Introduction. - Movement disorders are uncommon in multiple sclerosis, except for tremor. Patients rarely have paroxysmal dystonia (or tonic spasm), which can be the presenting manifestation of the disease.Observations. - Two videotaped observations are presented. The first patient was a 27-year-old woman, treated for relapsing-remitting multiple sclerosis, who presented daily several short (<1 minute) paroxysms of right hemibody dystonia. Brain MRI revealed several areas of cerebral demyelination, including the posterior limb of the left internal capsule with gadolinium enhancement. These events disappeared 7 days after corticosteroid infusion. The second patient was a 62-year-old man who presented brief episodes (<1 minute) of daily painful left hemibody dystonia. Three months later, similar paroxysms affecting the right hemibody including the face occurred. At times, the two hemibodies were affected simultaneously. The brain MRI showed multiple areas of white matter hyperintensity, including two symmetrical areas in the posterior limb of the internal capsules. Multiple sclerosis was diagnosed on clinical, MRI and biological data. Four days after starting corticosteroids, these paroxysmal phenomena disappeared totally.Conclusion. - Dystonia is an under-recognized aspect of paroxysmal events during multiple sclerosis. It might involve ephaptic transmission among abnormal demyelinated neurons; this ectopic excitation can arise at variable levels of the cordcospinal tract, but the analysis of reported cases and those described in this study shows that impairment of the posterior limb of the internal capsule seems to be a prevalent topography. Inflammation is likely to play a role because steroids often improve these phenomena. In this article, we review the clinical aspects, pathophysiology and outcome of paroxysmal dystonia in multiple sclerosis. (C) 2013 Elsevier Masson SAS. All rights reserved.

The endonasal transsphenoidal approach is employed for various pathologies involving the sella, suprasellar space, and sphenoid bone, including pituitary adenomas, Rathke pouch cyst, and craniopharyngiomas. Other indications include clival chordomas, meningiomas, metastatic lesions, and medial temporal lobe lesions such as encephaloceles. This approach is minimally traumatic to the brain, avoids brain retraction, does not create visible scars, provides excellent visualization of the pituitary, and is thought to cause less surgically related morbidity than transcranial approaches. This approach can be augmented with the use of an operative microscope and/or an endoscope. The operative microscope affords magnification, illumination, and three-dimensional viewing, and the endoscope expands the surgeon’s field of view. Both tools can be used simultaneously to complement each other.