Role of MR spectroscopy in diagnosis of intracranial neuroenteric cyst.

INTRODUCTION: Neuroenteric cysts are rare benign endodermal lesions of the central nervous system that result from incomplete resorption of neuroenteric canal and mostly found in cervical and upper thoracic spinal canal. Intracranial neuroenteric cysts are extra axial and commonly located anteriorly in the posterior cranial fossa. MRI demonstrates variable intensity within the lesion on T1, T2W, and DWI sequences. METHODS: Three cases of posterior fossa non-enhancing cystic lesions of variable signal intensity underwent MRI with MR spectroscopy, where MR spectroscopy demonstrated dominant peak at 2 ppm, mimicking normal Nacetyl aspartate (NAA). CONCLUSION: MR spectroscopy in addition to conventional MRI may help in differentiating intracranial neuroenteric cyst from its close differentials.

Clinical significance of magnetic resonance imaging findings in chronic low backache.

BACKGROUND & OBJECTIVES: Magnetic resonance imaging (MRI) is frequently done for the evaluation of chronic low backache (CLBA), however, its significance in Indian patients has not been evaluated. We report here the MRI findings in patients with CLBA and their sensitivity and specificity with clinical evidence of radiculopathy and localized CLBA as well as correlate these with pain severity and disability. METHODS: Seventy two patients with CLBA aged 20-70 yr without trauma, infection, tumour, metastasis and vascular malformation were included in the study. Their demographic characteristics, lifestyle, education and employment were noted. Lumbosacral MRI was carried out and 19 MRI parameters at six levels (D12-L1-L5-S1) were noted. The severity of pain was assessed by Numeric Rating Scale (NRS, 0-10) and disability by Oswestry Disability Index (ODI). RESULTS: MRI was abnormal in all patients, the most common being disc desiccation (90.3%) followed by facet joint arthropathy (FJA; 75%) and nerve root compression (NRC; 72.2%). Endplate changes and high-intensity zone were noted in 58 and 50 per cent of patients, respectively. One-third patients with FJA, however, were below 30 yr of age. NRC on MRI had 61.3 per cent sensitivity and 10 per cent specificity with clinical radiculopathy. FJA had 60.7 per cent sensitivity and 15.9 per cent specificity with localized CLBA. None of the MRI parameters and MRI sum score correlated with NRS and ODI. On multivariate analysis, NRS was independent predictor of ODI (odds ratio 0.58, 95% confidence interval 0.35-0.98, P=0.04). INTERPRETATION & CONCLUSIONS: In patients with CLBA, NRC on MRI showed poor specificity with corresponding clinical radiculopathy and FJA with localized backache. None of the MRI abnormality correlated with the severity of pain or disability.

A case report of rim enhancing lesion at the orbital apex.

We report a case of partial third nerve palsy resulting from a cystic lesion located at the orbital apex. Imaging was suggestive of cystic schwanomma but histopathology of the lesion confirmed epidermoid cyst, which is a rare tumour of the orbit.

Intradiploic leptomeningeal cyst in an adult: role of percutaneous contrast injection in dural defect demonstration.

Leptomeningeal cysts are commonly seen in children usually following trauma and associated with bulging leptomeninges at the site of fracture. Intradiploic leptomeningeal cyst is an important differential for an expansile lytic lesion in the bony calvarium especially in a patient with a previous history of trauma. Here we present a case of intradiploic leptomeningeal cyst and describe the usefulness of retrograde cisternogram by CT-guided direct percutaneous cyst puncture where a CT cisternogram after intrathecal contrast injection could not demonstrate the dural defect and communication of the subarachnoid space with the intradiploic leptomeningeal cyst.

Leptomeningeal Angiomatosis in a Case of Neurofibromatosis Type 2: An Unusual Finding.

Neurofibromatosis type 2 (NF2) is an autosomal dominant disorder characterised by multiple neoplasms of the central and peripheral nervous system associated with ocular abnormalities. Leptomeningeal angiomatosis has not been described with this tumour predisposition syndrome. This report documents an unusual association of leptomeningeal angiomatosis in a case of NF2.

Beware of parotitis induced by iodine-containing contrast media.

Carotid stenting is being increasingly used for revascularization of the moderate to severe carotid stenosis and thus its complications are increasingly being recognized. We report a rare complication of induced by iodine contrast in a patient undergoing carotid stenting. s. A 51 year old man after the second stenting developed multiple small infarcts in spite of the distal device. He also had painful parotid swelling which improved within a week. One should be aware of iodine parotitis s in the patients undergoing iodinated contrast study.

