Idiopathic unilateral complete oculomotor nerve palsy: a case report of diagnostic quandary.

Introduction and importance: When compared to other cranial nerve palsies idiopathic unilateral oculomotor nerve palsy with pupillary sparing is one of the least noted neurological conditions. Moreover, there lies a series of diagnostic dilemmas to come into a final diagnosis resulting in several array of clinical investigations. Hence, there is a delay in prompt management. Case summary: An elderly female without any known comorbidities presented with the complaint of headache, dizziness and dropping of left eyelid. Several arrays of diagnostic workups was done to come to a diagnosis, but even with rigorous laboratory investigations and radiological examinations, a common working diagnosis could not be made. Hence with a diagnosis of exclusion after proper neurological and neuro-ophthalmological examination, idiopathic unilateral common oculomotor nerve palsy was identified for which improvement with steroids was noted in the patient. Discussion: Idiopathic unilateral complete oculomotor nerve palsy is considered as a diagnosis of exclusion when all the diagnostic parameters fail to signify and positive results. The vague symptomatic presentation of the disease condition further compels the treating physician to carry out several panels of laboratory to radiological investigations. But if identified in time the treatment modality is straightforward. Conclusion: The diagnostic quandary in timely identification of such disease conditions needs a pertinent diagnostic guideline so as to avoid the unwanted panel of investigations.

Contiguous diastematomyelia with tethered cord, intradural extramedullary dermoid tumor, and lipomyelomeningocele: A unique case of spinal dysraphism.

Diastematomyelia, tethered cord, intradural extramedullary dermoid tumor and lipomyelomeningocele such disease entities themselves are rare in their own form and concurrent presentation of all those pathological states in a single individual can be considered one of the rarest forms of spinal dysraphism globally. Moreover for prompt management with optimal prognosis needs refined neurosurgical intervention guided by intraoperative neuromonitoring so as to bring about the best quality of life in the patient.

Cerebral venous sinus thrombosis in patient of immune thrombocytopenic purpura managed with mechanical thrombectomy: An anecdotal endovascular experience from lower middle income country.

Cerebral venous sinus thrombosis in itself is rarely encountered clinical entity and its association with immune thrombocytopenic purpura (ITP) makes it more unusual presentation. No any as such standard guidelines exist that guides the prompt evidence based management in such concurrent cases but neuroendovascular modality can play a pivotal role.

Clinical profile and dynamic magnetic resonance imaging in Hirayama disease: a single-centered cross-sectional study in Nepal.

Hirayama disease (HD) is juvenile monomelic amyotrophy of the distal upper limb first described by Hirayama in 1959 AD. HD is a benign condition with chronic microcirculatory changes. The hallmark of HD is necrosis of the anterior horns of the distal cervical spine. Materials and Methods: Eighteen patients were assessed for clinical and radiological Hirayama disease. Clinical criteria included insidious onset nonprogressive chronic upper limb weakness and atrophy in teens or early twenties without sensory deficits and coarse tremors. MRI was done in a neutral position followed by neck flexion to evaluate cord atrophy and flattening, abnormal cervical curvature, loss of attachment between the posterior dural sac and subjacent lamina, anterior shifting of the posterior wall of the cervical dural canal, posterior epidural flow voids, and an enhancing epidural component with its dorsal extension. Results: The mean age was 20.33 years, and the majority, 17 (94.4%), were male. Neutral-position MRI revealed loss of cervical lordosis in 5 (27.8%) patients, cord flattening in all patients with asymmetry in 10 (55.5%), and cord atrophy was observed in 13 (72.2%) patients with localized cervical cord atrophy in only 2 (11.1%) and extension of atrophy to dorsal cord in 11 (61.1%) patients. Intramedullary cord signal change was seen in 7 (38.9%) patients. Loss of attachment of posterior dura and subjacent lamina and anterior displacement of dorsal dura was seen in all patients. A crescent-shaped epidural intense enhancement was noted along the posterior aspect of the distal cervical canal in all patients, with dorsal level extension in 16 (88.89%) patients. The mean thickness of this epidural space was 4.38±2.26 (mean±2SD), and the mean extension was 5.5±4.6 vertebral levels (mean±2SD). Conclusion: The high degree of clinical suspicion can guide additional contrast studies in flexion as a set MRI protocol for early detection and avoiding false negative diagnoses of HD.

