Spontaneous intracranial hypotension: an interesting cause of intractable headache

Intracranial hypotension [ICH] is a benign syndrome which is often under-diagnosed. It is characterized by orthostatic headache which is predominantly occipital. ICH is diagnosed in the presence of a typical history and characteristic imaging findings. Further confirmation by Lumbar Puncture to document low CSF pressure is necessary in some cases. Treatment is mainly conservative. However, surgical intervention might be required if conservative measures fail. In this report we present a case of 42 year old male patient who presented with symptoms of orthostatic occipital headache of three months duration and was subsequently diagnosed with Intracranial Hypotension based of characteristic MRI findings

Silent cerebral infarctions in type II diabetes mellitus patients-could brain MRI be a routine investigation?

To study the prevalence of silent cerebral infarction in Type II diabetes mellitus. The study was a prospective study on 80 patients recruited from neurology, endocrine outpatient clinics. Patients were type II diabetics as described by the American Diabetes Association, 2011 criteria. All patients underwent full metabolic profiles to diagnose diabetes mellitus and MRI brain scans to detect cerebral infarction. Silent cerebral infarctions were detected in 60% of patients [48/80 patients] predominately along periventricular white matter area and subcortical areas [Basal ganglia, Thalamus]. Asymptomatic Type II diabetes mellitus patients could have vascular cerebral changes without neurological symptoms. MRI brain scans could be recommended as routine diagnosis [if possible] for early cerebral infarct detection in type II diabetic patients

case of intracranial sinus thrombosis

A male patient, 26 years old, presented at internal medicine clinic at GMC hospital with severe headache, blurred vision and double vision. He was given medical treatment and was referred to a neurologist the next day. After re-evaluation he gave a past history of repeated gastroenteritis which he claimed as typhoid, and recurrent sinusitis with right side mastoiditis, with frequent oral aphthous ulcers. His father had recurrent lower limb DVT. General examination was normal, while the neurological examination showed injury of left sixth cranial nerve, and horizontal diplopia with convergent squint. Fundus examination showed papilledema. This clinical picture was suggestive of increased intracranial pressure. Urgent CT brain was done, which showed right transverse and superior sagital sinus thrombosis. The patient was hospitalized as a case of superior and transverse sinus thrombosis. MRI brain and MRV showed right mastoiditis, and thrombosis of right transverse sinus without secondary hydrocephalic changes. Laboratory investigations were normal apart from low antithrombin three with normal protein S and C. Collagen battery, was within normal range. Treatment was started immediately with low molecular weight heparin, oral anticoagulant and antiplatelets. The patient subjectively showed improvement as regards clarity of vision, headache and diplopia. But his frequent fundus examination showed progression of papilledema and involvement of the right medial rectus muscle, which explained why dipolpia was less at this stage. Urgent follow up MRI brain and MRV showed stationary course of disease with failure of canalization of the sinuses, yet no hydrocephalic changes. The future plan involves increasing and adjusting the dose of anticoagulant and diuretics, and considering lumbar puncture for decreasing optic nerve compression. Diagnosis: Antithrombin three dysfunction with sinus thrombosis

case of multiple cranial nerve injuries

A female patient 30 years old, mother with one child, housewife with no special habits of medical importance complained of deviation of the angle of the mouth to the right side of two days' duration. Lacrimation of the left eye and difficulty in closing the left eye were present for two days, for which she had consulted aneurologist. She had a past history of chronic left ear discharge, tinnitus, and decrease in hearing acuity of left ear. General examination revealed no detectable abnormalities. Neurological examination revealed left trigeminal nerve palsy, sensory along three divisions. Corneal reflex was absent. There was decrease hearing acuity of left ear especially sensory neural affection. Left facial and hypoglossal nerves were affected. Long tract was not affected. High resolution power CT for left ear, and MRI brain with contrast were normal.ESR, CBC, C-RP were Normal. Sarcoidosis battery revealed elevated serum calcium, and Angiotensin converted enzyme [ACE] with elevated CSF ACE. The patient was treated with Methyl predinsolone l00mg/day in divided doses, Calcium supplement OD and Pantazole FBI 40 mg/day, and given physiotherapy. Recovery was seen within two weeks

Recent concepts in the pathophysiology and treatment of pseudotumor cerebri [PTC]

Study the role of intracranial venous system in the pathophysiology of Pseudotumor cereberi. Twenty patients diagnosed as PTC according to Dandy diagnostic criteria. All underwent general and neurological assessment. Full ophthalmologic assessment. Full Laboratory investigations were done. Radiological assessment included CT scan brain +/- MRI brain without contrast, MRV of the intracranial venous system. All underwent digital subtraction cerebral Angiography [DSA] [venous phase] to confirm the validity of filing gaps seen at the level of MRV whether they are true stenosis or not. Menstrual irregularity documented in 2 patients [10%]. Sixteen patients [80%] considered to be overweight or obese. MRV brain showed that 14 patients [70%] showed filling gaps suggestive of sinus stenosis. However, digital subtraction cerebral angiography [venous phase] gave different data that only 5 patients [25%] had stenosis in their dural sinuses. MRV showed to be a good screening tool since it had 100% sensitivity and negative predictive value. Therefore, if MRV is normal no further investigations are needed. However, since it has a moderate specificity [62%] with a positive predictive value [PPV] of only 35%, then lesions detected should be confirmed with digital subtraction cerebral angiography [venous phase] particularly those involving the transverse and sigmoid sinus. In our study most of the cases having venous sinus stenosis occurred among patients with age between 22-30 y old [p<0.05] and among those with BMI>30 [p<0.05]. Significant association was found between visual symptoms and stenosis since 80% of cases with stenosis had diplopia, TVO's, grade 3 papilledema and in grade 3 field defect [p<0.05]. By logistic regression model, diplopia and TVO's were considered as independent predictors of occurrence of stenosis among the studied cases. Studying the intracranial venous system in patients with PTC is and important step in understanding the pathophysiology of the disease. Detection of venous sinus stenosis opens the way to a novel therapeutic option for refractory patients like venous sinus stenting

