Intracranial hypotension due to shunt over drainagepresenting as reversible dorsal midbrain syndrome

Intracranial hypotension syndrome is an uncommon manifestation of shunt overdrainage; characterized by a triad of postural headache, diffuse pachymeningeal gadolinium enhancement and low cerebrospinal fluid opening pressure. We describe a young female with recurrent episodes of postural headaches and reversible dorsal midbrain syndrome due to intracranial hypotension as a complication of shunt overdrainage, and a subsequent improvement following shunt ligation.

Persistent cerebellar ataxia with cerebellar cognitive affective syndrome due to acute phenytoin intoxication: A case report

Phenytoin is one of the commonly used antiepileptic drugs. The common dose dependent and reversible neurological side effects of phenytoin are nystagmus, diplopia, dysarthria, ataxia, incoordination, chorioathetosis, orofacial dyskinesias and drowsiness. Persistent cerebellar dysfunction with cerebellar atrophy is a well known complication of long term phenytoin use. There are several mechanisms proposed including hypoxia due to frequent seizures or toxic effects of phenytoin on cerebellar Purkinje cells. However, irreversible cerebellar dysfunction following acute phenytoin intoxication is rare. We report a 20 year old female who presented with nystagmus, dysarthria, limb and truncal ataxia with orofacial dyskinesias and chorea. She also had cognitive and affective symptoms in the form of reduced attention, slow responses, lalling speech, blunting of affect, inappropriate laughter, reduced self care and executive dysfunction. The symptoms started 2 weeks following the initiation of phenytoin 300mg/ day, given prophylactically following left basal ganglia bleed. Her serum phenytoin was in toxic range, hence phenytoin was stopped. Her PET scan revealed bilateral cerebellar hypometabolism. At 6 months follow up, she had persistent ataxia with cognitive and affective dysfunction and follow up MRI showed diffuse cerebellar atrophy. The clinical and radiological fi ndings suggest that acute phenytoin intoxication is responsible for persistent ataxia and cerebellar cognitive affective syndrome.

Recurrent sixth nerve palsy in childhood ophthalmoplegic migraine: A case report

Ophthalmoplegic migraine is a rare disorder characterized by childhood onset recurrent attacks of migraineous headaches with paresis of ocular cranial nerves. The third cranial nerve is commonly involved. Involvement of fourth and sixth cranial nerve is uncommon. We present a child with opthalmoplegic migraine with recurrent sixth cranial nerve palsy on two occasions.

Progressive multifocal leukoencephalopathy in an immunocompetent patient: A case report

Progressive multifocal leukoencephalopathy (PML) is a progressive lethal demyelinating disease of the brain, caused by JC virus. Reactivation of JC virus due to reduction of cellular immunity especially in setting of AIDS, is the commonest underlying cause. PML has classically been described in individuals with profound cellular immunosuppression such as patients with AIDS, haematological malignancies, organ transplant recipients or those treated with immunosuppressive or immunomodulatory medications for autoimmune diseases. Rarely it has also been diagnosed in cases with no or minimal immunosuppression. Here, we report a 50 year-old man who presented with sudden onset multiple neurologic defi cits. Neuroimaging, histopathology, and virology studies confi rmed the diagnosis of PML. We could not however demonstrate any underlying immunodefi ciency state. Our case suggests that absence of immunodefi ciency does not exclude the possibility of PML and should be considered in immunocompetent patients with a typical clinical course and neuroimaging fi ndings.

Comparison of lead and cerrobend blocks for incident photon Flux of 6 and 15 MV X-rays

During radiotherapy treatment, critical organs are shielded using lead and cerrobend blocks. The objective of this study is to compare the effects of lead and cerrobend shielding blocks on incident photon beam. Collimator scatter factors were measured for open square fields [3 x 3 cm to 40 x 40 cm] defined by collimator jaws and for fields blocked down to smaller asymmetric fields by using five different Lead and Cerrobend blocks for 6 and 15 MV photon beams from a Varian Clinac 2100C accelerator. The measurements in air were performed using Farmer type ionization chamber fitted with acrylic build up caps. The Block Tray Factor [BTF] increased with field size for both 6 and 15 MV photon beams. In case of Lead blocks, the extreme variations in BTF for 6 MV photon beam are 0.70%, 0.84%, 0.56%, 0.80% and 1.15%. Similarly, for 15 MV the maximum variations for Lead blocks are 0.46%, 0.60%, 0.83%, 0.88% and 1.10% respectively. No significant difference has been observed in the BTF of Cerrobend blocks for 6 and 15 MV photon beams. The dose received by a point in air apparently shielded by lead blocks has three main contributions: 1. Due to primary photon beam transmitted through the block, 2. Due to scattered photons, 3. Due to contamination electrons. These three factors collectively cause the increase in BTF with increasing field size, energy, and decreasing block size. The effect of shielding on the beam output increases with field size, beam energy and shield size. This increase follows almost the same pattern for both lead and cerrobend shielding blocks. Therefore shield factors for all field sizes, beam energies and shield sizes should be determined separately for precise patient dose delivery

Intestinal parasitic infections in children from Northern Pakistan

Intestinal parasitic infections cause significant morbidity in children of developing countries, where the vicious cycle of infections and malnutrition impairs their physical growth and development. A community based cross-sectional study on randomly selected children under 15 years of age was performed in two towns of Northern Pakistan. Information on hygiene, sanitation, waste disposal, water supply and maternal education was collected and the nutritional status of these children was assessed. Stool samples of the subjects were collected, immediately preserved and later examined for parasites, with severity of infection being quantified. Of the 89 samples examined, 91% contained one or more parasites. The lowest prevalence of infection was in children less than one year old. Majority of those infected in both towns were girls. Fifty-one percent of the infected children from Yasin and 38% from Singal suffered from malnutrition. Maternal education, family income and drinking water treatment did not affect the prevalence of infection in either town. The most frequent parasites isolated were Ascaris lumbricoides [66.3%], Entamoeba histolytica [27%], Blastocystis hominis [27%], Giardia lamblia [24.7%], and Trichuris trichiura [15.7%]. The results of this study indicate that parasitic infections in northern Pakistan have a high prevalence but low intensity. Programs for early detection and interventional strategies, along with improved hygiene, sanitation and waste disposal facilities are urgently needed to improve the health of these children

Sacral agenesis: a report of two cases and review of literature

Two cases of sacral agenesis are reported and literature is reviewed

Preoperative cholangiography Karachi experience

The results of preoperative Cholangiography [P C] were evaluated at six centres in Karachi. In four centres P.C. was done routinely. Pooled results showed that 14.8% of 222 cases had such exploration and 12.1% yielded stones. In two other centres P.C was employed selectively for cases with a 'relative' clinical indication for duct exploration, pooled results showed that 16.6% of 253 cases had ducts explored and the positive yield was 12.3%. As compared with the results of duct exploration on clinical ground alone, a practice in one of the centres [prior to employing routine P C] it was found that rate of stone retrieval from ducts explored on the basis of P C was much higher