Lumbar Canal Diameter Evaluation by CT Morphometry-Study of Indian Population.

STUDY DESIGN: A cross-sectional study. BACKGROUND: To document dimensions of the lumbar vertebrae and bony canal in an Indian population and to compare with other studies from the subcontinent as well as from other parts of world. METHODS: An observational study was conducted on the basis of a review of thin-cut (3 mm) computed tomographic images of lumbar vertebrae. A total of 302 patients were studied, and various dimensions were analyzed. RESULTS: In general, the vertebral and bony spinal canal dimensions were found to be greater in male patients. Comparison of populations revealed statistically significant differences in the spinal canal between an Indian population and others. OVERVIEW OF LITERATURE: Lumbar canal stenosis is a condition in which the anteroposterior and lateral dimensions of the bony spinal canal are less than normal for corresponding age and sex. Numerous studies have been conducted to determine morphometry of the lumbar vertebrae and spinal canal, mostly in western populations, using fresh cadaver or osteologic specimens. These studies did not mention the difference between the vertebral parameters in men and women. Moreover, many of these studies have limitations such as a small sample size and lack of demographic data including race, age, and sex. In this study, we have conducted morphometric analysis of the lumbar vertebrae in a relatively large number of Indian patients by using computed tomography scan. The morphometric data thus compiled may provide a baseline of body and canal dimensions that could guide clinical experts in their practice. CONCLUSIONS: The dimensions of the lumbar vertebrae and bony canal thus obtained shall provide a baseline normative data for evaluation of patients presenting with low backache and lumbar canal stenosis in an Indian population.

Brain herniations in patients with intracerebral hemorrhage.

OBJECTIVES: To study the types, frequency and clinical correlates of brain herniations in patients with intracerebral hemorrhage (ICH). METHODS: In 24 patients with ICH (putaminal 22 and thalamic 2) features of raised intracranial pressure (ICP), such as hyperventilation, extensor rigidity, pupillary asymmetry and pyramidal signs on the non-hemiplegic side, were recorded. Depth of coma was assessed by using the Glasgow Coma Scale (GCS) and severity of stroke by using the Canadian Neurological Scale (CNS). On MRI, evidence of herniation, horizontal and vertical shifts and the edema-hematoma complex were measured and compared with that of 15 matched controls. The clinical signs of herniation correlated with radiological parameters. RESULTS: The mean age of the patients was 57.7 years, six of them were women. Cerebral herniations were present in 11 (46%) patients. Subfalcian herniation (in six) was the commonest followed by uncal (in three). Combination of subfalcian and uncal herniations was present in one and subfalcian, uncal and tonsillar herniations in another. Herniations had significant correlation with the GCS, pupillary abnormalities, cortical atrophy, hematoma size and the edema-hematoma complex. One-month mortality was related to the GCS score, pupillary abnormalities and the edema-hematoma complex. Horizontal shift was related to the GCS score. CONCLUSION: In patients with ganglionic ICH, subfalcian herniation was the commonest. Herniation was associated with increased mortality. Horizontal shift correlated with clinical features of raised ICP and outcome.

Endovascular treatment of ruptured pica aneurysms and association with its extradural origin: A single-center experience.

BACKGROUND: Posterior inferior cerebellar artery (PICA) like other intracranial arteries is prone to aneurysm formation. Aneurysms usually arise from the vertebral artery (VA)-PICA junction and the proximal segment of the PICA. The surgical clipping of PICA aneurysms can be challenging and carries a potentially significant risk of morbidity and mortality. Experience with endovascular therapy has been limited to a few studies; however, the use of endovascular therapy as an alternative treatment to surgery has been increasing. We present our experience of last 5 years in treating the ruptured PICA aneurysms. MATERIALS AND METHODS: A total of 11 patients with PICA aneurysms, out of them 7 were at proximal PICA, 2 at the vertebral-PICA junction, and 1 each at mid and distal PICA, underwent endovascular treatment at our institution between 2011 and 2016. RESULTS: All the patients presented with an acute intracranial hemorrhage, confirmed on CT head. Most of the aneurysms were at proximal PICA (anterior and lateral medullary segments) with the partial incorporation of PICA origin in the sac. Low origin of PICA was seen in 7 (out of 11) cases, out of these cases, 5 had proximal PICA, aneurysm, and one (n = 1) had VA-PICA, junction aneurysm (1/7) and. one distal PICA aneurysm. There were seven proximal PICA aneurysms, and out of them, parent vessel occlusion was done in six and selective coiling in one (n = 1) case. From seven (n = 7) proximal PICA aneurysms, there were five cases of low origin and rests showed normal course and origin. Two (n = 2) junctional aneurysms were treated with simple coiling. Low origin was seen in right VA-PICA junction aneurysm. Endovascular treatment of all the 11 aneurysms was successful. The treatment consisted of selective aneurysm coiling in four (36.3%) patients and aneurysm with parent vessel trapping in seven patients (63.6%). Out of these seven patients, in one (n = 1) patient where aneurysm was distal PICA, glue embolization was done. There was no intra-procedural rupture/contrast extravasation or any thrombo-embolic complications. Follow-up studies ranged from 6 months to 5 years. CONCLUSION: Endovascular therapy of ruptured proximal PICA aneurysms is possible and safe with the use of adjuvant devices and should be considered as first-line treatment.

