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A 69-year-old man was admitted for investigation of a 2-month history of left-sided weakness and headache with dizziness. There was no history of trauma. Initial cranial computerized tomography (CT) showed an extra-axial crescentshaped hyperdense lesion in the right frontoparietal region (top left). CT performed 1 month later showed no involution of the collection and persistence of its hyperdensity. Magnetic resonance imaging (MRI) revealed an extra-axial pachymeningeal lesion that was hypointense on T2 weighting (top right), with intense pachymeningeal and leptomeningeal enhancement on a T1-weighted image after contrast administration (bottom left); hypointensity on an apparent diffusion coefficient map (bottom right) confirmed restricted diffusion. These findings suggested meningeal lymphoma. Serum protein electrophoresis showed a monoclonal peak of immunoglobulin M (4Á26 g/l) and bone marrow biopsy showed extensive interstitial infiltration by small lymphoplasmacytic cells. A diagnosis of lymphoplasmacytic lymphoma was made.The patient received six cycles of rituximab plus cyclophosphamide, vincristine and prednisone (R-CVP), and achieved regression of the meningeal lesions.The typical radiological picture of an acute subdural haematoma on CT (hyperdense extra-axial collection) in a patient without a history of trauma and the persistence of this abnormality on follow up CTs suggests an alternative diagnosis and the need for further radiological investigation with MRI.

A 42-year-old male, HIV (human immunodeficiency virus) positive for 13 years, but without use of antiviral therapy, presented weight loss of 6 kg and erythematous-purplish lesions in the right buttock. Biopsy was showed cutaneous diffuse large B-cell lymphoma.  The patient received antiretroviral therapy and six cycles of chemotherapy achieving complete remission.After 5 years, the patient presented progressive headache with an episode of loss of balance with fall and mental confusion. Brain magnetic resonance imaging (MRI) showed a mass lesion in the periventricular region, involving the splenium of the corpus callosum with restricted diffusion. The brain images were consistent with glioblastoma (GBM) or DLBCL (diffuse large B-cell lymphoma). The hypoperfusion of the lesion on MRI was of fundamental importance for the differential diagnosis, favouring the diagnosis of  DLBCL.

Introduction: Gradenigo Syndrome is characterized by suppurative otitis media, pain in the distribution of the trigeminal nerve, and abducens nerve palsy. Sixth nerve palsy is secondary to nerve entrapment through the Dorello canal, petroclinoid ligament and petrous apex of the temporal bone. It is a report of a single case based on a retrospective analysis of the patient’s medical records. Case report: A 12-year-old girl was admitted due to new-onset binocular horizontal diplopia, worse with far vision, and right-side headache. She also complained of otalgia and fever for one week before admission. She has an unremarkable past medical history and up-to-date vaccination. On her neurological examination, she was alert and oriented, there was right eye abduction palsy, reduced right corneal-palpebral reflex and pain in the distribution of the right ophthalmic branch of the trigeminal nerve; meningeal irritation signs were absent. Otoscopy revealed a tender right tympanic membrane. Brain and ear computed tomography revealed abnormal right temporal petrous apex aeration and opacification of the petromastoid air cells. Brain and ear magnetic resonance imaging show abnormal hyperintensity compatible with right petrous apicitis. Gradenigo syndrome secondary to otitis diagnosis was made. An empirically-guided intravenous antibiotic was started and a myringotomy tube was placed by the ENT team. The culture of the middle ear revealed a Streptococcus pneumoniae infection. The patient was discharged after 14 days with an improvement in neurological symptoms. Conclusion: Gradenigo syndrome is a cause of sixth nerve palsy. The syndrome is classically described after suppurative otitis media, but it has already been described after complications of trauma and skull-base metastases. Nowadays, it is more uncommon due to early and widespread treatment with antibiotics to avoid complications of otitis media.

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