0:01

Well, I'm going to do a little mea culpa on this case.

0:04

This was a patient who had a Horner syndrome and was being

0:08

evaluated for the first time in the emergency

0:10

room at Johns Hopkins.

0:12

We really didn't have much in the way of clinical

0:14

history other than the Horner syndrome.

0:16

So we started looking at the brain portion.

0:19

Remember that we want to be concerned about the brain stem,

0:22

as well as the hypothalamus in patients who have a Horner

0:27

syndrome. And when we started to look at this, we said, "Oh,

0:30

my goodness, look at all these white matter plaques."

0:33

This patient looked like a classic case of multiple

0:38

sclerosis, and it was a woman who was 45 years old.

0:41

So we started getting involved in the multiple

0:44

sclerosis plaques. As you know,

0:46

the posterior fascia and deep structures of the brain for

0:51

MS plaques are better seen on the T2-weighted scan.

0:54

So in the T2-weighted scan,

0:56

I was looking very carefully at the medulla,

0:59

because the medulla is one of the areas where you

1:03

can involve that first neuron of Horner syndrome.

1:08

And I was reading the case with the fellow.

1:10

The fellow had not called anything in the medulla.

1:12

I said, "No, this is positive in the medulla."

1:15

And we looked in the hypothalamic region,

1:17

which is down here, and we thought that was okay.

1:21

So going into it, we said, all right, well,

1:23

it looks like the medulla might be the culprit.

1:26

Next thing we looked at was the cervical spine

1:28

that was involved with multiple sclerosis.

1:32

And remember that the first motor neuron goes down to the

1:35

C7 T1 level. So I looked at the cervical spine on the sagittal,

1:39

didn't look all that bad,

1:41

but when I was looking at the gradient echo scan,

1:45

I noticed that there was some bright signal intensity in the

1:48

central posterior white matter of the cervical spine.

1:52

And continuing to scroll, I said, "Ah,

1:54

here's something on the left side."

1:55

Again,

1:56

the fellow had not called these as positive plaques in the

1:59

cervical spine. It was a left sided Horner syndrome.

2:02

So I sort of castigated the fellow and said, "Look,

2:05

you're missing MS plaques in the cervical spine on the left side,

2:10

and also centrally here in the posterior white matter."

2:14

So I hope that this is demonstrating a little right

2:17

sided plaque. So I was talking with the fellow,

2:22

and then I said, "Well, we should look at the optic nerves,

2:24

because the optic nerves may be involved with MS.

2:29

And we were looking on the thin section images and

2:32

didn't see anything involved with the optic nerves.

2:34

So in the end, we said,

2:36

Horner syndrome, secondary to possible MS plaques involving

2:40

the medulla, as well as the cervical spine on the left side,

2:46

and it was a left-sided Horner syndrome.

2:48

Well, the next day, the neurologist called me and said,

2:52

"You know, I'm concerned about a dissection."

2:56

I said, "What do you mean?"

2:57

I said, "The patient has MS and there's multiple

3:00

plaques that can account for the Horner syndrome."

3:02

And she said, "Well,

3:04

what about on the section here on the flare scan?"

3:10

And sure enough,

3:12

this patient not only had MS,

3:14

but the internal carotid artery on the left side showed a wall

3:20

hematoma of a dissection, which I completely went past,

3:25

as I was too busy criticizing the fellow.

3:28

And not to make it much worse than it really was,

3:32

but you can see that there is the hemorrhage in the wall of

3:38

the internal carotid artery with a small luminal size on

3:42

the left side, the affected side versus the right side.

3:46

So, indeed,

3:47

pretty rock solid example of a patient whose Horner

3:53

syndrome was secondary to the carotid dissection,

3:56

which I missed, and not related to

3:59

the patient's multiple sclerosis.