A 16-year-old girl presented with progressive diffuse pain in the lower limbs associated with paresis and unstable gait. She reported a 20dayhistoryofhighfever,rash,andseverearthralgiaonherhands,wrists, and knees. On presentation, neurologic examination showed severe quadriparesis presenting full-range movement of the upper and lower limbs only with gravity eliminated, without any changes in reflexes or sensitivity. The patient did not show any signs of vision impairment.Analysis of the spinal fluid revealed increased cellularity (white blood cell count of 91/μL [to convert to ×10 9 per liter], being 85% lymphocytes, 7% monocytes, 4% neutrophils, and 4% eosinophils; no red blood cells were found), protein level of 435 g/dL (to convert to grams per liter, multiply by 10), glucose level of 44 mg/dL (to convert to micromoles per liter, multiply by 0.0555), and normal cultures for both bacteria and fungi. Magnetic resonance imaging showed focal T2 and fluid-attenuated inversion recovery hyperintense lesion in corpus callosum, subcortical white matter, and medulla without restriction to diffusion. Spine magnetic resonance imaging showed extensive T2hyperintense area, predominantly posterior from C1 to C7 and central in the thoracic spine (Figure 1 and Figure 2).

RESUMOAs complicações da Derivação Ventriculoperitoneal (DVP) podem variar de 6% a 40% nas séries da literatura, estando o hematoma subdural crônico (HSDC) presente em até 24% de algumas dessas séries. Preconiza-se o uso de uma válvula de alta pressão, para evitar uma possível hiperdrenagem, nos casos de sintomatologia semelhante à hidrocefalia de pressão normal (HPN) com grande aumento ventricular. Nesse caso, o paciente apresentou a tríade clássica de Hakim-Adams, sendo diagnosticado clinicamente com a hidrocefalia de pressão normal e submetido a uma derivação ventrículo-peritoneal com uma válvula de alta pressão. O paciente evoluiu com a formação de hematoma subdural crônico bilateral (HSDC), sendo necessária a drenagem da coleção sanguínea. O Palavras-chave: Hidrocefalia. Complicações. Hematoma subdural crônico. Síndrome de Hakim. ABSTRACTComplications of ventriculoperitoneal shunt (VPS) can range from 6 to 40% in literature series, being the chronic subdural hematoma present in up to 24% of some of these series. The use of a high pressure valve is praised to avoid a probable hyperdraining in instances of similar symptomatology to normal pressure hydrocephalus (NPH) with huge ventricular increase. In this case, the patient presented the classic Hakim-Adams' triad, being clinically diagnosed with NPH and submitted to a VPS with a high pressure valve. The patient evolved with a bilateral chronic subdural hematoma formation, being necessary a draining of this blood colection. The presented case allows to notice complications after this procedure and also a bibliographic review about NPH's physiopathology.

A previously healthy 25-year-old woman presented with headache, dysarthria, double vision, and dizziness for 1 week. She denied any history of fever, head trauma, vomiting, diarrhea, abdominal pain, or cough. She had traveled to northeastern Brazil 2 months before the onset of the neurological symptoms.On examination, she had a mild right-side hemiparesis with hyperreflexia and hemiataxia. She could walk unassisted but presented with a broad base. There were no meningeal signs. She did not present with hepatosplenomegaly of lymphadenopathy. Her cranial magnetic resonance imaging showed a T2-weighted fluid-attenuated inversion recovery hyperintense lesion with heterogeneous gadolinium enhancement in the pons (Figure). There were no signs of diffusion restriction on diffusion-weighted imaging or hemorrhages on susceptibility-weighted imaging.The laboratory test results showed a hemoglobin level of 15.3 g/dL (to convert to grams per liter, multiply by 10.0), total leukocyte count of 10 390/uL (to convert to ×10 9 /L, multiply by 0.001), of which 1703 (16.4%) were eosinophils, and a platelet count of 284 000/μL (to convert to ×10 9 /L, multiply by 0.001). The patient's liver and kidney function test results were normal. Computed tomography of the chest revealed bilateral patchy pulmonary infiltrates.Cerebrospinal fluid (CSF) analysis showed 640 cells, of which 57% were lymphocytes, 26% were eosinophils, and 13% were monocytes; protein levels were 70 mg/dL, and glucose levels were 46 mg/dL. Her blood cultures were found to be sterile.

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Background:The posterior longitudinal ligament (PLL) extends from the foramen magnum to the sacrum. In some cases, it becomes calcified/ossified; the term for this is ossification of the PLL (OPLL).Case Description:A 50-year-old female presented with acute sphincter dysfunction and paraparesis attributed to T2–T4 OPLL. The patient underwent a C7-T5 laminectomy to decompress the spinal cord. After 1 postoperative week, and certainly by 6 months postoperatively, the patient's motor and sensory deficits showed improvement.Conclusion:Surgery for thoracic OPLL includes laminoplasty, laminectomy with/without fusion, anterior decompression through a posterior approach (transpedicular, costotransversectomy), and circumferential decompression (e.g. combined anterior/posterior approaches). In cases like the one presented, patients who originally present with acute paraparesis/sphincter dysfunction may demonstrate postoperative improvement.