Limited experience in the early management of fractured penis

To review the effect of early surgical exploration and repair, of penile fractures, on the overall prognosis of these injuries and the maintenance of erectile function. This was a retrospective study in which we reviewed a total of 16 patients with penile fracture who presented over a period of 36 months. Associated urethral injuries were found in 3 out of the 16 patients [18.75%]. All patients were treated by early surgical repair within 24 hours from the time of injury.They were discharged in good condition and were followed up, both clinically and pharmacocavernosographically, in the outpatient department with excellent results. We recommend early surgical exploration and repair of these injuries because of the excellent results, shorter hospitalization, less morbidity and earlier return to full sexual activity

Modifying effects of soybean and nigella sativa against experimental hepato-carcinogenesis induced by nitrosamine precursor in rats. [Histopathological and electron microscopically study]

Cancer has become an important topic in medicine since it is a major cause of death in the developing countries and it is now only secondary to that of myocardial infraction. Nitrosamines precursors are known to be carcinogenic to humans, in various organs at relatively low levels of exposure. It induces benign and malignant tumors especially liver tumors following its administration by various routes, including ingestion and inhalation. Humans may be exposed to Nitrosamines through the ingestion of food that contains it, such as cured meat products, and smoked fish. Other exposures to Nitrosamines may be from drinking contaminated water and from breathing cigarette smoke and contaminated ambient air. Individual are most likely to be exposed to Nitrosamines in occupational settings such as in the rubber, tannery, fish processing, dyes, and surfactant industries. The prevalence of liver tumors throughout the world makes in imperative to seek chemo preventive agents. Vegetables, natural products of plant origin and numerous non-nutritive dietary constituents have been shown to play a salutary role in cancer chemoprevention. The present study aims to evaluate the chemo preventive efficacy of soy bean and Nigella sativa on hepato-carcinogenesis induced by dibuty1 nitrosamine [DEN]. It could be observed that both soy bean and Nigella sativa have a good effect of amelioration against liver hepatoma induced by nitrosamine. Soy bean more or less showed more prerogative effect than Nigella 9 and 12 months after administration

Mycoplasma pneumonia associated with severe autoimmune hemolytic anemia

Mycoplasma pneumonia is an uncommon cause of autoimmune hemolytic anemia [AIHA]. It is usually mild and self-limiting. Rarely, it is severe necessitating steroidtherapy. We present a case of severe autoimmune hemolytic anemia [AIHA] caused by Mycoplasma pneumoniae t h a t required steroids, intravenous immunoglobulin, plasma pheresis, and cyclophosphamide. The mechanism of action of each line of treatment has been discussed

Hyperinfection with strongyloides stercoralis

A case of Strongyloides hyperinfection syndrome, associated with corticosteroid therapy is described here. A 69-year-old male patient was admitted with a minor stroke. A history of headache arid a markedly elevated ESR prompted a temporal artery biopsy, which was consistent with temporal arteritis. Treatment was started with prednisolone 60 mg per day and the patient was discharged for follow-up. He was readmitted with a dense hemiplegia arid high fever. Blood culture grew E.co/i. He rapidly deteriorated arid died with evidence of disseminated intravascular coagulation and acute respiratory distress syndrome. Wet smears of sputum were positive for larvae of Strongyloides sterco ru/is, suggesting generalised infection. The importance of early diagnosis arid therapy, and screening methods for detection of parasites in stool are discussed

Abdominal tuberculosis as seen in Farwania hospital in kuwait

Experience gained in the management of 32 cases of abdominal tuberculosis in Kuwait is summarised. They were admitted to the Farwania Hospital Medical Department. The hospital serves a population of about 439,337 [101,965 Kuwaitis and 337,272 Expatriates] as per the 1985 census record of the Ministry of Civil Information. They presented over a 4 year-period from January 1986 till January 1990. Of the 32 cases, 10 had intestinal tuberculosis, 6 mesenteric-lymphnodal [nodular] tuberculosis, and 16 peritoneal tuberculosis. Fourteen of them were Kuwaitis and 18 were classified as expatriates. An association with pulmonary tuberculosis was found in 4 cases only [12.5%].The duration of hospitalisation ranged between 1-2 weeks in 37.5% of the cases, and 2-4 weeks in 43.8% of the cases. The yearly incidence of abdominal tuberculosis was found to be higher in Kuwaitis [3.43/100000 population, p< 0.05] than in expatriates[1.33/100000 population. p< 0.05]. In spite of its being a potentially lethal disease no mortality was documented