Shalini Agarwal

Reversible white matter abnormalities in a patient with migraine

A 35-year-old female with migraine without aura, presented with sudden onset of visual aura along with loss of vision on the left side. Following this she had nausea, vomiting and headache. Magnetic Resonance Imaging (MRI) performed at this stage revealed ill-defined lesions hyperintense on Flair images, located in the right temporal and right occipital region. Diffusion weighted images, MR angiogram, T1-weighted and T2-weighted images were normal. She got relief with symptomatic treatment. Twenty days after this attack of migrainous aura she had a similar episode. An MRI scan was performed again. It revealed similar lesions only in the right occipital lobe. Follow-up MRI performed seven weeks later was normal.

Semilobar holoprosencephaly in seckel syndrome

Seckel syndrome is a rare genetic disorder with autosomal recessive inheritance. It is associated with many CNS anomalies along with involvement of other systems. We present a case of Seckel syndrome with semilobar holoprosencephaly as associated CNS anomaly, which to the best of our knowledge has not been reported earlier.

Diaphragmatic hernia mimicking hydropneumothorax: common error in emergency department

Detection of diaphragmatic hernia in the acute setting is problematic and diagnosing diaphragmatic hernia as hydropneumothorax is not an uncommon mistake. We present a series of four such cases diagnosed over a 7-year period, from December 2004 to January 2011 and analyse them for how this mistake can be avoided. In case of all the patients reported by us the initial radiographs were technically compromised because the patient could not be positioned properly. Also they were examined by non-radiologists. We feel that treating surgeons in emergency department tend to overdiagnose pneumothorax as it is a life-threatening condition. We feel that in the appropriate setting suspicion of diaphragmatic hernia should be raised in patients having fractured ribs associated with homogenous opacity, which cannot be differentiated from the diaphragm. Evidence of loculation of hydropneumothorax in the appropriate setting should also raise the possibility of diaphragmatic hernia.

Intramedullary Neurocysticercosis Successfully Treated with Medical Therapy

To the Editor: Spinal cysticercosis is a rare presentation of neurocysticercosis. Surgical excision of cysticercus followed by cysticidal therapy remains the mainstay of treatment [1]. Authors have reported variable success of treating intramedullary cysticercus with praziquantel or albendazole alone [2–4]. Treatment with cysticidal drug alone in intramedullary lesion remains controversial and paradoxical worsening is feared [5]. We describe an eight-year-old boy with a history of back pain and slowly progressive weakness of both upper limbs and lower limbs for the last 1 mo. Weakness was most prominent in left upper limb with a history of numbness in entire left upper extremity. Examination revealed spinal tenderness along the cervical and thoracic spine. Motor system examination revealed asymmetric spastic quadriparesis (left upper limb predominant) with brisk deep tendon reflexes and extensor plantar response bilaterally. Sensory examination showed decreased response to pain from C6 dermatome to T1 dermatome on left upper limb. Magnetic resonance imaging (MRI) spine revealed intradural intramedullary cysticercosis at C5-C6 level with surrounding cord edema (Fig. 1). MRI brain study was normal. He was started on albendazole therapy (15 mg/kg/d) for 28 d under the cover of oral dexamethasone (0.6 mg/kg/d for 5 d). He had a remarkable improvement in motor weakness and sensory symptoms. In view of clinical improvement with medical treatment, surgically inaccessible intramedullary lesion and fear of post-operative myelotomy related complication, surgical intervention was deferred. At 4 wk follow-up, he had no residual motor weakness and complete resolution of sensory symptoms. There were no adverse effects in terms of the fresh neurological deficit on oral albendazole therapy. The presence of ring enhancing lesion with an eccentric scolex in an endemic area favors neurocysticercosis over other radiological differentials of the intramedullary cystic lesion. The present case describes a child with intramedullary cysticercosis who showed remarkable improvement with albendazole under the cover of steroids with no adverse consequences. The debate of whether steroid worked or albendazole worked in our patient remains unanswered. This report in conjunction with the similar observation by other authors warrants re* Jaya Shankar Kaushik jayashankarkaushik@gmail.com

