Menachem Gold

Marchiafava-Bignami disease in a trauma patient.

Marchiafava-Bignami disease (MBD) is a rare pathological condition affecting the corpus callosum (CC), characterized by progressive demyelination and necrosis. While usually found in patients with chronic alcoholism, it has rarely been characterized in non-alcoholics. We describe a trauma patient with an unknown mechanism of injury, who was found to have MBD after remaining comatose for a prolonged period of time. Magnetic resonance imaging (MRI) demonstrated restricted diffusion involving the genu, body, and splenium of the CC. The patient eventually awoke but was non-communicative and uncomprehending prior to discharge to a nursing facility. We reviewed the literature and report here the first case of MBD encountered in a trauma patient. In conclusion, MBD is an extremely rare condition in non-alcoholic patients, and the use of MRI is crucial for its identification.

Imaging prevalence of nasal septal perforation in an urban population

OBJECTIVE To determine the prevalence of nasal septal perforation (NSP) on CT imaging in an urban hospital setting. METHODS Facial bone CT scans from 3708 consecutive patients were reviewed for the presence of NSP. Size of the perforation was measured in two dimensions. Medical records were reviewed for possible risk factors. RESULTS The prevalence of NSP was 2.05%. The most common risk factor was a history of drug abuse. Cocaine was the most prevalent drug used. CONCLUSION The prevalence of NSP was more than double of that previously published, likely related to intranasal drug use in our urban population.

Posterior epidural cyst associated with Baastrup disease.

A 57-year-old man presented with a-several-year history of midline lower back pain radiating down both legs. The patient reported that the pain was relieved on flexion and worsened with extension. On physical examination, he had an antalgic gait, 4/5 strength in the left lower extremity, allodynia of left lower extremity from hip to mid leg, and brisk bilateral deep tendon reflexes. There was bilateral lumbar paraspinal tenderness to palpation. Lateral radiograph (Fig. 1) demonstrated apposition of the dorsal spinous processes that is characteristic of Baastrup disease. Magnetic resonance imaging (Fig. 2) demonstrated bursal fluid between the L4 and L5 spinous processes, as well as a posterior epidural cyst resulting in significant canal stenosis.

Laryngeal fracture after coughing

Nontraumatic laryngeal fractures are exceedingly rare disease entities. Only 3 prior instances have been described in the medical literature (Br Med J 1950;1:1052; Acta Otorrinolaringol Esp 2007;58:73-4; Otolaryngol Head Neck Surg 2012;147:801-2). We present a case of thyroid cartilage fracture and associated phlegmon formation after a vigorous coughing spell in a 47-year-old man. On presentation, the patients symptoms included the triad of odynophagia, dysphagia, and dysphonia as well as diffuse swelling and tenderness over the thyroid cartilage. Computed tomography and magnetic resonance imaging revealed a mildly displaced anterior thyroid cartilage fracture as well as a phlegmon in the strap muscle compartment adjacent to the fracture (Figs. 1 and 2). Intravenous dexamethasone and antibiotics were initiated, and the patient was admitted to the medical intensive care unit. On fiberoptic examination with the flexible laryngoscope, the patient was found to have slightto-moderate watery edema of the right aryepiglottic fold and right greater than left arytenoid cartilages. After 48 hours, the patients neck swelling and pain significantly improved. On hospital day 4, the patient was discharged with a course of oral antibiotics. One week later, the patient reported only mild odynophagia and persistent dysphonia. He otherwise felt well and was tolerating fluids and soft food without difficulty. A preexisting, congenital abnormality resulting in a focal weakness in the thyroid cartilage might predispose patients to nontraumatic fractures (Otolaryngol Head Neck Surg 2012;147:801-2). Patients in prior case reports of nontraumatic laryngeal fractures presented with similar symptoms (Table). The triad of odynophagia, dysphagia, and dysphonia after a severe coughing or sneezing episode should raise the clinicians suspicion of a thyroid cartilage fracture.

Partially Thrombosed Internal Maxillary Pseudoaneurysm after Gunshot Wound.

A 29-year-old man arrived in our emergency department after being shot on the face. Computed tomography (CT) revealed multiple facial bone fractures along the bullet trajectory. On day 10 of admission, CT angiogram of the neck revealed a partially thrombosed pseudoaneurysm in the parapharyngeal fat pad. The pseudoaneurysm was successfully treated with coil embolization. This report discusses diagnosis and treatment of a partially thrombosed internal maxillary artery pseudoaneurysm. Although digital subtraction angiography is the gold standard for pseudoaneurysm diagnosis, CT angiography may provide complimentary information, as seen in this case.