Effect of single mannitol bolus in intracerebral hemorrhage.

Because of existing controversy about use of mannitol in intracerebral hemorrhage (ICH) this open exploratory trial with blinded outcome assessment of single mannitol bolus in ICH was undertaken. CT proven primary supratentorial ICH patients having midline shift of > or =3 mm were randomized into 20% mannitol (1.5 g/kg) and control groups. Clinical evaluation included Glasgow coma scale (GCS) score, Canadian Neurological scale (CNS) score, pupils, breathing, extensor posturing and contra-lateral pyramidal signs. On cranial MRI horizontal (HS), superior sagittal sinus to pontomesencephalic junction (SSS-PMJ) distance and edema hematoma complex were measured. Twelve patients each were in mannitol and control groups. The age, sex, GCS score, CNS score, pupillary asymmetry, contra-lateral pyramidal signs, HS and SSS-PMJ distance in mannitol and control groups did not differ significantly. Mannitol infusion resulted clinical improvement in five patients, which lasted for 30-60 min. HS and SSS-PMJ distance in mannitol and control groups did not change at 30 or 60 min from the baseline. The change in HS and SSS-PMJ distance were also not significantly different between the two groups both at 30 and 60 min. Mannitol led to transient clinical improvement in five patients without significant reduction in HS or SSS-PMJ distance at 30 and 60 min.

Aneurysm of the internal carotid artery in a female patient of Behcet's disease: a rare presentation.

Behcet's disease is a systemic inflammatory disease characterized commonly by oral and genital ulcerations, with skin and eye involvement. Unlike other manifestations, involvement of the central nervous system and vascular manifestations can be late in the course and are the leading causes of death. Aneurysms are relatively common in visceral vessels but extremely rare in intracranial arteries, being limited to few case reports. Moreover, vascular involvement is significantly less common in female than in male patients. In this paper, we report a case of aneurysm of internal carotid artery in a female patient of Behcet's disease who had presented with subarachnoid hemorrhage and was treated successfully by a brief course of corticosteroids followed by endovascular treatment.

Anterior spinal artery aneurysm in aortic stenosis of different etiology: Report of three cases.

Isolated aneurysms of spinal arteries are rare. Spinal artery aneurysms are commonly found in association with spinal cord arteriovenous malformation and coarctation of aorta and rarely with aortic arch interruption and Klippel-Trenaunay syndrome. Spinal angiograms are the gold standard for diagnosing these spinal artery aneurysms but with the advances in computed tomography technology these aneurysms can also be very well demonstrated in computed tomography angiograms. We describe three cases of anterior spinal artery aneurysm, those are flow related aneurysms, associated with coarctation of aorta and with Takayasu arteritis.

Localized congestive venous encephalopathy associated with cavernous dural arteriovenous malformation.

An unusual case of venous congestive encephalopathy associated with cavernous sinus dural arteriovenous malformation is reported. The parenchymal changes consisted of a well-demarcated area of hyperintensity on T2-weighted MR images involving the cortex and underlying white matter in the ipsilateral temporal and posterior frontal region. It showed mass effect and persisted for 2 years before evolving into a venous infarction.

Subarachnoid haemorrhage as a presentation of cerebral venous sinus thrombosis.

Cerebral venous sinus thrombosis can present with a variety of clinical symptoms ranging from isolated headache to deep coma. Subarachnoid haemorrhage is a rare presentation. In the report, we describe a case of non-puerperal venous thrombosis of many dural sinuses manifesting on imaging solely as localized subarachnoid haemorrhage without underlying parenchymal involvement.

Inferior petrosal sinus route microcatheterization study and embolization for primary orbital varix.

