Rajendra V. Phadke

Iatrogenic renal vascular injuries and their radiological management

Twenty-nine patients with significant haematuria after a renal invasive procedure (27 of whom had undergone a percutaneous renal procedure and 2 surgical pyelolithotomy) were investigated with angiography. Out of the 21 patients with evidence of arterial injury, 19 were treated by transarterial embolization with gelfoam with or with hydrogel particles; (n = 11), steel coils with gelfoam (n = 4), hydrogel particles (n = 1), surgicel (n = 2), silk with gelfoam (n = 1). The efficacy and technique of the therapeutic embolization procedure is emphasized.

Central pontine myelinolysis following ‘slow’ correction of hyponatremia

Two patients with central pontine myelinolysis are described for the peculiar mode of development. Both patients were in chronic renal failure and admitted in a stuporous state due to hyponatremia. Both developed central pontine myelinolysis during the hospital stay following slow and judicious correction of hyponatremia. The role of chronicity of hyponatremia prior to its correction, in the genesis of central pontine myelinolysis, particularly in the patients who have chronic debilitating illness, septicemia or malnutrition, is highlighted.

Management of idiopathic Budd-Chiari syndrome with primary stent placement: early results.

PURPOSE To evaluate the utility of primary stent placement in the management of Budd-Chiari syndrome (BCS) secondary to idiopathic inferior vena caval (IVC) obstruction. PATIENTS AND METHODS The case records of nine patients (four women, five men), ranging in age from 22 to 58 years (median, 26 years), with idiopathic IVC obstruction were reviewed. Hepatosplenomegaly, esophageal varices, and prominent collateral veins were found in all patients, while four also had ascites. Hepatic functional reserve was graded as Child class A in three patients and class B in the remaining six. All had at least one patent hepatic vein opening into the IVC below the site of occlusion. Percutaneous angioplasty of the IVC was performed, followed by the placement of double-skirt Gianturco-Rösch or hybrid Gianturco stents. Clinical follow-up was supplemented with duplex ultrasound (n = 8), endoscopy (n = 4), and cavography (n = 2). RESULTS Caval lesions were segmental. Revascularization was technically successful in all patients. The median pressure gradient across the lesion dropped from 38 mm Hg (range, 27-61 mm Hg) to 15 mm Hg (range, 10-20 mm Hg) (P = .008). Residual stenosis after stent placement ranged from 9% to 40% (median, 20%). One patient died of presumed pulmonary embolism; another patient experienced an episode of epistaxis. The procedure was followed by regression of signs and symptoms in the eight survivors. During the follow-up period (range, 3-31 months; median, 7 months) the IVC remained patent in all patients, and clinical features of BCS did not recur. CONCLUSION Primary stent placement could serve as the first line of treatment in patients with idiopathic BCS when the underlying lesion is not amenable to angioplasty.

Multiple infected extradural parasellar hydatid cysts

BACKGROUND Intracranial hydatid disease constitutes 1%-2% of all cases of hydatid disease. Multiple, infected, extradural, parasellar hydatid cysts in a patient constitutes an extremely rare presentation. CASE REPORT This 21-year-old man presented with a progressive left supraclavicular swelling of 3 years duration and raised intracranial pressure of 6 months duration with a past history of left-sided chronic suppurative otitis media that had resolved with antibiotics. On neurologic examination, he had bilateral deterioration of vision with optic atrophy; right temporal field defect; left III, IV, VI, VI, and V2 cranial nerves palsy; and left ear conductive deafness. The patients E.S.R was raised. His computed tomography (CT) scan showed a hypodense, lobulated lesion in the middle cranial fossa with a hypodense, nonenhancing rim, septations, and focal calcification without perifocal edema. A purulent fluid was aspirated from the left supraclavicular swelling, which did not reveal any organism on staining and culture. Aspiration of the left temporal swelling showed whitish watery fluid, the cytology of which revealed an infected hydatid cyst. Excision of the left temporal extradural, hydatid cysts was done, except the portion of the capsule adherent to the dura, and albendazole was started. One month later, the supraclavicular hydatid cysts were removed. Six months later, a left mastoidectomy was performed for chronic suppurative otitis media. A repeat CT scan showed complete resolution of the hydatid cysts. There was no recurrence at 1 year follow-up. CONCLUSIONS A rare case of multiple infected extradural hydatid cysts of the parasellar region is reported. The unusual CT picture of a hypodense lobulated mass with septations and a hyperdense rims is presented. The difficulties in its complete excision and successful management with long-term albendazole therapy are discussed.

Cranial imaging findings in dengue virus infection

BACKGROUND The aim of this study is to evaluate cranial CT or MRI changes in dengue encephalitis and their correlation with clinical and biochemical findings. METHODS Twenty-one serologically confirmed patients with dengue with altered sensorium were included who underwent MRI (20)/CT (1) scan study. Their clinical details including seizure, hypotension, bleeding diathesis, focal neurologic deficit, and Glasgow Coma Scale (GCS) score were noted. Blood counts, hematocrit, renal and liver function tests, electrolytes, cerebrospinal fluid (CSF) and ECG were done. MRI findings on T1, T2, FLAIR, DWI and T1 gadolinium contrast were noted. RESULTS The median age of the patients was 30 (5-69) years and 5 were females. MRI was abnormal in 9(45%) and CT scan in 1 patient with dengue shock syndrome revealed cerebellar and subdural hematoma. The MRI lesions were in thalamic and basal ganglia in 3, focal cortical areas in 3, white mater in 2 and meningeal enhancement in 3 patients. Seven of these patients had CSF pleocytosis. The presence of abnormal imaging was not related to outcome. One patient died, 1 was bed ridden and 19 had complete recovery on discharge. CONCLUSION Cranial imaging reveals nonspecific changes and is not related to hematological and biochemical changes or outcome.

