Cavernous hemangiomas of the optic chiasm are rare, and hemorrhage from cavernous hemangiomas causes acute visual loss. Although some cases have been reported, the appropriate treatment has not been determined yet because of the scarcity of these reports. Here, we describe a patient with recurrent hemorrhage from a cavernous hemangioma of the optic chiasm after a long clinically stable period, and we discuss the surgical implication of this lesion. A 45-year-old man sustained right visual loss due to hemorrhage from a cavernous hemangioma of the optic chiasm 20 years ago and was conservatively observed. He suffered from acute visual loss in the left eye following sudden onset of headache, and he was hospitalized in our hospital. The patient complained of severe visual disturbance in the left eye in addition to long-term right visual loss. Magnetic Resonance Imaging showed recurrent hemorrhage from the lesion, and the whole chiasm was affected. We performed total excision of the lesion, and his vision improved, enabling him to return to work. This is the first report of recurrent hemorrhage from a cavernous hemangioma of the optic chiasm. We recommend surgical resection, even in clinically stable patients, to prevent recurrence.
Clostridium botulinum is the bacterium that releases the most potent neurotoxin known and is responsible for causing botulism. There are seven different serotypes of C. botulinum (A-G), but only the serotypes A, B, and E cause human botulism via colonization of the lower GI tract after ingestion of contaminated food. Botulism can present as muscle weakness, paralysis, dysarthria, dysphagia, constipation, and urinary retention. Death can occur in up to 10–25 % of cases. It has got use in various neurological disorders like spasticity, dystonia, hemifacial spasm, migraine and several non-neurological specialties like cosmetics, GI tract and GU tract disorders and ophthalmology . Parkinson’s Disease (PD) is a progressive, neurodegenerative disorder with pathological hallmark being the degeneration of dopaminergic neurons in the substantia nigra pars compacta and the presence of alpha synuclein-positive neuronal inclusions in several motor and non-motor brain circuits. It is a disorder marked not only by the motor features but also the presence of non-motor symptoms including sleep disorders, fatigue, pain, urinary dysfunction, constipation, sialorrhea, cognitive dysfunction, and depression/anxiety [2-5]. Botulinum toxin (BoNT) has been successfully used to treat a variety of symptoms related to PD including cervical dystonia, foot dystonia, focal hand dystonia, laryngeal dystonia, oromandibular dystonia, blepharospasm, lid apraxia, camptocormia, hand and jaw tremor, sialorrhea, hyperhidrosis,
dysphagia, constipation, and overactive bladder3. Here overview off its role for various important indications is given below.
Various clinical features of Foot Dystonia (FD) are observed in Idiopathic Parkinson’s Disease (IPD), ranging from simple forms such as inversion or hallux extension, to complex forms combining inversion, plantar and toe flexion, intra rotation, and dorsal and hallux extension. FD can occur in the morning before the first dose of levodopa has been taken and/or during daily off-periods, but also, during on-periods . In a double-blind randomized trial, two injection sites (Flexor digitorum longus vs. Flexor digitorum brevis) in lower limb muscles were compared at baseline and after 6, 12 and 18 weeks. The primary outcome measure was the improvement of the patient’s clinical state evaluated by the Clinical Global Impression of change (CGI) and Burke-Fahn-Marsden (BFM) Scale. Patients treated by botulinum toxin A showed a moderate improvement with a CGI score of 3.14 ± 0.22 at 6 weeks and 2.90 ± 0.20 at 18 weeks.
There were no significant differences between the 2 injection sites evaluated5. In another open label pilot study, 30 patients with off foot dystonia were treated with Botox. The selection of muscles was based on foot posture and included muscles like tibialis anterior, tibialis posterior, gastrocnemius, FDL, and EHL. The muscles were injected with a median dose of 40 units in each muscle. Dystonia was evaluated using a quantitative rating scale
and all Patients showed an improvement in their foot posturing
Cervical dystonia can occur as a manifestation of PD or
secondary to levodopa. Anterocollis is the most common
dystonia in PD or MSA. Cervical dystonia (CD) is a focal dystonia
that causes abnormal postures of the head, neck and shoulders.
