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KASTURI NEURO BULLETIN
Volume 13: 9.
EDITORIAL:
Dear Colleagues and Friends,
It is my immense pleasure to share some of the interesting cases with you. Now being the Unit Head of
Neurology in PSG Hospitals, the responsibilities like setting Goals and shaping the Department etc., are increasing. In
the midst of time, I will always try to be in touch with you through this bulletin.
This Bulletin concentrates mainly on cases with MRI as its use is increasing in Neurological Diagnosis.
The first article describes a case of trigeminal pain due to Demyelinating lesion. This was missed for several
years as the patient did not undergo MRI evaluation earlier.
A school girl got panicked as she was told some intracranial abnormality was present in her MRI and she
stopped going to school. She was worried that she may need a neurosurgical intervention. With proper counseling
about the benign nature of the lesion, we could make her life pleasurable.
Again the third case is about trigeminal pain. This patient was misdiagnosed, as trigeminal neuralgia, but her
clinical symptoms are totally different. An elongated styloid process causing constant retro mandibular pain was her
problem.
Paraplegia is pathetic. The patient has to depend on others for ADL. After suffering from paraplegia for several
years, if anyone is asked to choose either to have few more years of life or to have both upper limbs working, it will
be really a difficult situation. One such patient is described in here.
61 yrs old male was brought to the hospital with left focal seizures. The Physician does a CT for making a
diagnosis. If the CT makes him more confused rather than making it clear, with several differential diagnoses like
Encephalitis, Hemorrhagic Infarct, AVM, Cavernoma etc., the physician has to depend on senior’s expertise.
Management of such kind of patient was described here.
The last case is more of a practical problem. An old lady of left hemiplegia presented with increasing weakness
and if her CT did not show any fresh lesions, where can you localize? Find the answer from the case report.
We have organized a simple Neuro Quiz session from basic neurology to select candidates for sending them to a
Quiz program. I am herewith enclosing a part of it for your casual answering. This contains 75 MCQs. Please send
your answers before 1st
Nov, 2013, to me either by post or by e-mail. Amazing prizes are awaiting. I thank Dr.
Thirumurthy, Dr.Balakrishnan and Dr. GnanaShanmugam for their contribution in preparing the questions.
I once again welcome you to submit your interesting cases to Kasturi Neuro Bulletin just by E-mailing it to
[email protected]. Those who like to support the Bulletin can send DD / Cheque in favor of “Kasturi
Welfare Trust” to 89-A, East Lokamanya St, RS Puram, Coimbatore or pay directly through Karur Vysya Bank, RS
Puram, Coimbatore, Account number 1122 1350 0000 2452. I do welcome your suggestions. With warm regards,
Dr. B.Prakash,
Editor.
INSIDE THE ISSUE:
1. Use of MRI in Trigeminal Neuralgia 2
2. The role of Clinician in MRI interpretation 2
3. A case of Eagle’s syndrome 3
4. Limb or Life? 3
5. A case of temporal lobe lesion 4
6. A case of stroke on stroke 4
7.Supplement : Neuro Quiz – 75 Questions 5-8
6.
For Internal Circulation only. Not for Sale. Supported by KASTURI WELFARE TRUST and SANOFI
Dr.B.PRAKASH. MD.,DM(Neuro)., FAGE,.
Professor & Chief (Unit IV) of Neurology (PSG H)
KASTURI NEURO DIAGNOSTIC CENTRE
89-A, East Lokamanya Street, R.S.Puram.
COIMBATORE – 2. Mob: 978 948 1179
E.Mail: [email protected]
USE OF MRI IN TRIGEMINAL PAIN THE ROLE OF CLINICIAN IN MRI
INTERPRETATION
INTRODUCTION:
Usually Trigeminal neuralgia is
idiopathic and MRI will be normal. The
common finding in MRI is vascular loop
pressing the trigeminal nerve. However
other causes are not unusual. Mostly
surgery is invasive and the patients tend to
avoid / postpond it.
