Sarcoma de Ewing mesencefálico: reporte de caso / Mesencephalic Ewing sarcoma: Case report

El sarcoma de Ewing es una neoplasia de origen más frecuentemente óseo; otras localizaciones son excepcionales. En el caso de las presentaciones primarias intracraneales, resulta imprescindible descartar que se trate de un secundarismo así como también de otros tumores neuroectodérmicos que puedan requerir distintos abordajes diagnósticos y terapéuticos. Se presenta a una paciente de 14 años que consultó por ptosis palpebral de ojo izquierdo asociado a diplopía de 2 meses de evolución; los estudios por imágenes mostraron una lesión tumoral extraaxial situada a nivel de la cisterna interpeduncular. Se realizó la exéresis completa, con diagnóstico anatomopatológico de sarcoma de Ewing de ubicación mesencefálica

Ewing's sarcoma is a malignant neoplasm mainly occurring in the bone, with other locations being exceptional. In the case of primary intracranial presentations, it is essential to rule out metastatic lesions as well as other neuroectodermal tumors that may require different diagnostic and therapeutic approaches. We present a 14-year-old patient who consulted for upper eyelid ptosis of left eye associated with a 2-month history of diplopia, with imaging evidence of extra-axial tumor lesion, located at the level of the interpeduncular cistern. Complete excision was performed, with a pathological diagnosis of Ewing's sarcoma of midbrain location.

Hemicorea como presentación clínica de hemorragia mesencefálica / Hemichorea as clinical presentation of hemorrhagic ictus

Paciente masculino, hipertenso con inicio súbito de trastornos de movimientos hipercineticos, involuntarios, continuos e irregulares, de la cabeza y hemicuerpo izquierdo. Cursó con afectación de diversos segmentos corporales, principalmente la porción distal de las extremidades, que disminuyen significativamente durante el sueño y se exacerban con emociones, stress o alta concentración. Este trastorno puede tener múltiples causas: genéticas, degenerativas, cerebrovasculares, metabólicas, endocrinas, tóxicas y medicamentosas; en este caso no hay historia de consumo de tóxicos o medicamentos, ni tampoco, datos de causas metabólicas como hiper o hipoglicemia, hipercalcemia significativa o hipernatremia o hiponatremia, entre otras. Se descartó la etiología degenerativa por el curso agudo de la enfermedad. Las imágenes tomográficas fueron compatibles con hemorragia mesencefálica, lo cual motiva esta presentación por lo infrecuente de los trastornos del movimiento involuntario tras un ictus, aunque está descrita en la bibliografía(AU)

We describe a male patient, with hypertension, who consulted for sudden onset of continuous hemichoreic movements of the head and left side of the body. These movements diminished during the sleep and exacerbated with emotions, stress or alertness. Usually this clinical presentation can be due to genetic, degenerative, cerebrovascular events, metabolic causes, medications, toxic substances and several electrolytic disturbances. None of the later were found in this patient, and degenerative origin was not an option due to the sudden onset of his symptoms. The brain cat-scan showed a mesencephalic hemorrhage, which is infrequent with this clinical presentation(AU)

Propentofylline reverses delayed remyelination in streptozotocin-induced diabetic rats

Objective The diabetic state induced by streptozotocin injection is known to impair oligodendroglial remyelination in the rat brainstem following intracisternal injection with the gliotoxic agent ethidium bromide (EB). In such experimental model, propentofylline (PPF) recently showed to improve myelin repair, probably due to its neuroprotective, antiinflammatory and antioxidant effects. The aim of this study was to evaluate the effect of PPF administration in diabetic rats submitted to the EB-demyelinating model. Materials and methods Adult male rats, diabetic or not, received a single injection of 10 microlitres of 0.1% EB solution into the cisterna pontis. For induction of diabetes mellitus the streptozotocin-diabetogenic model was used (50 mg/kg, intraperitoneal route – IP). Some diabetic rats were treated with PPF (12.5 mg/kg/day, IP route) during the experimental period. The animals were anesthetized and perfused from 7 to 31 days after EB injection and brainstem sections were collected for analysis of the lesions by light and transmission electron microscopy. Results Diabetic rats injected with EB showed larger amounts of myelin-derived membranes in the central areas of the lesions and considerable delay in the remyelinating process played by surviving oligodendrocytes and invading Schwann cells after the 15th day. On the other hand, diabetic rats that received PPF presented lesions similar to those of non-diabetic animals, with rapid remyelination at the edges of the lesion site and fast clearance of myelin debris from the central area. Conclusion The administration of PPF apparently reversed the impairment in remyelination induced by the diabetic state. Arch Endocrinol Metab. 2015;59(1):47-53 .

