Morphometric evaluation of great vein of Galen and its clinical implications.

The Galenic venous system plays a vital role in the drainage of blood from deeper parts of the brain. This venous system is contributed by many major veins. These veins are located closer to the pineal gland making the surgical approach in this region difficult. Any accidental injury or occlusion of the vein of Galen could lead to devasting results. Thus, studying the dimensions of the vein of Galen is more important. Hence, we aimed to evaluate the morphometry and trajectory to the vein of Galen. About 100 computed tomographic venography records were evaluated and the length, diameter of vein of Galen, angle between straight sinus and vein of Galen and distance from internal occipital protuberance and roof of fourth ventricle to vein of Galen were studied. The mean length and diameter of vein of Galen were 9.8±2.7 and 4.08±1.04 respectively. The mean angle between straight sinus and vein of Galen was 64.2°. The mean distance between external occipital protuberance and roof of fourth ventricle to vein of Galen were 52±6.9 and 33.3±4.5 respectively. No significant morphometric differences were observed between the age groups as well as between the sexs. The results obtained from this study may be helpful for the neurosurgeons in better understanding of the anatomy of the Galenic venous system and to adopt a safe surgical approach to improve the efficacy of the surgeries of the pineal gland and also in the region of vein of Galen.

Evaluation of White Matter Tracts Fractional Anisotropy Using Tract-Based Spatial Statistics and Its correlation with Amyotrophic Lateral Sclerosis Functional Rating Scale Score in Patients with Motor Neuron Disease.

Background Motor neuron diseases cause progressive degeneration of upper and lower motor neurons. No Indian studies are available on diffusion tensor imaging (DTI) findings in these patients. Aims This study was done to identify white matter tracts that have reduced fractional anisotropy (FA) in motor neuron disease (MND) patients using tract-based spatial statistics and to correlate FA values with Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R) score. Settings and Design A case-control study in a tertiary care hospital. Materials and Methods We did DTI sequence (20 gradient directions, b -value 1,000) in 15 MND patients (10 men and 5 women; mean age: 46.5 ± 16.5 years; 11 amyotrophic lateral sclerosis [ALS], 2 monomelic amyotrophy, 1 progressive muscular atrophy, and 1 bulbar ALS) and 15 age- and sex-matched controls. The data set from each subject was postprocessed using FSL downloaded from the FMRIB Software Library, Oxford, United Kingdom (http://www.fmrib.ox.ac.uk/fsl). Statistical Analysis The statistical permutation tool "randomize" with 5,000 permutations was used to identify voxels that were different between the patient data set and the control data set. Mean FA values of these voxels were obtained separately for each tract as per "JHU white-matter tractography atlas." SPSS was used to look to correlate tract-wise mean FA value with ALSFRS-R score. Results We found clusters of reduced FA values in multiple tracts in the brain of patients with MND. Receiver operating characteristic curves plotted for individual tracts, showed that bilateral corticospinal tract, bilateral anterior thalamic radiation, bilateral uncinate fasciculus, and right superior longitudinal fasciculus were the best discriminators (area under the curve > 0.8, p < 0.01). FA values did not correlate with ALFRS-R severity score. Conclusion In MND patients, not only the motor tracts, but several nonmotor association tracts are additionally affected, reflecting nonmotor pathological processes in ALS.

Is percutaneous glue injection one of the treatments for arteriovenous malformation pinna?

Arteriovenous malformation (AVM) of the head and neck is a rare phenomenon, more so when it is an extracranial AVM like the auricle. AVMs are caused by genetic mutations. Most are probably present in the subclinical form at birth and then evolve; some may arise postnatally or during adolescence or get aggravated by precipitating factors like trauma, infection or hormonal influence like puberty or pregnancy. Once diagnosed, the feeding vessels have to be identified using radiological investigations. They are then embolised via means of percutaneous embolisation and surgical resection.

Pseudoaneurysm of uterine artery complicating caesarean section: a rare cause of intractable secondary postpartum haemorrhage managed with uterine artery embolisation.

A 27-year-old woman presented 6 weeks after an uncomplicated lower segment caesarean section with excessive bleeding per vagina. On examination, she had mild pallor with a pulse rate of 86 beats per minute and blood pressure of 116/80 mm Hg, uterus well involuted with closed cervical os and bleeding demonstrated through the cervix. A transvaginal ultrasonography with colour Doppler revealed a normal size uterus with an empty cavity and a hypoechoic area with blood flow within it in the left side of the uterus with a prominent arterial feeder vessel. A CT angiogram confirmed the diagnosis of a 1.3×0.7 cm pseudoaneurysm of the uterine artery near the left cornua of the uterus. After failed attempts to control the bleeding with antifibrinolytics, bilateral uterine arteries were embolised using gel foam. Post procedure, bleeding resolved immediately. A follow-up transvaginal ultrasound after a year revealed no evidence of the pseudoaneurysm and her fertility was preserved.

Post-traumatic carotid-cavernous fistula with bilateral proptosis simulating cavernous sinus thrombosis.

