Thalamic strokes may present with a wide variety of symptoms depending on their location, volume and lateralization. Hypersomnia is a less frequent manifestation, that has been associated with unilateral paramedian thalamic ischemic lesions. We report a case of a patient who presented to the emergency department (ED) with sudden onset of hypersomnolence. Initial head computed tomography (CT) showed no signs of acute ischemia. Follow-up head CT 24 h after thrombolysis exposed a hypodense lesion on the left ventromedial thalamic and mesencephalic regions, with corresponding T2/FLAIR hyperintensity and diffusion restriction on brain magnetic resonance imaging, confirming a recent ischemic stroke. Clinicians should be aware of the association between acute hypersomnia and strategic unilateral thalamic infarcts, particularly when the initial CT scan has no signs of acute ischemia.

Introduction:Cranial nerve involvement in polyarteritis nodosa(PAN) is underrecognized and rarely reported. The aim of this article is to review the available literature and present an example of oculomotor nerve palsy in the course of PAN.Material and methods:Evaluation of texts describing the analyzed problem using the terms "polyarteritis nodosa", "nerve", "oculomotor", "cranial nerve" and "cranial neuropathy" for searching the PubMed database was done. Only full-text articles in English language with titles and abstracts were included in the analysis. As a guideline for the analysis of articles, the methodology described in the Principles of Individual Patient Data systematic reviews (PRISMA-IPD) was used.Results:After screening articles only 16 reported cases of PAN with cranial neuropathy were included in the analysis. In 10 the cranial neuropathy was reported as the initial manifestation of PAN with optic nerve involvement as the most frequent (62.5%); among these cases the oculomotor nerve was involved in 3 cases. Treatment with glucocorticosteroids and cyclophosphamide was the most common.Conclusions:Although cranial neuropathy, especially oculomotor nerve palsy is a rare first neurological manifestation of PAN, this clinical problem should be considered in the differential diagnosis.Especially patients with peripheral neuropathy, general symptoms, skin lesions and hepatitis B virus infection should be evaluated for cranial nerve involvement in the course of vasculitis.In the case of unclear involvement of the cranial nerves, PAN should also be considered in the differential diagnosis as the cause of symptoms and the first manifestation of the disease.

Progressive multifocal leukoencephalopathy (PML) is a severe demyelinating disease of the central nervous system, caused by reactivation of the JC polyomavirus. Although classically described in scenarios of severe immunosuppression, PML can on rare occasion affect patients with discrete, transient, or occult immunosuppression. An HIV-negative 57-year-old man with history of alcoholic cirrhosis (Child-Pugh A) presented with confusion and behavioral disturbances, difficulty speaking, and gait instability that developed over the last two months. His altered behavior was characterized by psychomotor retardation and aggressivity. Neurological examination revealed mixed aphasia, right hemiparesis, and ipsilateral hemianopia. The patient regularly consumed alcohol and was not taking any medication. Head computed tomography revealed confluent hypodensity in the white matter of the left frontal, parietal, and temporal lobes that extended to the contralateral parietal region through the splenium of the corpus callosum. Brain magnetic resonance imaging confirmed an extensive lesion involving the periventricular and subcortical white matter (including the subcortical U-fibers) of these regions that was hyperintense on T2-weighted images, hypointense on T1-weighted images (with no enhancement), and showed a typical rim of restricted diffusion along the active margins of inflammation, which was characterized by an increased signal in diffusion-weighted imaging with corresponding low values on the apparent diffusion coefficient map. Multiple T2-weighted images showed hyperintense punctate areas surrounding the lesion, as well as in the right hemispheric white matter, consistent with a ‘‘Milky Way’’ pattern (Figure 1). The patient had mild leukopenia (white blood cell count 3.3 10/L) that normalized two days later (4.5 10/L). HIV serology was negative and the CD4+ T cell count was 0.230 10/L. Cerebrospinal fluid analysis showed slightly elevated proteins (0.64 g/L) and a normal cell count and glucose levels. Polymerase Chain Reaction analyses identified JC polyomavirus in the cerebrospinal fluid (3300 copies/mL). Based on these findings, PML was diagnosed, presumably linked to alcoholic cirrhosis, since other causes of immunosuppression were excluded. Until recently, severe immunosuppression was considered an absolute requirement for developing PML. However, there are case reports of PML with less overt immunosuppression or with no documented immunosuppression. In chronic diseases (i.e., alcoholic cirrhosis), transient or discrete failure in cellular immunity might be enough to promote JC polyomavirus reactivation. A literature search yielded only 8 PML cases related to hepatic cirrhosis (3 with alcoholic etiology), including 1 woman and 7 men whose ages ranged from 41 to 64 years. Additional similarities to the present case included 3 cases with documented CD4+ lymphocytopenia or leucopenia and three descriptions of psychiatric symptomatology, which ranged from disorientation to severe mental confusion. Clinical manifestations of PML are nonspecific. Patients frequently present with gradually worsening focal neurological deficits and may develop seizures, altered mental status, or cognitive deficits. Our patient presented with confusion and behavioral disturbances, indicating that psychiatric symptomatology may be the cornerstone of this condition’s clinical presentation. Definitive diagnosis of PML requires histopathological examination or the detection of JC polyomavirus in the cerebrospinal fluid of patients with consistent clinical and imaging manifestations. The prognosis is poor and there is no specific treatment; thus, it is important to identify and, if possible, treat the underlying cause of immunosuppression. In conclusion, PML has variable clinical manifestations and can affect patients with discrete or transient immunosuppression, making diagnosis particularly challenging. Although probably rare, it might be underdiagnosed in cases of cirrhosis. Therefore, early consideration of PML in cirrhotic patients with neurological and/or psychiatric manifestations is essential, along with adequate brain imaging and cerebrospinal fluid analysis.