Clinical signs, MRI features, and outcomes of two cats with thiamine deficiency secondary to diet change

Two cats were presented with vestibular signs and seizures. Both cats were diagnosed with thiamine deficiency. The transverse and dorsal T2-weighted magnetic resonance (MR) images revealed the presence of bilateral hyperintense lesions at specific nuclei of the midbrain, cerebellum, and brainstem. After thiamine supplementation, the clinical signs gradually improved. Repeated MR images taken 3 weeks after thiamine supplementation had started showed that the lesions were nearly resolved. This case report describes the clinical and MR findings associated with thiamine deficiency in two cats.

Morphometry MRI in the differential diagnosis of parkinsonian syndromes / Morfometria por ressonância magnética no diagnóstico diferencial das síndromes parkinsonianas

This study evaluates the diagnostic value of morphometric magnetic resonance imaging (MRI) in the differential diagnosis among Parkinson's disease (PD), progressive supranuclear palsy (PSP) and multiple system atrophy (MSA). We studied 21 PD cases, 11 MSA-c, 8 MSA-p and 20 PSP cases. Midbrain area (Ams), pons area (Apn), middle cerebellar peduncle (MCP) and superior cerebellar peduncle (SCP) were measured using MRI. Comparisons were made between PD, MSA-p, MSA-c and PSP. Apn, MCP and SCP morphometry dimensions presented differences among groups. Ams below 105 mm² and SCP smaller than 3 mmwere the most predictive measures of PSP (sensitivity 95.0 and 80.0 percent, respectively). For the group of MSA-c patients, Apn area below 315 mm² showed good specificity and positive predictive value (93.8 percent and 72.7 percent, respectively). In conclusion, dimensions and cut off values obtained from routine MRI can differentiate between PD, PSP and MSA-c with good sensitivity, specificity and accuracy.

Morfometria pela ressonância magnética (RM) no diagnóstico diferencial entre doença de Parkinson (DP), paralisia supranuclear progressiva (PSP) e atrofia de múltiplos sistemas (AMS). Este estudo avaliou a RM no diagnóstico diferencial de 21 casos com DP, 11 AMS-c, 8 AMS-p e 20 com PSP. A área sagital do mesencéfalo (Ams), área sagital da ponte (Apn), largura do pedúnculo cerebelar médio (PCM) e pedúnculo cerebelar superior (PCS) foram medidas pela RM e realizadas comparações entre destes pacientes. A Ams <105 mm² e a largura média do PCS <3 mm foram preditivas para PSP (sensibilidade de 95,0 e 80,0 por cento, respectivamente). Nos casos de AMS-c a área pontina <315 mm² apresentou boa especificidade e valor preditivo positivo para o diagnóstico (93,8 por cento e 72,7 por cento). Em conclusão, as dimensões e valores de cortes obtidos a partir da RM podem diferenciar PD, PSP e AMS-c, com sensibilidade, especificidade e precisão.