Postauricular, transpetrous, presigmoid approach for extensive skull base tumors in the petroclival region: the successes and the travails

PurposePostauricular, transpetrous, presigmoid approach combines a supra/infratentorial exposure with partial petrosectomy to access third to the twelfth cranial nerves and extraaxial lesions situated anterolateral to brainstem. It provides a shorter working distance to large petrosal, petroclival, cerebellopontine, and cerebellomedullary cisternal lesions and their extensions to the subtemporal–infratemporal areas. This study reviews the surgical technique, corridors of extension, and complications encountered utilizing this approach for excising extensive lesions in these locations.MethodsThe lesions (n = 14) included petroclival meningiomas [(n = 5), including three recurrent lesions], dumbbell lower cranial nerve schwannomas (n = 2), giant acoustic schwannomas (n = 2), recurrent giant trigeminal nerve schwannoma (n = 1), glomus jugulare (n = 3), and recurrent petrous aneurysmal bone cyst (n = 1). The approach was combined with a retrosigmoid suboccipital craniectomy (n = 3), with an infratemporal approach (n = 2), and with an extreme lateral transcondylar approach and a translabyrinthine approach in one patient each, respectively. External auditory canal was not ligated in nine patients, superior petrosal sinus and tentorial division was performed in all patients, and sigmoid sinus–internal jugular vein was excised in three patients (with a glomus jugulare (n = 1) and petroclival meningioma (n = 2), respectively). Repair was performed with fat–fascia, pedicled pericranium, and temporalis muscle. Lumbar drain was placed for three to five postoperative days.ResultsTotal excision was performed in nine patients. Small tumor remnants were left attached to the brainstem (n = 3, petroclival meningioma), carotid canal and cavernous sinus (n = 1, glomus jugulare), and sigmoid sinus–jugular bulb (n = 1, recurrent trigeminal schwannoma). A two-staged procedure was performed in three patients. Two patients with recurrent giant petroclival meningiomas died: one with lower cranial nerve paresis due to aspiration pneumonitis and the other with cerebrospinal fluid otorrhoea and secondary meningitis.ConclusionsThe approach facilitates direct tumor decompression and its retraction away from the brainstem without initially encountering the intracisternal cranial nerves and neuraxis. It provides multiple corridors for excising extensive posterior fossa tumors. Preoperative assessment of sigmoid sinus dominance, jugular bulb height, labyrinth, vein of Labbe, and space available through Trautman’s triangle considerably helps in complication avoidance.

Diffusion-Weighted MR Imaging in Posterior Ischemic Optic Neuropathy

We read with interest the case report by Mathur et al[1][1] in which they have described an acute ischemic event in the posterior part of the intraorbital optic nerve consequent to rhinocerebral mucormycosis and its early detection by diffusion-weighted MR imaging (DW-MR imaging). In this regard, we

Neuroimaging in mental retardation.

Objective : To determine the diagnostic yield of neuroimaging ina cohort of children with mental retardation of unknown origin.Methods: Neuroimaging was performed in a total of 47 patients with developmental delay/mental retardation, where no etiologic diagnosis could be made following clinical examination and preliminary investigations.Results : Thirty (63.82%) children had abnormal neuroimaging findings of which 19 (42.42%) were specific abnormalities useful in arriving at etiological diagnosis. Positive outcome of neuroimaging increased with the severity of mental retardation and in presence of microcephaly and neurologic deficits other than mental retardation.Conclusion : Neuroimaging should be the standard clinical practice for a child with global developmental delay where no cause is apparent after examination and relevant investigations.

Selective involvement of basal ganglia and occipital cortex in a patient with acute endosulfan poisoning

We report a teenage girl with acute endosulfan poisoning who developed psychosis, generalized tonic-clonic seizures, myoclonic jerks, cortical blindness and limb rigidity. Serial magnetic resonance imaging (MRI) showed bilateral reversible lesions localized to caudate nucleus, putamen and occipital cortex; internal capsule and thalamus were spared. This selective involvement may have a bearing on mechanisms underlying endosulfan toxicity.

Role of Radiotherapy in a Recurrent Aneurysmal Bone Cyst of the Temporal Bone: Case Report

OBJECTIVE AND IMPORTANCE: A rare case of aneurysmal bone cyst (ABC) of the temporal bone is presented which, following recurrence after surgery, was successfully treated with radiotherapy. The role of radiotherapy in such cases is reviewed. CLINICAL PRESENTATION: A 30-year-old man presented with a recurrent swelling and pain in right temporal region following surgery for ABC at that site. INTERVENTION: Local radiotherapy to a dose of 31.5 Gy in 18 fractions over 3.5 weeks was delivered to the site of recurrence. The patient had a near total regression of the ABC as evident clinically and on radiological images. CONCLUSION: To the best of our knowledge, radiation for the recurrent ABC at the temporal bone has not been described in the literature. However, in view of the response evident in this patient, radiotherapy seems to be effective for recurrent cases of ABC at the temporal bone and a dose of around 30 to 36 Gy could be effectively delivered with satisfactory results.