Posterior mediastinal neuroblastoma masked as flaccid paraparesis in a 3 year child.

Neuroblastoma is an embryonic tumor of the sympathetic nervous system originating from neural crest cell remnants, which may be found in the adrenal glands or sympathetic chain. We report a case of a three-year-old girl who presented with flaccid paraparesis, and acute respiratory distress that required mechanical ventilation after a multiple-day history of gradual-onset dyspnea and right upper-lung opacity that was initially misdiagnosed as pneumonia. Chest and spinal magnetic resonance imaging (MRI) revealed a tumor in the posterior mediastinum with intra-spinal canal extension. The patient underwent thoracotomy and surgical en bloc resection with spinal canal decompression. Histopathology revealed neuroblastoma. The postoperative period was uneventful. The patient was administered a course of chemotherapy but died due to advanced stage tumor, severe pancytopenia, and septicemia with renal failure. The aim of this report is to consider posterior mediastinal neuroblastoma in the differential diagnosis of dyspnea and acute lower limb weakness in young children.

Intradural Extramedullary Epidermoid Cyst at the Conus Medullaris Level with Thoracic Syringomyelia: A Case Report.

Spinal epidermoid cysts are benign tumors. Syringomyelia secondary to intramedullary tumors are frequently observed. However, the association between syringomyelia and spinal intradural extramedullary epidermoid cyst in the conus medullaris region is extremely rare. We present the case of a 3-year-old male who was admitted with paraparesis and urinary retention. Magnetic resonance imaging (MRI) of the spine demonstrated intradural extramedullary lesion, compatible with epidermoid cyst, that at the conus medullaris level and a large syringomyelia extending from T4 to L1 vertebrae. Total microsurgical excision of the cyst was performed. No additional drainage was carried out for the syringomyelic cavity. Histopathological examination verified the diagnosis of the epidermoid cyst. Total excision of the cyst and disappearance of the syringomyelia were observed on MRI at 15 days postoperatively. We have clarified the etiology, clinical, histopathological and radiological features, differential diagnosis, and treatment modalities of spinal epidermoid cysts. In addition, we have discussed the possible mechanisms of syringomyelia formation in spinal intradural lesions.

Seno dérmico lumbar: consecuencias de un retraso diagnóstico / Lumbar dermal sinus: Consequences of a delayed diagnosis

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Natural Course of Myxopapillary Ependymoma: Unusual Case Report and Review of Literature.

BACKGROUND: Spinal cord ependymomas are the most frequent primary intramedullary tumors of the cord in middle age (40-60 years of age). Myxopapillary ependymomas are low-incidence tumors and occur in the cauda equina and conus medullaris. They are typically described as fleshy, sausage-shaped, vascular lesions. CASE DESCRIPTION: In this report, we present a 36-year-old woman who was seen in another hospital with complaints of back pain radiating into both legs 5 years ago. Magnetic resonance imaging (MRI) examinations revealed a lesion releated to the spinal cord. At that point, the patient refused the proposed surgical treatment. Five years later, the patient was referred to our clinic with advancement of the complaint to paraparesis. The new MRI showed an intradural mass at the level of T11 and S1. We performed a total intradural tumor resection. Histopathologic examination revealed a myxopapillary ependymoma. CONCLUSIONS: Myxopapillary ependymomas grow slowly and are well defined by MRI. Advancements in radiologic technology and surgical equipment have allowed this tumor type to be treated successfully. Unfortunately, if untreated, these lesions have poor prognosis and result in clinical symptoms such as paraparesis. Surgical treatment of these lesions using total resection was performed total resection and was associated with an excellent postoperative outcome. We highlight the natural course of myxopapillary ependymomas.

Histopathological proof of the pathogenicity of a rare GFAP mutation in a patient with flaccid paraparesis.

Infantile Alexander disease is a rare progressive leukodystrophy caused by autosomal dominant mutations in the (GFAP) gene typically presenting with psychomotor retardation, progressive macrocephaly and refractory epilepsy. Neuroradiological hallmarks are extensive white matter lesions with frontal preponderance as well as signal intensity changes of basal ganglia and medulla oblongata with variable contrast enhancement. Here, we report an atypical manifestation in a 21-month-old boy presenting with flaccid paraparesis and areflexia. Cognitive, visual as well as fine motor skills and muscular strength of the upper extremities were appropriate for age. Weight and height as well as head circumference were within normal range. Clinical or electroencephalographic signs of seizures were absent. Cranial MRI demonstrated bifrontal cystic tumorous lesions with partial contrast rims, as well as space-occupying focal lesions of the caudate nuclei. Spinal MRI revealed swelling of the lumbar and cervical spinal cord. CSF and blood chemistry showed normal results. Histopathology of a subcortical lesion showed large amounts of Rosenthal fibers and protein droplets characteristic of Alexander disease. Sequencing detected a heterozygous mutation of the GFAP gene (c.205G > A; p.(Glu69Lys)) that has been reported before as probably pathogenetic in another case of lower spinal involvement. This well documented case draws attention to atypical spinal manifestations of Alexander disease and gives histopathological proof of the pathogenetic role of a rare GFAP mutation with marked spinal involvement.

A thoracic vertebral brown tumor presenting with paraparesis in a patient with end-stage renal disease.

Vertebral brown tumors are rare, non-neoplastic bone lesions that occur in the setting of hyperparathyroidism. There are differences in the management of them in the literature. Because brown tumors usually resolve after a parathyroidectomy. We present a case of a thoracic vertebral brown tumor with paraparesis.

Warfarin-associated Intraspinal Hematoma.

