinations, and reported an episode of gastroenteritis the previous week that resolved spontaneously without treatment.</p><p id="par0040" class="elsevierStylePara elsevierViewall">On examination he had an uncorrected visual acuity of 0.8 in both eyes. Intraocular pressure with ICare tonometer was 14 mmHg in the right eye (RE) and 15 mmHg in the left eye (LE). Pupils were isochoric and normoreactive, with no relative afferent pupillary defect.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Oculomotor examination revealed an inability of the LE to adduct accompanied by nystagmus of the RE in abduction (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), with preserved convergence. In the remaining gaze positions, a spring nystagmus of moderate frequency and fine amplitude was observed, which was vertical in superior and inferior gaze and horizontal in levoversion, with a much higher frequency and amplitude in dextroversion.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">There was no fever or other systemic symptoms. It was decided to admit the patient for a left internuclear ophthalmoplegia (LIO).</p><p id="par0055" class="elsevierStylePara elsevierViewall">During the first 48 h of admission, there was also evidence of limited abduction of the LE and adduction of the RE (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), left peripheral facial paralysis, loss of sensation of the left hemiface and tongue deviation to the right. In view of the freezing of the horizontal gaze of the LE together with the LIO of the new appearance of the RE and left facial paralysis, a finding known as eight-and-a-half syndrome, an emergency brain CT scan was requested, pending the performance of a spinal and brain MRI scan, the result of the CT scan being normal.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The MRI showed a T2 hyperintense lesion in the floor of the fourth ventricle with cranial direction towards the left medial longitudinal fascicle (MFL) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), as well as multiple hyperintense FLAIR lesions without uptake in bilateral parietal deep white matter and around the occipital horns, suggestive of parainfectious and/or autoimmune demyelinating lesion.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Serology, nasopharyngeal swab, antibody study and lumbar puncture were performed to complete the study, and in view of the suspicion of demyelinating disease, intravenous treatment was started with corticotherapy at megadoses (30 mg/kg/day) and immunoglobulins 0.4 g/kg/day for 5 days.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The antibody study and microbiological results for the nasopharyngeal swab were negative. Lumbar puncture showed non-specific inflammatory data and absence of oligoclonal bands, with negative microbiology. Serology was positive for adenovirus IgM and IgG, establishing the diagnosis of adenovirus AED.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Twenty-four hours after starting treatment with glucocorticoids and immunoglobulins, a favourable evolution was observed with complete recovery of the left peripheral facial paralysis. After 72 h of treatment, the adduction limitation of both the LE and the RE disappeared, with only a slight limitation of abduction of the LE persisting during hospitalisation, which disappeared in the check-up performed one month after hospital discharge. MRI scans performed at 4 and 12 months after the episode revealed no new lesions, although the above described lesions persisted.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Internuclear ophthalmoplegia (INO) is a disorder of the horizontal conjugate gaze caused by a lesion at the level of the MFL, limiting adduction of the eye on the side of the lesion with a nystagmus on abduction of the contralateral side. Etiology is varied, the main causes in adults being ischemia or multiple sclerosis (MS).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In children, LIO is less common, and a thorough history and examination should be performed to discover the various causes: trauma, infectious or demyelinating meningoencephalitis, brain tumours, iatrogenesis, vasculitis or cerebral haemorrhage.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">When a patient presents with an ipsilateral horizontal conjugate palsy (one) together with an ipsilateral LIO (half), it is called Fisher’s one-and-a-half syndrome. This syndrome, described by Fisher in 1967, is the result of a lesion in the paramedian pontine reticular formation (PPRF), the ipsilateral MFL and the nucleus of the ipsilateral cranial VI par.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">A variety of disorders fall within the spectrum of one-and-a-half syndrome depending on the structures affected at the level of the pons. The most common variant is the eight-and-a-half syndrome, first described in 1998 by Eggenberger<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> after reporting 3 cases secondary to ischemic stroke. This syndrome adds to horizontal conjugate palsy and ipsilateral LIO an ipsilateral paralysis of the cranial VII par. With regard to its etiology, the eight-and-a-half syndrome etiology matches that described for LIO, the two pathologies being differentiated by the more extensive involvement of the pontine tegmentum in the case of the eight-and-a-half syndrome. This anatomical area should be studied by means of imaging tests to determine the etiology and to be able to carry out specific treatment depending on the cause. In adults, ischemic origin is more frequent due to involvement of a perforating branch of the basilar artery, while in children MS is more frequent.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8</span></a> In pediatrics, a single case of infectious eight-and-a-half syndrome secondary to tuberculoma has been reported in a 4 year-old girl.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The imaging test of choice is brain and spinal cord MRI, which will help to guide the diagnosis. If demyelinating lesions are present, the study should be expanded to differentiate between monophasic demyelination as the first manifestation of ADE or MS, as 18% of diagnoses of ADE have been reported to be a first attack of MS.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Radiological differences that may help differentiate between MS and ADE include location, presence of bilateral involvement or black holes. The periventricular location of hyperreflective lesions on T2 and FLAIR sequences, the presence of black holes and the absence of bilateral diffuse involvement point to MS, as opposed to ADE, which is characterised by bilateral diffuse involvement in 45% of patients, with the presence of black holes and periventricular involvement in a very low percentage of patients.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In addition to radiological features, the diagnosis of ADE is based on a thorough clinical history, with a history of recent vaccination or infectious symptoms in the last 2 days–4 weeks being characteristic. It is more frequent in winter and spring, with a slight male predisposition and an age between 5 and 8 years old.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> At the time of diagnosis, the patient presents with clinical signs of encephalitis, with headache, fever, nausea, vomiting and varied neurological focality, reflecting multifocal CNS involvement.