Prevalence of risk factors for coronary artery disease in the community in eastern Nepal--a pilot study.

INTRODUCTION: Coronary artery disease is a major cause of morbidity and mortality in Nepal, however, there are very few published reports of prevalence of various risk factors for coronary artery disease in the community from Nepal. METHOD: We evaluated 140 adult subjects by simple randomization from all wards in the community in Dharan, a small city located in the foothills in eastern Nepal. After exclusion of subjects with insufficient data, 119 subjects were included for the final analysis. Age ranged from 35 to 86 (mean 54.1+ 10.5) years and there were 63 males and 56 females. Various parameters which were studied included :history of diabetes mellitus, hypertension, coronary artery disease, smoking, hereditary history, family history, measurement of blood pressure, anthropometric parameters such as body mass index and waist hip ratio and biochemical parameters such as random blood sugar and serum cholesterol. RESULTS: The prevalence of various risk factors for coronary artery disease was found to be: hypertension 42 (35.3%), diabetes mellitus--19 (15.9%), history of current smoking--46 (38.7%), hypercholesterolemia--15 (12.6%), sedentary life style 56 (47.1%), body mass index>25 kg/m2--40 (33.6%) and central obesity 50 (42.1%). Approximately one third of the subjects had more than one risk factor. CONCLUSIONS: The study highlights prevalence of various risk factors for coronary artery disease in the community. Since majorly of the risk factors are modifiable, timely intervention can help in reducing morbidity and mortality due to this disease.

Does Diffuse Axonal Injury MRI Grade Really Correlate with Functional Outcome?

OBJECTIVE: Diffuse axonal injury (DAI) is a common form of primary head injury. This study was done to see the association of DAI grades with extended Glasgow Outcome Scale (GOSE). METHODS: We retrospectively reviewed the charts and radiology reports of a cohort of patients discharged with the diagnosis of diffuse axonal injury. We collected data on variables like age, sex, Glasgow Coma Scale (GCS) at admission, grade of DAI, length of hospital stay, and occurrence of post-traumatic seizures. We contacted the patients after 6 months to assess their GOSE. Outcome analysis was done with SPSS version 23. RESULTS: For 40 patients, DAI and 6-month GOSE were available for analysis. Mean age was 27.8 years, with male to female ratio of 12:1. There were 8 patients with DAI grade I (20.5%), 13 patients with DAI grade II (33.3%), and 18 patients with DAI grade III (46.2%). Nine of 39 patients (23.07%) had post-traumatic seizures. Mean GCS at admission was 9.67. Mean length of hospital stay was 24.12 days. Mean GOSE after 6 months was 6.10. There were 5 mortalities. Patients with low mean GCS portended significant unfavorable outcome. Higher DAI grades were not associated with unfavorable outcome. CONCLUSIONS: Mean GCS at presentation is a better predictor of outcome after DAI rather than its grade.

Morphometric Measurement of Cranial Vault Thickness: A Tertiary Hospital Based Study.

INTRODUCTION: The skull's main function is to protect the brain. Total skull bone thickness is the total thickness of diploe and the external and internal tables. The measurement of the human skull based on CT images results are of great practical value in the fields of anatomy, clinical medicine, biomechanics study and head injury analysis. There are few literatures about imaging assisted measurement of the cranial vault thickness while sparse literature among Nepalese population. In this study, we aim to measure the thickness of calvarian bones of and find the difference between gender and ethnic groups. METHODS: This was a descriptive cross-sectional study conducted in our center during a period of 6 months. Patient of age 15 to 50 years with normal CT finding were included in the study. Using the axial view of brain CT, the thickness of cranial vault was measured and recorded in millimeter. RESULTS: Among 100 patients, 51 were male and 49 were female. Mean thickness of frontal bone, parietal, temporal and occipital bone were 8.02±1.97 mm, 7.04±1.43 mm, 4.71±1.34 mm and 7.98±2.47 mm respectively. CONCLUSIONS: There was no significant difference in cranial vault thickness among sex or ethnical groups in patients of a hospital.