CASE REPORT:
47 yrs old male was referred for
right V2 V3 pain of six years duration. Two
surgical interventions were attempted so
far. He is on optimum dose of medications.
No focal neurological deficits made out.
MRI brain (fig-1) done, which showed T2
hyperintence signal in right middle
cerebellar peduncle, suggesting focal
demyelination. No other abnormalities
noted. No vascular loop impingement.
Hyper intense signals noted in FLAIR image
is shown in (fig-2). No extra axial pathology
(fig-3) made out.
CONCLUSION:
Even though the extra axial lesions
are the common causes in Trigeminal
Neuralgia, we should not miss the unusual
demyelinating lesion as noted in our case.
Among the intra axial lesions,
demyelination is the most common
etiology.
INTRODUCTION:
MRI plays a vital role in the neurological
diagnosis and it has become almost mandatory
for most cases. However, if misinterpreted or
only relied on, it may mislead us.
CASE REPORT:
19 yrs old Ms.F, presented with severe
headache of 3 yrs duration. She was doing her
school final, but discontinued due to the daily
severe headache. She felt better only for few
hours on taking medications. She has nausea,
photophobia and sonophobia. Sunlight and
hunger aggravates her pulsating headache. She
was told her MRI was significantly abnormal.
Examination revealed no focal neurological
abnormalities. The clinical diagnosis was a
transformed migraine. A CT brain was done
during March’2011 and MRI with contrast, one
month later were reported that there was a
ruptured dermoid cyst. (Refer fig). A second
opinion from Senior Radiologist had revealed
the lesion was lipoma. The incidental finding
and the benign nature of the lesion was
explained to the pt. She was started on
migraine prophylaxis and is advised to attend
the classes. She had come for follow-up after
two months and was asymptomatic.
CONCLUSION:
It needs proper clinical assessment and
good radiological interpretation to make a
correct diagnosis, but the Clinician should spend
time with the patient to prevent unnecessary
anxieties.
1. Clinical Journal of pain – Jan 2002 Vol 18 (1) – 14 to 21
2. Acta Neuro Logica - March 82 Vol 65 (3), 182 to 189
Proc (Bayl Univ Med Cent). 2012 January; 25(1): 23–25. Am J Roentgenol. 1990;155 (4): 855-64
KNB 13: 9 -2
A CASE OF EAGLE’S SYNDROME
LIMB OR LIFE ?
INTRODUCTION:
Eagle’s Syndrome is a rare condition
in which elongated styloid process is
producing dysphagia, tinnitus, ear, face and
neck pain. Even though it is easily
diagnosed by ENT Surgeon and Dentist an
awareness of this syndrome is a must for
any clinician.
CASE REPORT:
A 24 years old female was referred
to us as right trigeminal neuralgia. She had
continuous retro mandibular pain, with
tinnitus. It is not electric shock like or
intermittent as like trigeminal neuralgia.
When the patient was asked to show the
site of the pain with her finger, she had
touched her right retro mandibular region
(fig-1), where she had tenderness too. No
neurological deficits made out. ENT
surgeon’s opinion obtained. She was
diagnosed to have right eagle’s syndrome
with an OPG x-ray (fig-2).The pictorial
representation was shown in fig-3.
DISCUSSION:
Eagle’s Syndrome is suspected when
the patient presents with retromandibular
pain, tinnitus or dysphagia. The treatment is
surgical Styloidectomy. The condition was
first described by Watt Weems Eagle in
1937.
INTRODUCTION:
It will be difficult to answer if anyone is
asked to have either functioning limb or to
undergo a life saving surgery.