PURPOSE: Primary orbital varix is a rare lesion but difficult to treat. Our main aim was to demonstrate the varices and their central venous communication and to explore the feasibility of embolization of these lesions. METHOD: In four patients with clinical suspicion of varix, in whom MRI showed retro-global vascular channels, microcatheter digital subtraction angiography (DSA) of the varices was performed using femoral venous access. Embolization was carried out in two patients. RESULTS: In all four patients orbital varices could be accessed with a microcatheter through inferior petrosal sinus and ophthalmic vein (superior or inferior) route. Microcatheter angiography showed opacification of varices and demonstrated their central venous communication. Two patients were treated with coil embolization. Complete resolution of symptoms was seen in one patient and partial relief in the other. CONCLUSION: The study presents microcatheterization of orbital varices via the inferior petrosal sinus-cavernous sinus-ophthalmic vein route with injections into distal ophthalmic veins for demonstration of these variceal sacs and their central venous connection. Coiling to disconnect the venous communication should be the primary goal of embolization.

A population-based study of brain arteriovenous malformation: long-term treatment outcomes.

BACKGROUND AND PURPOSE: By undertaking long-term follow-up of a functionally isolated population study group, we sought to achieve a true picture of intrinsic brain arteriovenous malformation (BAVM). We sought to assess the validity of earlier population-based series and to determine the effects of newer treatment methods on the overall morbidity and mortality of BAVM. METHODS: We excluded other intracranial vascular pathologies by defining criteria. By retrospective and prospective study, 240 patients with BAVM were followed for a mean of 10.11 years from first diagnosis. RESULTS: Death rates were as follows: all causes, 12.9%; all BAVM related, 8.75%; BAVM related during conservative management, 24.6%; and BAVM related during active management, 3.9% (P=0.031). Mean diagnosis-to-death interval was 10.6 years. Oxford neurological disability scale grades of 209 survivors (July 2001) were as follows: grades 0 to 2, 74.1%; grade 3, 17.2%; and grades 4 to 5, 9.5%. Death rates were higher for patients who had bled or suffered nonhemorrhagic neurological deficit at original presentation. Incidence of first-ever hemorrhage in untreated patients was as follows: 0 to 9 years, 4.6% (P=0.0035); 30 to 39 years, 21% (P=0.02); and 60 to 69 years, 40.0% (P=0.045). The first bleed was fatal in 4.6%. CONCLUSIONS: We find no evidence of a substantial undiagnosed reservoir of nonsymptomatic BAVM. All BAVM are potentially hazardous. The great majority of BAVM patients become symptomatic during the patient's lifetime, and the majority will bleed. The risk of first hemorrhage is lifelong and rises with age. Compared with earlier population-based series, our low overall patient mortality is predominantly due to higher proportions of active treatment in the 1980s and 1990s.

Osteodysplastic primordial dwarfism type II with normal intellect but delayed central nervous system myelination.

We describe a 7-year-boy with severe prenatal and postnatal growth retardation, skeletal changes, normal intellect, and unusual facial appearance. The skeletal changes are suggestive of osteodysplastic primordial dwarfism type II (OPD II). He is the first patient of this kind from the Indian subcontinent and the 18th to be reported, based on a literature search (MEDLINE; 1982 to April 1997). He also represents the first case of OPD-II with normal intellect but delayed central nervous system myelination.

Spontaneous regression of cerebral AVM due to thrombosis of draining vein--angiographic and MRI demonstration.

Spontaneous regression of cerebral arteriovenous malformation (AVM) is rare and poorly understood phenomenon. We present a case of spontaneous complete and asymptomatic occlusion of the AVM associated with thrombosis of the draining cortical vein. The thrombosed draining cortical vein is beautifully demonstrated on magnetic resonance imaging (MRI).

Selective involvement of basal ganglia and occipital cortex in a patient with acute endosulfan poisoning.

We report a teenage girl with acute endosulfan poisoning who developed psychosis, generalized tonic-clonic seizures, myoclonic jerks, cortical blindness and limb rigidity. Serial magnetic resonance imaging (MRI) showed bilateral reversible lesions localized to caudate nucleus, putamen and occipital cortex; internal capsule and thalamus were spared. This selective involvement may have a bearing on mechanisms underlying endosulfan toxicity.

Giant cell tumor of sphenoid-diverse presentation: report of two cases.

Two rare cases of giant cell tumors of the sphenoid bone are presented. We discuss their imaging, unpredictable biological behavior and management together with a review of the pertinent literature.