A 48-year-old woman presented with bilateral non-pulsatile proptosis and ophthalmoplegia after 3 days following blunt orbital trauma. It was associated with fever, malaise and loss of vision in right eye. She was provisionally diagnosed with cavernous sinus thrombosis and was treated with intravenous antibiotics with no improvement. A subtle bruit was present on examination, and digital subtraction angiography revealed a right direct (type A) carotid-cavernous fistula (CCF). The patient underwent right coil embolisation of direct CCF. On follow-up at 4 months, her proptosis resolved completely and extraocular movements improved.

The “Lip Sign” in MRI of the Spinal Cord

No abstract available.

Two Cases of Craniospinal Rachischisis Totalis: Role of Magnetic Resonance Imaging in Diagnosis and Review of Neural Tube Defects in the Indian Context with Implications for Folate Fortification.

Craniospinal rachischisis is a rare and severe form of neural tube defects (NTDs), which is always fatal. It is characterized by anencephaly accompanied by a bony defect of the spine and exposure of neural tissue. We describe the two patients with ultrasonographic and magnetic resonance imaging appearance of craniospinal rachischisis totalis, detected antenatally at 22 and 25 weeks of gestation, and confirmed after termination of pregnancy. The multifactorial etiology of NTDs, with specific reference to folate deficiency, is discussed with possible role of folate fortification in the Indian context.

Takayasu arteritis (TA) first presenting with intestinal ischemia: a case report and review of gastrointestinal tract involvement (ischemic and non-ischemic) associated with TA.

Takayasu arteritis (TA) is a large vessel vasculitis involving the aorta and its major branches. Insidious inflammation usually results in gradual arterial narrowing; however, critical organ ischemia is rare. We describe a young male with TA who presented with acute mesenteric ischemia requiring intestinal resection, followed by critical limb ischemia. In our literature review, we identified intestinal gangrene as a rare manifestation of TA. However, intestinal ischemia as the first manifestation of TA has been scarcely reported in the literature. Also, ischemia of the intestine occurring together with critical limb ischemia is extremely unusual. Rheumatologists should be aware of TA as a rare cause of gastrointestinal vasculitis in young adults, which can be easily suspected by routinely examining all the peripheral pulses.

A Rare Case of Basioccipital Encephalomeningocele with Tethered Dermoid Presenting as Cranial Nerve Palsy: A Case Report.

The basioccipital skull base is an extremely rare site for meningoencephalocele. The herniation of the brainstem or part of it through a basioccipital defect is even rarer. We report a case of rhombencephalomeningocele associated with a tethered dermoid. An extensive literature search revealed no such case report of basioccipital cranial dysraphism so far presenting with cranial nerve palsy.

Neurotuberculosis immune reconstitution inflammatory syndrome in the setting of HIV infection: A case report and review of literature.

Immune reconstitution inflammatory syndrome (IRIS) is an exaggerated immune response which can occur with various coinfections in human immunodeficiency virus (HIV) infected patients, of which the most commonly implicated in central nervous system (CNS)-IRIS are progressive multifocal leukoencephalopathy (PML), cryptococcosis, and tuberculosis (TB). TB-IRIS is a known complication of pulmonary TB or TB lymphadenitis coinfection in HIV infected patients who are on antituberculosis treatment (ATT) after the initiation of antiretroviral therapy (ART). However, development of IRIS in extrapulmonary TB such as CNS TB is very rare. Our case is that of an isolated CNS-TB-IRIS, presenting as increase in the size and perilesional edema of the ring enhancing lesions in the brain, which was observed in two sequential magnetic resonance imaging done over a period of 2 months in a retropositive patient who presented with clinical deterioration after commencement of ART. As prompt diagnosis was made and specific management aimed at IRIS was started without delay, the patient improved symptomatically.

Ovarian serous borderline tumors with noninvasive and invasive peritoneal implants: A case report each.

Serous borderline tumors (SBT) are defined by the World Health Organization (WHO) as serous neoplasms that show epithelial proliferation greater than that seen in serous cystadenomas, as evidenced by cellular stratification, cytologic atypicality, and epithelial tufting, but which exhibit no evidence of "destructive stromal" invasion and can show extra-ovarian implants. Characterization of invasive peritoneal implants from patients with noninvasive serous ovarian tumors has important prognostic and treatment implications. Peritoneal implants have been classified as either noninvasive or invasive based on their histopathologic appearance. Three criteria were applied for the diagnosis of "invasive" implants: Invasion of underlying normal tissue, micropapillary architecture, and solid epithelial nests surrounded by clefts. We encountered two cases of unilateral ovarian serous borderline tumors with non-invasive peritoneal implants in a 43-year-old female, and invasive peritoneal implants in 76-year-old female.

Infantile maxillary sinus osteomyelitis mimicking orbital cellulitis.

Periorbital soft tissue swelling may result due to primary orbital pathology or from adjacent facio-maxillary or sino-nasal inflammatory causes. Osteomyelitis of maxilla in the pediatric age group is a rare entity in this era of antibiotics. We present an 11-month-old female infant who was brought with peri-orbital selling and purulent nasal discharge. Computed Tomography showed erosions of the walls of maxillary sinus suggestive of osteomyelitis. Culture of sinus scraping showed Staphylococcus aureus growth and the child improved with intravenous cloxacillin therapy. This case is presented due to the rarity of its presentation in this age group and for awareness to consider this entity in children having fever and peri-orbital swelling.