Anaplastic astrocytoma mimicking herpes simplex encephalitis in 13-year old girl

Astrocytoma is the most common childhood brain tumor. Anaplastic astrocytoma (AA) are high grade gliomas (HGG), found very rarely in pediatric patients. AA mainly results from a dedifferentiation of a low grade astrocytoma. Clinical features of supra-tentorial tumors vary according to their anatomic location, biologic aggressiveness and age of the patient. They can be either completely asymptomatic or present with signs of raised intracranial pressure, seizures (about 40% of cases), behavior changes, speech disorders, declining school performance, or hemiparesis. There have been published adult cases of brain tumor misdiagnosed as viral encephalitis. Due to variety of clinical presentations, diagnosis of AA can be challenging. Here we report a case of a 13 year old girl who presented with clinical features suggestive of viral encephalitis, such as fever, headache, dizziness, and first seizure with postictal sleep and prolonged drowsiness. However, her brain MRI findings were consistent with long standing mass effect from the underlying intracranial contents and that coupled with her history of unusual taste led to further investigations and the diagnosis of the AA. In retrospect, this presentation could have been a temporal epileptic aura. High grade astrocytomas are particularly difficult to treat with a two-year survival rates range from 10% to 30%. The treatment is multimodal with gross total surgical resection of the tumor, followed by radiotherapy with or without nitrosourea-containing chemotherapy regimen. Recent promising results seen with the use of temozolamide in adults has not been yet demonstrated in the pediatric patients. The extent of tumor resection remains the most significant indicator of survival and early recognition of this tumor is essential. This case report emphasizes the fact that mass lesions in the temporal lobe, including high-grade astrocytoma, should be considered in the differential diagnosis of suspected herpes simplex encephalitis, especially those not responding to therapy. Remodeling of the calvarium adjacent to an intracranial lesion suggests a long standing process.

Right-left propensity of cardiogenic cerebral embolism in standard versus bovine aortic arch variant: Cerebral Embolism in Standard vs Bovine Arch

Left‐hemispheric ischemic strokes are more frequent overall and often have a worse outcome than their right‐hemispheric counterparts. We hypothesized that the right‐left propensity of CE cerebral infarcts differs between patients with standard and bovine arch variants. We retrospectively identified all patients with acute stroke of the anterior circulation admitted to our primary stroke center between January 2011 and June 2017 who had moderate‐ to high‐risk cardio‐embolic sources according to the SSS‐TOAST classification. From amongst these patients, only those with available cross‐sectional imaging of the aortic arch were included. Lesion side and patterns on diffusion‐weighted magnetic resonance imaging were determined blinded to the aortic arch imaging. One hundred and nineteen patients met the TOAST criteria for moderate‐ or high‐risk cardio‐embolic source. Of these, 58 (49%) were men and the median age was 71.9 years; 33% of the patients had a bovine arch. The most common etiologies of CE were atrial fibrillation (n = 80 [67%]) and congestive heart failure with ejection fraction <30% (n = 18 [15%]). In patients with bovine arch there was an approximately 50% chance of having a right‐ or left‐sided infarct. Although there was a trend towards right‐sided lesions in patients with standard arches, this did not reach statistical significance. No statistically significant difference in embolic stroke laterality was demonstrated in our relatively small sample. Bovine arch could be an independent risk factor for cardio‐embolic embolism. Clin. Anat. 31:310–313, 2018.

Acute upper extremity flaccid paralysis in a 5 year old child secondary to enterovirus infection

ABSTRACT The incidence of acute flaccid paralysis has been on a declining trend with the global efforts on eradication of polio virus. A few scattered clusters of acute flaccid paralysis associated with pathogens like enterovirus other than polio virus and flaviviruses have recently come to limelight. This is a case of acute onset flaccid paralysis of left upper extremity in a fully immunized 5 year old child in New York.

Isolated Right Vein of Labbe Thrombosis.

A man in his 30s with a history of sickle cell disease presented to the emergency department after experiencing 2 tonic-clonic seizures. He reported having several headaches in the week leading up to the seizure. Neurologic examination findings were nonfocal. Laboratory test result values were significant for the following: hemoglobin, 11.2 g/dL; mean corpuscular volume, 95.2 μm3; and platelets, 736 × 103/μL. Electrophoresis revealed a hemoglobin S level of 52%. The patient reported approximately 1 sickle cell crisis per year and had undergone a left hip replacement due to avascular necrosis. Magnetic resonance imaging revealed a large hemorrhagic infarct in the right temporal lobe (Figure 1). There was a suggestion of thrombosis of the vein of Labbe, which was confirmed on magnetic resonance venography (Figure 2). The patient was treated with phlebotomy (removal of 200 mL of blood) and intravenous hydration, with the goal of lowering the hemoglobin level to less than 10 g/dL. Thrombophilia workup performed when the patient was an outpatient revealed elevated factor VIII levels. The vein of Labbe is part of the superficial venous system, draining the lateral surface of the temporal lobe. The vein arises in the sylvian fissure and travels posteriorly and inferiorly to empty into the transverse sinus. Isolated vein of Labbe thrombosis is rare. To date, almost all previously reported cases have occurred on the left.1 Risk factors for the development of cortical vein thrombosis include thrombophilia, pregnancy or peripartum, malignant neoplasm, oral contraceptive use, and central nervous system infections. The most common presenting symptoms of vein of Labbe thrombosis are seizure and headache.2 Altered consciousness and papilledema, findings associated with increased intracranial pressure in cases of sinus thrombosis, have not been reported with vein of Labbe thrombosis. The association between elevated factor VIII (antihemophilic factor) levels and sickle cell disease has been previously described.3 The cause of the venous thrombosis in this patient is unclear but could be secondary to a number of factors, including stasis due to sickled erythrocytes, thrombophilia, or blood hyperviscosity.

Middle turbinectomy after nasotracheal intubation.

Nasotracheal intubation (NTI) is used for maintaining airway access during maxillofacial surgery or in cases of severe oral trauma. We describe a case of middle turbinectomy complication as a result of NTI. The purposes of this paper are to raise awareness of this complication and review associated imaging findings.