Intracerebral hemorrhage is a well-known complication resulting from warfarin use; however, warfarin-associated intraspinal hematoma is very rare. Warfarin-associated intraspinal hematoma may exhibit delayed progression, and patients may present with atypical symptoms, occasionally resulting in delayed diagnosis. We report the case of a 65-year-old man who visited our emergency department (ED) with acute urinary retention. He had been previously diagnosed with non-valvular atrial fibrillation, arterial hypertension, and benign prostatic hyperplasia, and he used warfarin for the prevention of systemic embolism. The patient was initially diagnosed with worsening of the prostatic hyperplasia. After 2 days, he revisited the ED with painless paraparesis. Magnetic resonance imaging of the thoracic spine revealed an intraspinal hematoma at Th7-8, and blood coagulation tests indicated a prothrombin time-international normalized ratio of 3.33. Despite attempts to reverse the effects of warfarin with vitamin K administration, the paraparesis progressed to paraplegia, necessitating urgent surgical removal of the hematoma. Partial recovery of motor function was evident after surgery. From the present case, we learned that intraspinal hematoma should be included in the differential diagnosis of patients using warfarin who present with acute urinary retention. Although there are no evidence-based treatment guidelines for warfarin-associated intraspinal hematoma, surgical treatment may be warranted for those who exhibit neurological deterioration.

Paraparesis after Primary Percutaneous Coronary Intervention for ST-segment Elevation Myocardial Infarction: Combined Uncommon Complications of Acute Aortic Syndrome in a Patient.

Acute aortic syndrome complicated by both ST-segment elevation myocardial infarction (STEMI) and spinal ischemia is exceedingly rare. We herein report the case of a 66-year-old man who presented with paraparesis after primary percutaneous coronary intervention for STEMI. He was found to have an intramural hematoma of the ascending aorta and a severe dissection in the descending aorta, which led to both STEMI and paraparesis.

Thoracic Hemangioma From Rib Presenting as Compressive Paraparesis in a Young Adult: A Treatment Dilemma.

STUDY DESIGN: A case report. OBJECTIVE: To describe the presentation of compressive paraparesis as a result of thoracic rib hemangioma in a young adult and its nonsurgical management. SUMMARY OF BACKGROUND DATA: Hemangiomas are rare bone tumors and those arising from rib are rarer. Only about 50 such cases have been reported in literature so far. METHODS: A 21-year-old male student, presented to us with a 6-week history of progressive weakness in both lower limbs and loss of bowel bladder control. Patient gave history of being operated for left periscapular tumor treated with wide excision and proven with biopsy to be a hemangioendothelioma (benign but locally aggressive hemangioma variant) a year ago. RESULTS: New radiograph of the chest showed an expansile lesion of left fifth rib and magnetic resonance image showed a tumor of left dorsal thoracic wall with AV malformation causing compressive thoracic myelopathy at T5 level vertebrae. We planned for immediate decompression surgery for spine along with excision of tumor with the help of a thoracic surgeon. However, on preoperative digital subtraction angiography, the tumor was found to be highly vascular with high risk of intraoperative bleeding and morbidity. So, the plan was revised and the patient underwent digital subtraction angiography, followed by embolization by an expert interventional neurosurgeon. The patient showed signs of recovery within a week. Lower limb power improved from grade 2 to 3/5 to grade 4 to 4+/5. The patient became ambulatory with single stick at 3-month follow-up; he was a nonwalker to start with. At 2 years plus follow-up, the patient fully recovered and walks without stick. CONCLUSION: This unique case brings to light the dilemma a spine surgeon sometimes faces. A case that warranted immediate surgical intervention based on clinical findings was treated with interventional fibrin glue embolizations with excellent results. LEVEL OF EVIDENCE: N/A.

Neurological deterioration induced by sitting in patients after cervicothoracic posterior decompression with instrumented fusion surgery for ossification of the longitudinal ligament: two cases reports.

BACKGROUND: We report on Japanese patients who showed neurological deterioration induced by sitting after cervicothoracic posterior decompression with instrumented fusion, but showed immediate neurological recovery after bed rest. CASE PRESENTATION: Patients showed incomplete paraparesis caused by the ossification of the posterior longitudinal ligament at uppermost thoracic spine. Cervicothoracic posterior decompression with instrumented fusion was performed. Postoperatively, the patients showed partial paraparesis when they were sitting. They showed rapid recovery from lower extremity paralysis upon lying down. After strict bed rest for one month, those patients showed no apparent development of paralysis during sitting. CONCLUSION: In patients with postoperative residual anterior spinal cord compression, micromotion might exacerbate neurological symptoms.

[Focal meningitis in a California sea lion (Zalophus californianus)--diagnostic procedure and pathology]. / Herdförmige Meningitis bei einem Kalifornischen Seelöwen (Zalophus californianus) - Diagnostik und pathologische Befunde.

A 15-year-old female California sea lion (Zalophus californianus) with progressive lameness of the hindlimbs and a chronic skin lesion was presented for clinical examination. The clinical neurological examination, showing a paraparesis, was completed by magnetic resonance imaging. MR images of the cervical and thoracic spine showed a well-defined muscle infiltrating lesion between the seventh cervical vertebra (C7) and the second thoracic vertebra (T2), which extended through the intervertebral foramina between C7 and T1 into the vertebral canal, causing spinal cord compression and displacement. Pathological examination revealed focal purulent meningitis resulting from widespread fistulas of the chronic skin leasion, which was infected with Escherichia coli var. haemolytica and Clostridium perfringens.