CASE REPORT:
45/M had a fall from height during
Oct’2007 and sustained multiple fractures and
burst Atlas (Jefferson #) shown in fig-1. He had
fracture D3-D4 causing paraplegia. A CT brain
done at that time showed a right parietal
hypodense lesion?contusion. The patient learnt
to live with paraplegia. He presented to us by
June’13 with 3 episodes of seizures. The CT
report was Rt parietal Glioma. He was given
AED, antiedema measures steroids and advised
surgery, But he was not willing as there is a
chance of developing left hemiplegia over
paraplegia. A tapering steroid course was
given. Meanwhile he developed LRI and the
steroid was stopped. He got re-admitted for
recurrence of serial seizures. No fresh
neurological deficits. No increase in the size of
tumor. The importance of undergoing surgical
excision was insisted, but the patient got
discharged AMA.
CONCLUSION:
It is difficult to decide for the pt
whether or not to undergo surgery which may
lead to weakness of left limb, leaving him to live
with only Rt UL. This may not give a meaningful
life. We had advised surgery for protection of
life. But this may add only years to the life at
the expense of quality of life.
1. Journal .Neuro Radiology Vol 34 (5) 344 to 345
2. Journal.Maxilo fascial surgery Vol 41(2) 162 to 166
1. Neurol Clin. 1995 Nov;13(4):847-59.
2. Jou of Cl Oncology, 20, 8 (April 15), 2002
KNB 13: 9 -3
A CASE OF TEMPORAL LOBE
LESION A CASE OF STROKE ON STROKE
INTRODUCTION:
Temporal lesions when presenting with
seizures may be confusing, especially if imaging
modalities do not give a proper diagnosis.
CASE REPORT:
By Aug’13, a 60/M, presented to a local
hospital with acute confusional state and left
focal seizures. He has DM, HT & renal
impairment. His CT showed left temporal
resolving bleed with edema, on which varying
diagnoses like AVM / Cavernoma etc., were
made (fig-1). He was treated with anti epileptics
and discharged. Later MRI brain was done
which was reported as left temporal neoplasm.
He was having right LL marching parasthesia
without any focal neurological deficits. A
detailed EEG with additional leads showed
epileptic focus at left temporal region (fig-2). A
repeat MRI with MRS with 1.5 Tesla machine,
confirmed 5x2.5x2 cm left medial temporal low
grade glioma (fig-3). He was admitted, anti-
epileptic drugs and other doses were adjusted.
The crawling sensation totally subsided. Blood
Sugar and Blood Pressure brought under
control.
CONCLUSION:
Initial presentation of low grade glioma
may be seizures, altered sensorium or
confusional state. For correct diagnosis of intra
cranial lesions, high quality MRI scans cannot be
compromised. Non contrast CT, lower Tesla MRI
can be utilized for screening purpose only.
INTRODUCTION:
If a patient develop a stroke on a
preexisting stroke, it will be possible to make
a clinical diagnosis, only if the area and/or
pathology of two strokes are different.
Suppose a patient with right MCA infarct,
develop again right MCA infarct, it will be
difficult to make a correct diagnosis of site,
size of the lesion. It will also be difficult to say
whether the second stroke is organic.
CASE REPORT:
50/F, a known case of DM/HT/DCM
had left hemiplegia by Sep’12 (fig 1). She
improved over a period of 2 wks, and she
could gradually walk in a circumduction gait
without support. She had Rt CCA intraluminal
thrombus with severe LV dysfunction. Her CT
showed moderate sized Rt MCA infarct.
During Aug’13, she had worsening of left
hemiparesis which could not be assessed
correctly. A repeat CT showed almost the
same findings as that of old infarct(fig2). 90%
occlusion in Rt CCA was noted. MRI brain
revealed two small foci of high parietal infarct
(hyperintense in DWI) within the old infarct
(fig 3). She received a course of Heparin,
improved to some extent and discharged.
CONCLUSION:
Diffusion weighted images are more
helpful in diagnosing acute infarct even if it
occurs within the region of old infarct.