Introduction: Acne is an extremely prevalent condition. The healing of active acne lesions may result in the development of scars. Atrophic scars are the main scars caused by acne and result from the degradation of collagen fibers. Carboxytherapy is a minimally invasive method that involves the application of carbon dioxide subcutaneously through small infiltrations in the skin, which improves scar tissue by increasing collagen's deposition and reorganization. The aim of this study is to review the role of carboxytherapy in the treatment of atrophic facial scars, alone or in combination with other techniques. Methods: A literature search was conducted on several databases using MeSH terms “carboxytherapy”, “carbon dioxide/therapy” and “wounds” for guidelines, systematic reviews, randomized controlled trials, and observational studies, published over the last 20 years in Portuguese, English or Spanish languages. Results: A total of 129 articles were retrieved, of which four experimental studies and one case series were selected. Comparing the techniques of microneedling and carboxytherapy, both were considered non-invasive treatment modalities with equal effectiveness, tolerability and safety, resulting in similar histopathological changes. On the other hand, despite the improvement of acne scars in both treatment modalities, the results were significantly better in favor of carbon dioxide fractional laser, despite having more side effects than carboxytherapy. When these techniques are combined and carboxytherapy is used as a subcision method, there is a more marked and rapid improvement in the appearance of acne scars. Discussion: Carboxytherapy is a promising modality in the treatment of atrophic acne scars, alone or in combination with other techniques.

Frontal fibrosing alopecia (FFA) is a primary lymphocytic cicatricial alopecia, characterized by recession of frontotemporal hairline with frequent involvement of eyebrows and affecting occasionally other body areas. Entitled an emerging epidemic, due to its rising incidence, FFA etiology remains unclear without proven effective therapies. This study reviews relevant publications on FFA, regarding pathogenesis, clinical findings, histology along with treatment and prognosis. A bibliographic search was conducted in the main international databases, using the term ‘FFA’. Guidelines, observational studies, randomized controlled trials, reviews, systematic reviews and meta-analysis regardless of publication date, presented in English, Portuguese or Spanish, were included in this review. 50 publications were fully analysed. The majority of FFA cases were observed in postmenopausal women, although both men and women from younger ages can be victims. From an etiological point of view, immune-mediated hypothesis is widely spread, as stem cells localized in the bulge region of the follicle are destroyed by an inflammatory infiltrate. However, environmental factors raised interest, since sunscreen use was related to a bigger incidence of FFA. Three clinical patterns have been described. Yet the failure to use standardized assessment methods in addition to the absence of prospective studies evaluating available therapies, do not concede comparable data. Spontaneous stabilization of disease can occur, but regrowth was only seen in scarce cases. Outcomes from randomized controlled trials and prospective studies are missing to draw further understanding of FFA.