Single voxel 1 H magnetic resonance spectroscopy in the diagnosis of musculoskeletal mass lesions

Introduction: In vivo magnetic resonance spectroscopy (MRS) is an established technique for evaluation of malignant tumors in brain, breast, prostate, etc., However, its efficacy in the diagnosis of musculoskeletal (MSK) mass lesions is yet to be established. We present our experience with MRS of these lesions. Materials and Methods: Magnetic resonance imaging (MRI), dynamic contrast-enhanced MRI and single-voxel 1 H MRS was performed in 30 consecutive patients with histologically proven benign and malignant MSK tumors/mass lesions each, on a 1.5-T magnetic resonance scanner. MRS was performed with echo times (TE) of 40, 135 and 270 ms. A clearly identifiable peak at 3.2 ppm in at least two of the three spectra acquired at the three TE was taken as positive for choline. MRS imaging and enhancement patterns were compared in these two groups and were analyzed by a Radiologist blinded to the histopathological findings. Results: Ages of patients in the malignant age group ranged from 2 to 65 years (M: F - 19:11) while that of patients in the benign group ranged from 7 months to 56 years (M: F - 17:13). There were two patients with Type I curve, 18 with Type II curve and 10 with Type III curve on dynamic contrast enhanced images in the malignant group while there were no patients with Type I curve, 5 with Type II curve and 25 with Type III curve in the benign group. The sensitivity of MRS for predicting malignancy was 60%, specificity was 93.33%, positive predictive value was 90%, negative predictive value was 70% and accuracy was 76.66%. Conclusion: MRS is a promising technique for evaluation of MSK mass lesions. The accuracy at present remains low. We recommend that it be used as an adjunct to routine MRI.

Fallen lung sign (on chest radiograph).

A 30-year-man came to the casualty department with anteroposterior compression injury to the thoracoabdominal region. The patient was in severe respiratory distress. Chest radiograph (Fig. 1) revealed a right-sided pneumothorax, associated rib fractures, and surgical emphysema with the collapsed lung in the dependent position—the “fallen lung sign.” A repeat radiograph also showed persistence of pneumothorax after chest tube insertion. Patient was taken up for operation, which revealed a right bronchial transection and reanastomosis was done. Tracheobronchial injuries occur in less than 1% of blunt chest trauma patients.1 Admission chest radiograph is a reliable screening test, even if it remains unremarkable in upto 20% patients with such lesions. Tracheobronchial injuries on chest radiographs are diagnosed through frequent indirect signs and infrequent direct ones. Indirect signs include bilateral upper rib fractures, tracheal shift, mediastinal widening, pneumomediastinum, pneumothorax persisting despite adequate chest tube drainage, or eventually hemothorax and subcutaneous emphysema.2–4 Semi indirect signs include oblique orientation or extraluminal position of the endotracheal tube and over distension of the endotracheal balloon cuff.5 Finally, direct radiologic signs feature interruption of the radiolucent lumen, sharp angulation described as “bayonet deformity,” other distortions of the normal tracheal column,2,3 and the “fallen lung” sign. Air leak through the lacerated bronchial wall leads to lung collapse. Because the intact pulmonary vessels are unable to sustain it, the collapsed lung drops toward the diaphragm.5,6 The “fallen lung” sign was initially described by Oh et al.6 in 1969 and Kumpke et al.5 in 1970. In routine practice, this sign is rarely observed possibly because, first, the collapse of the whole lung is rare. Second, 79% of the pneumothoraces secondary to bronchial tears reexpand spontaneously within 24 hours or with simple chest tube drainage. Third, a chest tube can be inserted before any chest radiograph is obtained, and the collapse can be resolved.7