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Lumbar puncture results may help to differentiate between the two entities, the main discriminating feature being the presence of oligoclonal IgG bands in cerebrospinal fluid (CSF) but not in serum, which occurs in 40%–95% of MS cases and only in 0%–29% of ADE cases. ADE would yield a non-specific inflammatory result in CSF, absent in MS.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The presence of micro-organisms in the CSF also supports the diagnosis of ADE. In the case of adenovirus, encephalitis incidence data of 1.9% have been published.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Since CSF was positive in only 15% of cases, it is postulated that the disease is caused by immune damage secondary to circulating antigen-antibody complexes rather than primary CNS infection.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">First-line treatment in ADE is based on the use of corticosteroids at a dose of 30 mg/kg/day for 3–5 days, followed by a tapering regimen for 4–6 weeks. In cases with poor response, use has been combined with immunoglobulins at a dose of 2 g/kg for 2–5 days. The combined use of corticosteroids, immunoglobulins and plasmapheresis has been reported in refractory patients or those with immediate onset symptoms,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> and a single case was also treated with hypothermia and decompressive craniotomy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The prognosis is favourable in most patients, with complete recovery reported in 50%–75% of cases within 1–6 months of onset and a mortality rate of less than 10%. The main sequelae described are ataxia and mild hemiparesis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Follow-up should be performed with brain MRI, which shows complete resolution of lesions in 27%–55% and partial resolution in 45%–64%.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Other authors have suggested figures of 37%–75% complete recovery in EDA and 25%–53% partial recovery.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It is advisable to perform at least 2 Brain MRI during follow-up before discharge.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Brain MRI may also be useful for long-term differentiation between the diagnosis of ADE and MS. The presence of new lesions points towards a diagnosis of MS, as their presence has been reported in only 0%–9% of patients with ADE.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In conclusion, we present a case of 8.5 syndrome as a manifestation of adenovirus ADE. It should be suspected in children of pediatric age who report viral symptoms in recent weeks or recent vaccination, as well as in patients with neurological symptoms who present with lesions suspicious of demyelination on brain and spinal cord MRI together with a lumbar puncture with a non-specific result. The prognosis of the disease is favourable, with no or minimal sequelae after treatment with corticosteroids and immunoglobulins.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0130" class="elsevierStylePara elsevierViewall">This research has not received specific support from public sector agencies, the commercial sector or non-profit organisations.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">No conflicts of interest were declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1853066" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1610936" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1853065" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1610935" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-04-05" "fechaAceptado" => "2022-08-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1610936" "palabras" => array:5 [ 0 => "Eight-and-a-half syndrome" 1 => "Internuclear ophthalmoplegia" 2 => "Acute disseminated encephalomyelitis" 3 => "Adenovirus" 4 => "Multiple sclerosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1610935" "palabras" => array:5 [ 0 => "Síndrome del ocho y medio" 1 => "Oftalmoplejía internuclear" 2 => "Encefalomielitis diseminada aguda" 3 => "Adenovirus" 4 => "Esclerosis múltiple" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Acute disseminated encephalomyelitis is an immune mediated inflammatory-demyelinizing disease that usually manifests after infection or vaccination in school-age children. It typically presents a prodromal phase with flu-like symptoms, followed by a phase with varied clinical symptoms, neuro-ophthalmological alterations such as ophthalmoplegia or optic neuritis may occur.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The differential diagnosis includes tumor, vascular, infectious, inflammatory and demyelinating diseases. Diagnosis is based on the clinical history and the characteristics of brain magnetic resonance imaging, the gold standard test. The study of the cerebrospinal fluid can help to guide the clinical picture.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The prognosis is favorable, with an excellent response to corticosteroids and immunoglobulins, with minimal long-term sequelae in most cases.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">We report the case of an 8-year-old male with acute demyelinating disease due to adenovirus whose manifestation was an eight-and-a-half syndrome.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La encefalomielitis diseminada aguda es una enfermedad inflamatoria-desmielinizante inmunomediada que suele manifestarse tras una infección o vacunación en niños en edad escolar. Típicamente presenta una fase prodrómica con un cuadro pseudogripal seguida de una fase con clínica muy variada, pudiendo aparecer alteraciones neurooftalmológicas como oftalmoplejía o neuritis óptica.</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La etiología es variada, incluyendo enfermedades tumorales, vasculares, infecciosas, inflamatorias y desmielinizantes. El diagnóstico se basa en la historia clínica y en las características de la resonancia magnética cerebral, prueba de imagen de elección. El estudio del líquido cefalorraquídeo puede servir de ayuda en la orientación del cuadro clínico.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El pronóstico es favorable, con excelente respuesta a los corticoides e inmunoglobulinas y con mínimas secuelas a largo plazo en la mayoría de los casos.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de un varón de 8 años con enfermedad desmielinizante aguda por adenovirus cuya manifestación fue un síndrome del ocho y medio.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 525 "Ancho" => 1505 "Tamanyo" => 104553 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Left eye limitation for adduction with right eye nystagmus in abduction.</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" => 544 "Ancho" => 1505 "Tamanyo" => 132298 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Limitation of the left eye for adduction and abduction, limitation of the right eye for adduction.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 924 "Ancho" => 1674 "Tamanyo" => 156897 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Brain MRI. (A) Cross section in T2 sequence; the green arrow points to a hyperintense lesion in the floor of the fourth ventricle with cranial direction towards the medial longitudinal fascicle. (B) Same lesion in coronal T2 FLAIR sequence.</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" => "Acute disseminated encephalomyelitis: updates on an inflammatory CNS syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Pohl" 1 => "G. Alper" 2 => "K. van Haren" 3 => "A.J. Kornberg" 4 => "C.F. Lucchinetti" 5 => "S. 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