1. www. 191.9, 192.8, M9450/3 2. Neu ind mar-Apr, 2012.60(2), 243
Neurology. 1997 Apr;48(4):891-5.
medpagetoday.com/Neurology/Strokes/14475
KNB 13: 9 -4
1.Common site of Neuro fibroma
a.Extradural
b.Intramedullary
c.Extramedullary
d.Intraventricular
2.Contrast enhancing paediatric neoplasm
a.Choroid Plexus Papilloma
b.Giant cell astrocytoma
c.Medullo blastoma
d.All the above
3.Blood product Methemoglobulin seen in MRI
after one week of intracerbral haemorrhage is
a.Hypermagnetic
b.Paramagnetic
c.Diamagnetic
d.Conramagnetic
4.Pengiun sign in MRI is seen in
a.Parkinson’s disease
b..Multiple system atrophy
c. Progressive Supranuclear Palsy
d.Olivo Ponto Cerebellar Atrophy
5.Cortical ribbon sign in MRI is seen in
a. CNS HIV
b. CJD
c. SCA
d. Rabies
6.Frontal horn dilatation in CT scan is seen in
Huntington’s Chorea
a.True
b.False
7.Correct the jumbled letters of VALDREN
SHELTOR ZAP; degenerative disorder (NBIA)
which is not often used now a days
8.Unilateral temporal T2 hyperintensity seen in
a.Glioma
b.HSE
c.Infarct
d.All of the above
9.Match diagnosis and the needed skull Xray
1 Pituitary lesion a.Down’s view
2.Basilar invagination b.Lateral view
3.CP angle lesion c.AP view
4.Eagle’s syndrome- d.Open mouth
10.To differentiate between post operative
gliosis and recurrence of glioma the scan
advised is
a.MRI b.fMRI
c.PET d.SPECT
11.Shouldering in Myelogram is a feature of
a.Neurofibroma
b.Disc Prolapse
c.Pott’s spine
d.Spinal AVM
12.Non contrast CT scan may miss
a.Low grade glioma
b.CVT
c.Tuberculoma
d.All of the above
13.In routine MRA, the contrast agent used is
a.Iodine
b.Gadolinium
c.Non ionic contrast agent
d.None of the above
14.MRI sequence for diagnosing acute infarct is
a.FLAIR b.T1 & T2
c.DWI d. PWI
15. The location of tumor in intracranial NF is
a.Pons b.IV Ventricle
c.CP angle d.Pituitary
16.16 yrs old girl presented with Writer’s
cramp, she has a ring in her eye. The likely
diagnosis is
a.Parkinsonism
b.Wilson Disease
c.Hypothyroidism
d.Neurocysticercosis
17.60 yrs old male presented with large Rt MCA
Stroke seen in CT. The immediate action is
a.Thrombolysis b.Heparin
c.Decompression d.Ecospirn
18. The findings noted in CECT of CVT is
a. Eye of Tiger sign
b. SDH
c. Hyperdense MCA sign
d. Empty delta sign
Supplement to Kasturi Neuro Bulletin 13:9 - Mini Neuro Quiz
Editor’s Decision is final.
19. The prognosis of the Pontine bleed is
a.Poor b.Good
20. The likely diagnosis of enumerous ring
enhancing lesions by MRI is
a.Sarcoidosis
b.Secondaries
c.AV Malformation
d.Neurocystecercosis
21. Hypohalamo- hypophyseal fibres are
formed by the axons of
a. Supraoptic b. Paraventricular
c. Both d. None
22. Midbrain structure which projects to the
corpus striatum is
a. Pyramidal tract
b.Medial Longitudinal Fasciculus
c.Medial Geniculate Body
d.Substantia Nigra
23. A lesion of subthalamus results in
a.Chorea b. Athetosis
c.Hemiballismus d.Dystonia
24. Which lobe is directly above the tentorium?
a. Parietal lobe b. Temporal lobe
c. Cerebellum d. Occipital lobe
25. Which part of brainstem region is in the
tentorial region
a. Pons b. Medulla
c. Hypothalamus d. Midbrain
26. Myelin sheaths are formed by
a. Oligodendrocytes
b.Schwann cells
c.Both
d.None
27. Role of arachnoid granulation is to
a. Produce CSF
b. Stain CSF
c. Transfer CSF to venous system
d. Transfer CSF to lymphatic.
