Chetan R. Soni

Central post-stroke pain: Current evidence

This article reviews the definition, epidemiology, and current evidence on pathophysiology, neuroanatomy, clinical features, and treatment of central post-stroke pain.

Surgical Management of Rhegmatogenous Retinal Detachment: A Meta-Analysis of Randomized Controlled Trials

PURPOSE To examine possible differences in clinical outcomes between pars plana vitrectomy (PPV) and scleral buckling (SB) for uncomplicated rhegmatogenous retinal detachment (RRD). DESIGN Meta-analysis. PARTICIPANTS Adult patients with uncomplicated RRD from previously reported randomized controlled trials of PPV and SB. METHODS A comprehensive literature search using the Cochrane Collaboration methodology to identify randomized controlled trials comparing PPV with SB for uncomplicated RRD. MAIN OUTCOME MEASURES Analysis was divided into phakic and pseudophakic/aphakic patients. Primary outcome parameters included proportion of primary reattachment and difference of means of best-corrected visual acuity (BCVA) at 6 months or more between the PPV and SB groups. Secondary outcome parameters included the proportion of secondary reattachment and complications between the PPV and SB groups. RESULTS Seven studies were identified and analyzed for comparing PPV (636 eyes) with SB (670 eyes) for uncomplicated RRD. In the phakic group, there were no significant differences in the proportion of primary reattachments (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.69-1.46) or secondary reattachments (OR, 0.99; 95% CI, 0.34-2.87) between the PPV and SB groups. Meta-analysis showed a statistically significant difference in the logarithm of the minimum angle of resolution (logMAR) BCVA at 6 months between the PPV-treated and SB-treated phakic eyes (mean deviation, 0.14; 95% CI, 0.06-0.21; P<0.0004). In the pseudophakic/aphakic group, there were no significant differences in the proportion of primary reattachments (OR, 1.46; 95% CI, 0.79-2.71) or logMAR BCVA at 6 months between the PPV and SB groups (mean deviation, -0.03; 95% CI, -0.10 to 0.04). A statistically significant difference was noted in the proportion of secondary reattachments (OR, 2.08; 95% CI, 1.08-4.03; P = 0.03) between the PPV and SB groups in pseudophakic/aphakic eyes. Meta-analysis showed a statistically significant rate of cataract progression in the PPV group (OR, 4.11; 95% CI, 2.70-6.25; P<0.00001). CONCLUSIONS There were no significant differences in the proportions of primary reattachment in the PPV and SB groups in phakic eyes. The SB-treated phakic eyes had better postoperative BCVA at 6 months or more. This is most likely related to higher rates of cataract progression in PPV-treated phakic eyes. There were no significant differences in proportions of primary reattachment and postoperative BCVA at 6 months or more in pseudophakic/aphakic eyes.

Salmonella brain abscess in a patient on chronic azathioprine therapy for myasthenia gravis: report of an unusual case and review of literature in the postantibiotic era

Focal intracranial infections caused by Salmonella species in adults are exceedingly uncommon. Structural brain injury with coexisting immunocompromised status appears to predispose adults to this rare manifestation of Salmonella infection. We report a case of Salmonella brain abscess in a patient with myasthenia gravis on chronic azathioprine therapy without any prior structural brain lesion. We reviewed world literature and discuss their analysis of Salmonella brain abscess in adult population in the postantibiotic era.

Short-term use of inhaled and intranasal corticosteroids is not associated with glaucoma progression on optical coherence tomography.

Purpose To compare the changes in retinal nerve fiber layer (RNFL) thickness and optic nerve cup/disc ratio on optical coherence tomography (OCT) between users and nonusers of inhaled and intranasal corticosteroids (ICS). Methods Retrospective study of participants with glaucoma or glaucoma suspect having 2 or more OCTs during a 6-year period. The rates of change in Stratus OCT fast RNFL thickness scan and fast optic disc scan data were compared between ICS users and nonuser controls using random coefficient models. Results A total of 170 participants met the inclusion criteria, of whom 42 (25%) were ICS users and 128 (75%) were controls. The mean duration of follow-up was 3.2 years. There were no significant differences in the mean rates of change in superior RNFL (−0.8874 µm/y ICS users; −0.8592 µm/y controls; p=0.943), nasal RNFL (−0.0529 µm/y ICS users; −0.3577 µm/y controls; p=0.419), inferior RNFL (0.2703 µm/y ICS users; −0.1910 µm/y controls; p=0.165), and temporal RNFL (−0.3618 µm/y ICS users; −0.3612 µm/y controls; p=0.998) between ICS users and controls. There were no significant differences in the mean rates of change in horizontal cup/disc ratio (−0.0047 µm/y ICS users; 0.0002 µm/y controls; p=0.212) and vertical cup/disc ratio (0.0013 µm/y ICS users; 0.0029 µm/y; p=0.717) between ICS users and controls. Conclusions We found no significant difference in the rates of RNFL or optic nerve cup/disc ratio progression among individuals with glaucoma or glaucoma suspect following short-term ICS use.

