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Case report:

F.C. 81-years-old men was addressed to our department

due to suffering from clonic tonics movements and dysarthria

but conscious on. He had headache for 3 days, and from the

pathological history, arterial hypertension, Malta fever and dizziness

were verified. The general evaluation (EKG, blood tests, chest x-ray)

was an unremarkable neurological exam and an ophthalmologic exam

which show a progressive axial exophthalmos as well as decresed

visual acurity in the left eye and vascular episcleral congestion. Cranial

CT reported intraparenquimatoso bleeding. Therefore, CT angiography

was requested in order to confirm malformations or DAVFs., and

cerebral angiography was also done to definite the diagnosis. Finally,

the patient

s state was discussed with neurosurgery dept. and the

treatment with Levetirazetam and a sugery were ordered.


DAFVs are very interesting pathological entities. The

treatment is complex in most case and surgery is sometimes necessary

to complete the cure or to evacuate a hemorrhagic post rupture

hematoma. The meticulous angiographic study of venous drainage is

the key of treatment.


Unrecognized polycythemia vera

M.M. Luís, A.A. Sousa, C. Rozeira, M. Oliveira, A. Oliveira, D. Pinheiro,

V. Paixão Dias.



Polycythemia vera (PV) is a clonal disorder involving a

multipotente hematopoietic progenitor cell. The etiology is unknown.

Uncontrolled erythrocytosis causes hyperviscosity, leading to neuro-

logic symptoms. Case description. 79 year-old man. Hypertension

and dyslipidemia. Bifrontal headache. Decreased visual acuity.

Papilledema. Normal cranial CT scan. Aggravation of pain. Intracranial

hypertension. Lumbar puncture was performed. Magnetic resonance

angiography revealed thrombosis of sigmoid and transversus sinuses

and right jugular vein. Anticoagulation was started. Possible occult

malignancy. Probable peripherical embolization of the fifth right toe,

with amputation. Persistently elevated hematocrits. Low eritropoetin.

Ecographic splenomegaly. Thoracic, abdominal and pelvic scan with

no other abnormalities. JAK2 positivity. Bone marrow biopsy

supported hypothesis of high risk PV. Hydroxyurea and acetilsalic

acid were started. On follow up, complete remission on symptoms.

Magnetic resonance angiography documented partial recanalization.

Discussion. Clinical course in PV is complicated by thrombotic and

hemorrhagic events. The former may manifest in the preclinical

process. Acquired thrombophilias should be looked up in these



Cardiovocal syndrome; a case report

V. Price, A. Michael, A. McGrath.

Russells Hall Hospital, Dudley, UK

Case report:

A 90-year-old patient noticed gradual progressive loss of

voice for 12 months. Her medical history includes severe congestive

cardiac failure. On examination she was


and difficult to

hear. Her JVP was elevated with ankle oedema. Auscultation revealed

murmurs of AS and MR and bilateral basal crackles. Her FBC, LFTs, Ca

and TSH were normal. CXR demonstrated marked cardiomegaly with

no lung pathology. Echocardiography demonstrated severely dilated

left atrium (volume is 171 mm), mildly dilated right atrium (volume

is 22 mm), severe AS, severe MR, moderate TR and pulmonary

hypertension (estimated PASP 54

59 mmHg). The ENT surgeon

clinically diagnosed recurrent laryngeal nerve palsy however laryn-

goscopy was unsuccessful due to exaggerated gag reflex. She refused

CT of the neck and chest.

The gradual progressive loss of voice in presence of marked

cardiomegaly with biatrial enlargement and pulmonary hypertension

and in the absence of evidence of malignancy suggest cardiovocal


Cardiovocal syndrome or Ortner

s syndrome is hoarseness of voice due

to left recurrent laryngeal nerve palsy caused by mechanical effect on

the nerve by enlarged cardiovascular structures.


Hoarseness of voice is a common symptom; recurrent

laryngeal nerve lesion can be the cause. Surgical trauma and malig-

nant tumours are the most common causes of unilateral recurrent

laryngeal nerve injury. Compression of left recurrent laryngeal nerve

by enlarged cardiovascular structures can rarely be the cause of

hoarseness. Nobert Ortner in 1897 described three patients with

hoarseness of voice and severe mitral stenosis. He attributed the

hoarseness to compression of the left recurrent laryngeal nerve by

the enlarged left atrium. Subsequently hoarseness of voice was

described in patients with congenital heart disease, mitral regurgita-

tion, isolated ductus aneurysm, pulmonary hypertension either

primary or secondary, tortuosity of the great vessels and ventricular

and aortic aneurysms.

Postulated mechanisms of left recurrent laryngeal nerve palsy include

compression from a dilated pulmonary artery, atherosclerotic pul-

monary artery, right ventricular hypertrophy, ligamentum arteriosum,

the left bronchus, inflammation or scarring in the aortic window

or compression of the left recurrent laryngeal nerve between the

pulmonary artery and the aorta.

Prognosis depends on the underlying cause of the nerve palsy and

reversibility depends on the duration of injury.


Diuretics use in patients with Parkinson

s disease or Parkinsonism

A. Michael


, J. Barnes




Russells Hall Hospital,


Dudley CCG, NHS,

Dudley, UK


Urinary symptoms are common in Parkinson

s disease

(PD); mainly irritative due to detrusor over activity. Obstructive

symptoms may also be seen due to obstructive uropathy, antic-

holinergics or point to multiple system atrophy. Diuretics increase

these symptoms and may cause incontinence.

The BNF licensed indications for diuretics are pulmonary or peripheral

oedema due to heart failure. They should not be used continuously on

a long-term basis for gravitational oedema.

Diuretics increase the risk of falling in view of hyponatraemia,

hypotension, postural hypotension and increase of urine frequency.

Diuretics are not the best option in older people especially those

with poor mobility, lack of balance, overactive bladder syndrome or



To study the use of diuretics in patients with PD and



Prospective study of diuretics use in 200 consecutive patients

attending PD clinic in a UK teaching hospital. Patients

notes and

electronic records were reviewed. Data were collected on excel and

descriptive statistics were used.


200 patients were included; 115 males and 85 females with

mean age of 73 and 72 years respectively. 88% of patients had PD,

10% had secondary Parkinsonism and 2% had Parkinson

s plus

syndrome. 33% of patients had 1 or 2 falls in the previous 6 months,

18% had 3 or more falls. 8% had a previous fracture.

31% of patients (62) were on diuretics; 21% of whom (13 patients) had

left ventricular failure, 10% (6 patients) had congestive cardiac failure

and 69% (43 patients) were prescribed the diuretic for oedema.


Diuretics are commonly prescribed. In this study 31% of

Parkinsonian patients were on diuretics however just 31% of these had

heart failure.

Use of diuretics in older people in general and Parkinsonian patients in

particular should be limited to the licensed indications. Alternative,

age friendly, medications should be considered first.


Monitoring of cohort of patients with moderate or severe aortic


M. Ramos


, R. Toro


, M. Quezada


, J.G. Pavón


, G. Cristofori


, R. Ayala




Department of Cardiology, Hospital Universitario Central Cruz Roja,



Department of Internal Medicine, University Hospital Puerta del

Mar, Cádiz,


Department of Geriatrics, Hospital Universitario Central Cruz

Roja, Madrid, Spain

Poster presentations / European Geriatric Medicine 7S1 (2016) S29