28. Floor of IV ventricle is associated with
a. Medulla b. Pons and Medulla
c. Pons, Medulla and Cerebellum
d. Midbrain, Pons & Medulla
29. Ligaments attach between the exit and
entrance of ventral and dorsal roots following
each spinal nerve
a.Pial b.Dura
c.Collagen d.Flavii
30. Spinal C8 root, exits between the vertebrae
a. C6-C7 b. C7-C8
c. C7-T1 d. T1-T2
31. Cauda equina is formed by the dorsal and
ventral roots of _____ segments of spinal cord
a.Lumbar b.Sacral
c.Lumbosacral d.Coccygeal
32. Safest point to sample CSF is between
a. C7-T1 b. L1-L2
c. D12 – L1 d. L3-L4
33. In syringomyelia (expansion of central
canal) there will damage to the
a. Spinothalamic tract
b.Spino reticular tract
c. Corticospinal tract
d. All of the above
34. The vessel lateral to the chiasm is
a. Anterior cerebral artery
b. Middle cerebral artery
c. Posterior communicating artery
d. Internal cerebral artery
35. Central retinal artery is the branch of
a.Internal Carotid
b.External Carotid
c.Ophthalmic
d.Choroidal
36. Area of the medulla containing the spinal
nucleus of trigeminal nerve is supplied by
a. Anterior inferior cerebellar artery
b. Posterior inferior cerebellar artery
c. Superior cerebellar artery
d. Vertebral artery
37. Which limb of internal capsule contain
cortical approach
a. Anterior limb
b. Posterior limb
c. Both
d. Neither
38. Ganglionic ICH occur due to rupture of
a. Lenticulostriate A
b. Posterior Communicating A
c. Anterior Cerbral A
d. Internal cerebral Vein
39. The reception of the saccula and
semicircular canals are examples of
a. Chemoreception
b. Nociception
c. Mechanoception
d.Osmoreception
40. Incidence of post stroke seizure is > 30%
a. True b. False
41. Olivo cerebellar axons terminate in the
cerebellum by
a. Mossy fibers b. Climbing fibers
c. Basket cell axons d. None
42. Tumours originating from Schwann cells of
VIII Cr.N compress which cranial nerve?
a. IX & X b. VII
c. V d. VI
43. Tendon, joints, muscle spindle and skin are
innervated by axons whose cell bodies are in
a.Pyramidal tract b.Muscle Spindle
c.Spinal AHC d.Neurons
44. Most devastating effects are produced by
sudden occlusion of origin of
a. MCA b. ACA
c. VA d. PCA
45. Which vessels supply the speech area
commonly?