Child Neurology: A patient with dissimilar eye color and deafness

Waardenburg syndrome (WS) is a rare genetic disorder with developmental anomalies of tissues derived from the neural crest and characterized by auditory and pigmentary findings. Failure of neural crest-derived melanocyte differentiation results in a spectrum of phenotypic presentations that are subdivided into 4 clinical types. We present a case of Waardenburg type 2 and briefly discuss the genetic basis of phenotypic expression of WS. An 18-year-old woman undergoing evaluation of intercostal neuralgia was incidentally noted to have one blue and one brown eye (figure). Both pupils reacted equally to light and accommodation. The patients mother reported that at birth both her eyes were blue but after 2 weeks the left eye changed to brown while the right eye remained blue. At birth she had a tuft of white hair on the frontal area. She had profound sensorineural hearing loss since birth and communicated via sign language. No other family member had this condition. Her mothers eyes were brown and the color of her fathers eyes was unknown. The patient was subsequently lost to follow-up. Figure Heterochromia irides without dystopia canthorum in an 18-year-old woman The differential diagnosis included …

Recurrent epileptic Wernicke aphasia

We report a patient with recurrent epileptic Wernicke aphasia who prior to this presentation, had been misdiagnosed as transient ischemic attacks for several years. This case report emphasizes the consideration of epileptic nature of aphasia when a clear alternate etiology is unavailable, even when EEG fails to show a clear ictal pattern. We also present a brief discussion of previously reported ictal aphasias.

Transient CT Hyperattenuation after Merci Clot Retrieval and Intraarterial Thrombolysis in Acute Stroke Mimicking Subarachnoid Hemorrhage

Unenhanced computed tomography (CT) revealed hyperattenuating lesions in two patients with acute stroke immediately after clot retrieval with the Merci device in one patient and after intraarterial thrombolysis in the other. These areas of hyperattenuation were noted in the middle cerebral artery territory in the first patient and involving the brainstem, cerebellum, and tentorium in the second. Both were falsely interpreted as subarachnoid hemorrhage. The area of hyperattenuation resolved within a few hours in both patients, reflecting contrast medium extravasation/leakage. This report highlights the need to improve physician skill in recognizing contrast medium extravasation that is common following neuroendovascular procedures, which are becoming commonplace in modern day medicine.

Visual neuropraxia and progressive vision loss from thyroid-associated stretch optic neuropathy

Purpose. Animal models have provided information on the tensile strength of the optic nerve, but to our knowledge no in vivo study of the tensile strength of the human optic nerve has been reported. Accordingly, we present 3 cases of stretch optic neuropathy, an often unrecognized cause of vision loss from thyroid eye disease. Methods. Observational study of thyroid-associated stretch optic neuropathy. Results. Three cases of stretch optic neuropathy were identified. Visual acuity was better than 20/40. Two patients had arcuate scotoma. Moderate to severe proptosis of 25 to 33 mm was present, without evidence of apical orbital compression. Two patients had retinal hemorrhages suggesting venous stasis retinopathy; the venous stasis retinopathy resolved after orbital decompression. Orbital decompression resulted in improvement of visual function. The rate of decibel sensitivity loss on automated perimetry was estimated at −0.042 dB/da in one case, with complete blindness projected to occur within 785 days from the onset of visual symptoms. Conclusions. Stretch optic neuropathy presents initially as neuropraxia with temporary visual loss. Orbital decompression should be considered for treatment before permanent and irreversible visual loss ensues.

Metastases to Meckel's cave: Report of two cases and comparative analysis of malignant tumors with meningioma and schwannoma of Meckel's cave

OBJECTIVE To investigate clinical characteristics of patients with malignant tumors of Meckels cave with two illustrative cases. A comparative analysis of clinical features of malignant tumors of Meckels cave with meningioma and schwannoma of Meckels cave is discussed. METHODS We report two cases of malignant tumors involving Meckels cave. We identified 19 additional cases of malignant tumors of Meckels cave in the literature. We analyzed the symptoms, results of neurological and radiographic examination, pre-operative diagnosis and final diagnosis of these tumors. Our findings were then compared with well described case series of meningioma and schwannoma involving Meckels cave. RESULTS Of the 21 patients with malignant tumor involving Meckels cave, 76% (16/21) had pain, 67% (14/21) had paraesthesia, 89% (17/21) had objective evidence of trigeminal sensory involvement and 42% (8/21) had objective evidence of trigeminal motor involvement. In contrast, of patients with trigeminal schwannomas [1], only 23% presented with pain, 36% with paraesthesia, 74% with objective evidence of trigeminal involvement and 42% with trigeminal motor involvement. Pain and paraesthesia were seen more often in malignant tumors. In Delfini et al.s [2] series of meningiomas involving Meckels cave, 81% of patients presented with pain, 25% with paraesthesia, 63% with trigeminal sensory deficits and only 13% with trigeminal motor involvement. Patients with malignant tumors were more likely to be older, and have paraesthesia in comparison with patients with meningioma. CONCLUSION Subtle clinical clues may help differentiate malignant from benign involvement of Meckels cave. We emphasize the need to thoroughly investigate patients early for a possible primary as well as metastases, in those found to have a lesion in the Meckels cave.