Class A evidence has established botulinum toxin treatment as
an effective means to control the symptoms of CD. Anterocollis in
PD may respond to botulinum toxin injections as used for other
patterns of cervical dystonia . In a prospective, multicenter,
double-blind, placebo-controlled trial, subjects were randomized
to one of three arms: placebo, In botulinum toxin A 120 U and
240 Units. The primary efficacy outcome measure was change
in TWSTRS score from baseline to Week 4. There was continued
improvement at Week 8 and at the final visit in comparison to
baseline . In another study forty consecutive patients with
idiopathic CD were studied. As outcome measures, Tsoi scores,
VAS scores and patients’ subjective evaluations were assessed at
the first visit, after 12 weeks and one year.
Ten patients received injections with Botox and 11 with
Dysport with a median (converted) dose of 375 MU. The muscles
that were most frequently added to the muscles selected for
treatment were the Splenius (SPL), the semispinalis (SESP),
the Levator Scapulae (LS) and the trapezius (TPZ) muscles. The
mean Tsui score in these patients improved from a baseline
score of 11.2 to 10.3 after 12 weeks (8% improvement). After
one year of treatment the Tsui scores had significantly improved
to 9.1 (18.8% improvement, p <0.01). The subjective scores also
significantly improved after 12 weeks (p <0.01) and even further
after one year (p <0.001) of treatment .
Role of botulinum in camptocormia and PISA syndrome:
Based on the small studies and variable responses, there is
insufficient data for the use of toxin in camptocormia. Summary
of studies is given below in Table 1. Interestingly, evidence
for efficacy of botulinum toxin in the treatment of axial
postural abnormalities in PD is greater for Pisa syndrome than
camptocormia shown in Table 2 below .
Sialorrhea occurs in 32 to 74% of PD patients. Sialorrhea is
classified as primary or secondary. Primary sialorrhea occurs
when there is excessive production of saliva, while secondary
sialorrhea is the result of disorders of the coordinated activity of
the orofacial and palate lingual muscles decreasing the clearance
of saliva. Research has shown that saliva production is lower in
PD patients compared to healthy controls and that sialorrhea
is of a secondary nature. BoNT as a possible treatment for
sialorrhea was first proposed by Bushara, et al. . In a review
of 12 studies where the drooling score and drooling frequency
score (DS-DF), the Visual Analogue Scale (VAS) and cotton-roll
weight were the most frequently used methods of evaluation.
BoNT type-A was tested in the range of 64–450 U. BoNT type-B
was tested in the range of 1500-3500. For B type the best
results were seen at the higher dose (3500 U). Mancini et al. and
other several the studies reported a positive effect of BoNT on
sialorrhea ranging from 50–100 % of the patients with duration
of the effect varied from 1 to 6 months .
Blepharospasm is a focal dystonia characterized by
involuntary, intermittent, or persistent forceful eyelid closure
due to spasmodic contractions of the orbicularis muscles.
Benign essential blepharospasm describes the involuntary
contractions of only the orbital and periorbital muscles.
However, some patients may also have spasm of other facial,
oromandibular, pharyngeal, laryngeal, or cervical muscles,
which is a form of cranio-cervical dystonia called Meigs
syndrome. Blepharospasm typically begins in the fifth to
seventh decade of life and is more common in women. It occurs
in more advanced stages of PD but can also occur in atypical
Parkinsonism and is often associated with apraxia of eyelid
opening, defined as an intermittent inability to voluntarily open the eyelids due to levator inhibition, abnormal contraction of
the pretarsal orbicularis oculi, or eyelid freezing. BoNT has a
longstanding history in the treatment of blepharospasm and is
considered a first-line therapy. In an evidenced-based review
of the current clinical data available, it was concluded that
Onabotulinumtoxin A and Incobotulinumtoxin A are effective
in the treatment of blepharospasm (level A recommendation)
and Abobotulinumtoxin A is probably effective (level B
recommendation). There were no quality studies to confirm
the efficacy of Rimabotulinumtoxin B contributing to a level U
recommendation [13,14]. Summary: Parkinson’s disease is a
degenerative disorder with its complications extending much
beyond the motor features. In many cases pharmacological
therapies are of little help. Botulinum injection seems quite cost
effective, easily available worldwide, effective in counteracting
and improving many of the problems linked to Parkinson’s
disease. Common disorders treated with botulinum toxin and
level of evidence for the safety and efficacy of botulinum toxin
use. Evidence of its use for various indications in summarized
in Table 3.