a. Right MCA b. Left MCA
c. Left PCA d. Rt &Lt PCA
46.In uncal herniation, which portion of
brainstem is compressed
a.Midbrain b.Upper Pons
c.Lower Pons d.Medulla
47. In right frontal lobe infarct, eye balls will
look towards
a. Right Side b.Left Side
c.Upwards d.Downwards
48. in cerebellar herniation , which portion of
brainstem is compressed
a.Midbrain b.Upper Pons
c. Medulla d. None
49.IV fluid to be avoided in increased
intracranial pressure
a. Normal Saline
b. 3% saline
c. 5% dextrose
d. 5% dextrose in normal saline
50.Which of the following is not associated
with cytotoxic brain edema
a. Brain Tumor
b.Ischemic Stroke
c.Hepatic encephalopathy
d.Hypoxic encephalopathy
51.Which of the following is the first line
investigation in a patient with suspected
subarachnoid hemorrhage
a. Lumbar puncture b. CT brain
c. MRI brain d.EEG
52. Hemorrhage in which portion of brain
warrant urgent surgical evacuation
a. Pons b. Basal ganglia
c. Cerebellum d. Frontal lobe
53.Which of the following is most commonly
the cause of spinal epidural abscess
a.Lumbar puncture
b.Osteomyelitis
c. Penetrating trauma
d. Hematogenous spread
54. Which of the following drug is used in the
management of Guillaine Barre syndrome
a. Interferon alpha
b. IV immunoglobulin
c. IV methyl prednisolone
d. Oral prednisolone
55. With regards to headache which is not a
red flag
a. Fever
b. Rapidity of onset
c. Age >75years
d. Duration > 4 days
56.Which of the following is the only
thrombolytic agent approved for the
management of acute ischemic stroke
a. streptokinase b. alteplase
c. tenecteplase d. urokinsae
57.All of the following imaging features
favours tuberculous meningitis except
a. Basal exudates b. Abscess
c. Vasculitis d. Tuberculoma
58. Loading dose of phenytoin for management
of status epilepticus is
a. 5mg/kg b. 10mg/ kg
c. 15mg/kg d. 30mg/kg
59. Which portion of brain is preferentially
involved in Herpes Simplex Encephalitis
a. Frontal lobe b. Parietal lobe
c. Temporal lobe d. Occipital lobe
60.Which of the following is not the feature of
Neuroleptic Malignant Syndrome
a. fever b. altered sensorium
c. movement disorder d. hemiparesis
61.Empirical antibiotic therapy for bacterial
meningitis is
a. Ceftriaxone + Vancomycin
b. Ampicillin + Gentamycin
c. Ampicillin
d. Ampicillin + Vancomycin
62. BP reduction in acute ischemic stroke is not
warranted in
a. Carotid Dissection b. Associated MI
c. BP > 140/100 d.Thrombolysis plan
63. In which of the following situation, Heparin
is indicated in ischemic stroke
a. All Ischemic Strokes
b. Cardio Embolic Stroke
c. Carotid Artery Stroke
d. Lateral Medullary Stroke
64. All the following is associated with
increased CSF lymphocyte count except
a. Acute Pyogenic Meningitis
b. Partly Treated Pyognic Mengts
c. Tuberculous Meningitis
d. Fungal Meningitis
65. Drug preferred to treat psychosis in
parkinson’s disease a. Haloperidol b. Chlorpromazine
c. Quetiapine d. Trifluperazine
66. Starting AED therapy is indicated in all of
the following conditions, except
a. Abnormal neurological examination
b. Focal Seiz with todds paralysis
c. Single provoked Seizures
d. Abnormal EEG
67. Therapeutic concentration of serum
Phenytoin is
a.10-20 ug/ml b.20-30 ug/ml
c.30-40 ug/ml d.40-50 ug/ml
68.Checking Sr. AED is indicated for
a. Drug Toxicity b. Compliance
c. Sr. level Assessment d. All
69. First AED introduced was
a.Phenobarbitone b.Bromide
c.Phenytoin d.Primidone
70.All AEDs act at sodium channel except
a.Phenytion b.Carbamazepine
c.Oxcarbamazepine d.Gabapentin
71. All are side effects of topiramate except
a.Sedation b.Glaucoma
c.Renal stone d.Weight gain
72. % of patient who do not respond to
treatment with single AED
a.33 b.25 c.66 d.75
73. Drug of choice for absence seizure
a.Valproate b.Carbamazepine
c.Phenytoin d.Oxcarbazepine
74.All are seizure inducing AED, except
a.Phenytoin b.Valproic acid
c.Phenobarbitone d.Primidone
75. Oxcarbazepine is better than CBZ in the
following
a. Rash is less common
b. Hyponatremia is less common
c. Better pt tolerability
d. All of the above
I thank our neuro team (Dr.Thirumurthy, Dr.Balakrishnan, &Dr.Gnanshanmugam) in preparing and permitting the Q&A to present to you