Iatrogenic Horner's syndrome: A cause for diagnostic confusion in the emergency department

Abstract

Horner's syndrome (HS) results from interruption of sympathetic nervous supply to the eye and manifests clinically with partial ptosis, miosis and enophthalmos, along with anhidrosis of face on the affected side. [1] HS is not an uncommon finding in patients visiting emergency department (ED), being reported in those with brainstem strokes, myelitis, malignancies of lung and thyroid, dissections of carotid and vertebral arteries, traumatic injury to neck and thorax and cervical or thoracic intervertebral disc herniation. [1] Some of the iatrogenic causes of HS include cervical and upper thoracic sympathectomy, tube thoracostomy, thyroidectomy, carotid surgery/stenting and epidural anesthesia. [1] However, percutaneous internal jugular vein (IJV) central venous catheter (CVC) placement is a rare and underappreciated cause of HS. [2-4] Development of anisocoria in an unconscious patient, as a consequence of this iatrogenic HS, can give rise to diagnostic confusion [3] and undue investigations. Funding: None. Ethical approval: Not needed. Confl icts of interest: The authors declare that there are no confl icts of interest related to the publication of this paper. Contributors: Vinod KV and Sivabal V managed the index patient and wrote the case report. Vidya MV was involved with review of literature, writing and critical revision of the manuscript.

Horner's syndrome following single lung transplantation

“…It has been described in the literature as a less frequent complication of central line placement. 4 In our case here we diagnosed an incomplete Horner's syndrome. The central line placement was performed on the same site as the Horner's syndrome appeared further validating the diagnosis.…”

“…Common causes of Horner's syndrome are lesions of the primary neuron, brainstem stroke, trauma to brachial plexus, Pancoast tumors, carotid artery dissections or ischemia, or middle cranial fossa neoplasm. 1,2,4 There is no specific sex, age, or race preference in this syndrome. The common lesions that cause Horner syndrome interfere with the preganglionic fibers in the upper thorax.…”

“…As described in literature in some cases of traumatic central line placement CT chest could show a stellate ganglion hematoma on the cranial pole of the ganglion, which we was not seen in our patient. 2,4 Other side effects of central line placement include pneumothorax, traumatic puncture of the thoracic vessels, and even traumatic puncture of intrathoracic organs. 4,5 However, ophthalmic complications are uncommon.…”

“…2,4 Other side effects of central line placement include pneumothorax, traumatic puncture of the thoracic vessels, and even traumatic puncture of intrathoracic organs. 4,5 However, ophthalmic complications are uncommon. While some ophthalmic complications are due to medication side effects, others are attributed to systemic immunosuppression.…”

Unusual Complications of Ultrasound Guided Central Venous Cannulation

“…Sympathetic fibers may get disrupted centrally (ie, between the hypothalamus and the fibers' point of exit from the spinal cord [C8-T2]) or peripherally (ie, cervical sympathetic chain, superior cervical ganglion, or along the carotid artery [7]. Although there were case reports reported on Horners syndrome following internal jugular vein cannulation most of them were associated with failed or difficult catheterization [6]. Another possible cause of Horner's syndrome implicated is dissection of the carotid artery, with associated risk of severe cerebrovascular complications accordingly we have excluded carotid artery dissection in our patient.…”