3T MRI-SWI based volumetric analysis of the subthalamic and red nuclei in advanced Parkinson's disease.

BACKGROUND: Parkinson's disease (PD) is a neurodegenerative disease mainly involving the dopaminergic neurons of the substantia nigra. The subthalamic nucleus (STN) also plays an important role in the disease process and now is an important target for the surgical management of the disease. However, not much is known about its morphology as the disease progresses. The aim of this study was to evaluate the volume of STN and red nucleus (RN) on 3T MRI SWI and its possible correlation with the disease in patients with advanced Parkinson's disease. METHODS: A total of 30 patients were enrolled. They were evaluated by analysis of symptomatology, UPDRS III, MOCA. Radiological evaluation included volumetric SWI images in 3T MRI. The volumes of the STN and RN were measured on SWI coronal images. RESULTS: There were 24 (80%) males and 6 (20%) females. The mean volumes of STN and RN were 118.66 mm3 (80-170 mm3) and 379.66 mm3 (270-500 mm3). There was no significant difference between right and left STN volumes and RN volumes. There was a significant positive correlation between the disease duration and RN volumes (P=0.015) and STN volumes (in 6-13 years) (P=0.001). STN and RN volumes were negatively correlated with MOCA scores in males (P=0.008 and P=0.017), with no such correlation in females. In late-onset PD, there was a significant positive correlation between RN volume and UPDRS OFF and ON scores (P=0.028 and P=0.03). CONCLUSIONS: STN volumes show a positive trend as the disease duration increases and cognition declines. RN volumes also increase as the disease progresses.

Orbital Chordoid Meningioma.

Chordoid meningioma, classified as WHO grade II, are rare tumors comprising only 0.5% of all meningiomas. Chordoid meningioma is an aggressive tumor with high local recurrence. Orbital chordoid meningioma is a much rare entity with very few cases reported in the literature. We report a case of a 77-year-old male who presented with a painless progressive swelling over the right lateral orbital wall.

Prospective analysis of gross and fine motor manifestations following STN- DBS and their correlation with electrode position.

BACKGROUND: Deep brain stimulation (DBS) has been proven to be a safe, reversible, cost effective procedure for treatment of Parkinson's disease. Final electrode position remains a significant factor determining the outcomes of Subthalamic nucleus deep brain stimulation (STN-DBS). This study aims to analyze the final lead position in three-dimensional plane and its effect on gross and fine motor outcomes in cases of advanced Parkinson's disease operated for STN-DBS. METHODS: Patients who underwent bilateral STN DBS were prospectively followed for improvement in gross motor outcomes at 6 months. Improvement in dysgraphia was analyzed by Fahn-Tolosa-Marin Tremor Rating Scale Part B score. Postoperative outcomes were correlated with final electrode position. RESULTS: A total of 64 Patients (128 leads) were analyzed. Patients who were less than 65 years of age at time of surgery had more significant reduction in UPDRS III(p = 0.02). Cases with deviation of left x less than 3 mm had significant reduction in UPDRS III (p = 0.05) and speech sub-scores (p = 0.05). Deviation less than 2 mm in left x was associated with reduction in gait sub-scores (p = 0.04). Optimal placement of right y electrode was associated with reduction in UPDRS III (p = 0.02). Significant reduction in Fahn-Tolosa-Marin Tremor Rating Scale Part B score was noted after DBS(p =0.001). CONCLUSIONS: Subthalamic nucleus deep brain stimulation thus results in significantly improved functional outcome particularly in patients with age less than 65 years. Accurate final electrode position is associated with maximum clinical benefit and improvement in dysgraphia.

Double hangman's fracture.

STUDY DESIGN: Clinical case report and review of the literature. OBJECTIVE: To report a very rare case of bipedicular fracture of C2, C3 along with traumatic spondylolisthesis of the C2, C3 vertebral bodies together over C4 without any neurological deficits. SUMMARY OF BACKGROUND DATA: Cervical spine injury is a potentially fatal and debilitating incident because of the risk of damage of the cervical spinal cord. Hangman's fracture comprises 4% to 7% of all traumatic cervical spine fractures. Attempting closed reduction in a neurologically intact patient may cause the development of new deficits during time of traction, especially in the case of compromised neural canal. The management should be aimed at providing a stable well-aligned spine without causing any new neurological deficits. METHODS: A 35-year-old female had a motor vehicle accident and her forehead collided against the ground, causing hyperextension-compression type injury of the cervical spine that resulted in complaints of neck pain on movement. Cervical spine plain radiographs revealed spondylolisthesis of C2, C3 vertebral bodies together over C4 with bipedicular fracture of C2, C3. A computed tomographic scan confirmed these fractures. Magnetic resonance imaging further demonstrated spondylolisthesis without any spinal cord compression or signal abnormality. An anterior C2, C3 and C3-C4 cervical fusion was performed with iliac crest tricortical strut grafting and anterior cervical plating. The patient was turned to a prone position on the striker bed and posterior fixation was performed with lateral mass screws of C1 and C5. RESULTS: Reduction of the spondylolisthesis was achieved with gradual cervical traction in an awake intubation followed by 360º of fusion with both anterior and posterior fixation. CONCLUSION: Bipedicular fracture of C2, C3 along with traumatic spondylolisthesis of the C2, C3 vertebral bodies together over C4 without any neurological deficits is very rare injury and needs methodical 360º fixation.

Cervical osteochondroma presenting with acute quadriplegia.

Osteochondromas of the vertebral column are rare tumors and constitute about 3-4% of all primary vertebral column tumors. We report a case of osteochondroma arising from C3 lamina presenting with acute quadriplegia following a trivial fall. Computed Tomography (CT) and Magnetic Resonance imaging (MRI) showed bony lesion arising from C3 laminar arch compressing the cord with underlying spinal cord contusion. Emergency C3 laminectomy and complete enbloc excision of the lesion was performed, following which patient showed gradual recovery in neurological status. This acute presentation in this rare, slow growing, tumor has never been reported in literature till date.

Spinal canal stenosis at the level of Atlas.

We report here a rare case of high cervical stenosis at the level of atlas who presented with progressively deteriorating quadriparesis and respiratory distress. A 10-year-old boy presented with above symptoms of one-year duration with a preceding history of trivial trauma prior to onset of such symptoms. Cervical spine MRI revealed a significant stenosis at the level of atlas from the posterior side with a syrinx extending above and below. High-resolution computed tomography of the above level yielded an ill-defined osseous bar compressing the canal at the level of C(1) posterior arch, which appeared bifid in the midline. The patient was immediately taken up for surgery in view of his respiratory complaints. The child showed an excellent recovery after excision of the posterior arch of atlas and removal of the compressing osseous structure.