Prevalence of Ruptured Intracranial Aneurysms in a Tertiary Care Hospital of Nepal.

INTRODUCTION: Intracranial aneurysms affect 3-8 percent of the world's population, with ruptured aneurysms being the most common cause of subarachnoid hemorrhage. The sensitivity of Computed Tomography Angiogram in diagnosing intracranial aneurysm is 97%. The aim of our study is to find out the prevalence of ruptured intracranial aneurysms among all the admitted cases encountered in our hospital. METHODS: A descriptive cross-sectional study was done at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences from 2016 to 2018. Convenience sampling method was done. In order to detect the site and size of aneurysms, 16 slice Siemens Computed Tomography with Computed Tomography angiogram was used. Ethical approval was obtained from the Institutional Review Committee at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences. Based on demographic data and computed tomography angiography findings, various morphometric parameters along with demographic parameters were considered for the study. RESULTS: Among 10,856 cases, prevalence of ruptured intracranial aneurysms were found in 42 (0.386%) [Confidence Interval= 0.395 to 0.377]. Among 42 cases, Middle Cerebral Artery aneurysm was present on 16 (39.02%) followed by Anterior Communicating Artery on 14 (34.14%), then Posterior Communicating Artery on 5 (12.19%). The largest neck and dome size were seen in basilar tip aneurysm with size of 11mm and 8mm respectively. The most common type was Fischer grade 4. CONCLUSIONS: The prevalence of ruptured intracranial aneursyms were found to be higher as compared to the other international studies.

Role of MR Morphology and Diffusion-Weighted Imaging in the Evaluation of Meningiomas: Radio-Pathologic Correlation.

INTRODUCTION: Preoperative differentiation of benign, atypical and malignant meningiomas would significantly help in surgical planning and treatment. The aim of this study is to look at radio-morphologic behavior of various histopathological types and grades of meningiomas and their diffusion characteristics. METHODS: We performed an analytical cross-sectional study including all patients operated on for meningiomas at our hospital during January 2016 to July 2018. We studied 38 meningiomas in 38 patients aged 14 to 73 years old. All patients underwent MRI prior to surgery, including diffusion-weighted sequences, in a 1.5T scanner. Signal intensity in T2-weighted images, diffusion-weighted images (b=0, 90 and 1,000), and Apparent Diffusion Coefficient maps within the tumors and in the normal parietal white matter as a reference were evaluated. In the histological study, cellularity, proliferation index, histological grade, and cerebral invasion were evaluated. RESULTS: There was female predilection with male:female ratio of 1:2.4. Most meningiomas were supratentorial with most common origin being parafalcine and convexity. Of the 38 meningiomas, 31 were WHO grade I, 6 were WHO grade II (atypical) and one was WHO grade III (anaplastic). Among various tumors' behaviors, incomplete CSF cleft, pial invasion and parenchymal invasion were significantly high in high-grade tumors. Similarly, tumors showing pial invasion, breached tumor-brain interface, no capsular enhancement and parenchyma invasion showed significantly low NADC. Mean ADC value was 0.722±7.7x10-3 mm2/s (normalized ADC 0.9±0.1) in the atypical group and 0.876±24.56x10-3 mm2/s (normalized ADC 1.11±0.31) in the typical group. No statistically significant differences of ADC/NADC were found between histologic subtypes. Two subtypes of typical meningiomas, metaplastic and angiomatous meningioma had the highest values in the ADC maps. CONCLUSIONS: MR morphology like pial invasion, breached tumors brain interface, parenchymal invasion can predict aggressiveness and atypical nature of meningiomas. Meningioma shows moderately restricted diffusion. The signal on the ADC map is associated with tumors cellularity and aggressiveness suggesting its usefulness for predicting the histological grade.