Marginally low copper causes lesions of the midbrain in animal models: the implications for man

Serum copper levels must be maintained between very strict limits for the maintenance of good health. High levels have recently been linked to Alzheimer's disease while low levels during pregnancy cause enzootic ataxia (swayback disease) in offspring. In this study, we investigated the prolonged effect of serum copper that was maintained at and around 0.5 ppm, the level presently regarded as safe. Pregnant sheep and rabbits in the last trimester (1-4 weeks) of pregnancy were treated with the copper chelator ammonium tetrathiomolybdate (ATM). Treatment was continued until the young were one month old at which time the animals were sacrificed Serum copper levels of the parents and offspring were monitored by atomic absorption. The difference spectra (400-630 nm) was examined and SDS PAGE was used to evaluate the protein composition of the brain mitochondria. The anatomy of the midbrain was also studied. Although the young sheep and rabbits from the ATM-treated mothers showed no visible signs of disability or swayback disease, the midbrain of those young animals with serum copper between 0.3-0.9 ppm showed evidence of vacuolation, cavitation and chromatolysis. In contrast, the difference spectra and the protein composition of the brain mitochondria from these animals were all normal. These results suggest that although animals may appear normal and exhibit some normal biochemical markers, serum copper in the region of 0.5 ppm may not be safe for some breeds of sheep or rabbits. It is possible that a similar situation applies to man.

Los niveles séricos cúpricos tienen que ser mantenidos dentro de límites muy estrictos, si se quiere tener una buena salud. Los altos niveles de cobre han sido asociados recientemente con la enfermedad de Alzheimer, mientras que los niveles bajos durante el embarazo causan ataxia enzoótica (swayback) enla descendencia. En este estudio investigamos el efecto prolongado del cobre sérico mantenido a 0.5 ppm ó alrededor de 0.5 ppm – el nivel considerado seguro actualmente. Ovejas y conejas preñadas, en el último trimestre (1-4 semanas) de gestación, fueron tratadas con el quelante del cobre conocido como tetratiomolibdato de amonio (TM). El tratamiento continuó hasta que las crías tuvieron un mes,momento en el que los animales fueron sacrificados. Los niveles séricos cúpricos de los progenitores y la progenie fueron monitoreados mediante absorción atómica. Se examinaron los espectros de diferencia (400– 630 nm). Se usó la técnica de SDS-PAGE para evaluar la composición proteica de lasmitocondrias cerebrales. También se estudió la anatomía del mesencéfalo. Aunque la anatomía de las crías de ovejas y conejas madres tratadas con TM no mostraron señales visibles de discapacidad o enfermedad swayback, el mesencéfalo de estas crías con cobre sérico entre 0.3–0.9 ppm, mostróevidencias de vacuolación, cavitación y cromatolisis. En contraste con ello, los espectros de diferencia y la composición proteica de las mitocondrias del cerebro de estos animales, fueron todos normales. Estos resultados sugieren que aunque los animales puedan parecer normales y presentar marcas bioquímicas normales, el cobre sérico en el rango de 0.5 ppm, puede no ser seguro para algunas crías de ovejas y conejos. Es posible que una situación similar se aplique al ser humano.

Encephalitis lethargica like illness: case report and literature review.

Recent studies have revealed that encephalitis lethargica (EL) may not be related to influenza virus infection but more likely to be a post-infectious autoimmune disease. The diagnostic clinical criteria for EL like illness include subacute hypersomnolence and ophthalmoparesis followed by Parkinsonism, oculogyric crisis, neuropsychiatric disorders and central respiratory abnormality. Recently, Magnetic Resonance Imaging (MRI), which depicts hypersignal intensity on T2 weighted, and FLAIR images at midbrain, tegmentum, and basal ganglia, have been very helpful diagnostic tests in EL like illness. Nevertheless, EL like illness has never been reported in Thailand. A 17 year-old man presented with hypersomnolence one week before admission. Physical examination revealed drowsiness and ophthalmoparesis. MRI showed bilateral hypersignal intensity lesions on T2 weighted and FLAIR images at midbrain, basal ganglia and temporal lobes. CSF studies showed normal profiles. CSF-PCR for herpes simplex virus, varicella zoster virus, cytomegalovirus, Epstein-Barr virus, Pan-Enterovirus and Westnile virus were negative. CSF Dengue and Japanese encephalitis virus hemagglutination test were negative. He was treated with intravenous dexamethasone and immunoglobulin. Somnolence and ophthalmoparesis were improved. Two months later, he developed schizophreniform features and Parkinsonism. MRI revealed improvement of midbrain and basal ganglia lesions. CSF studies showed normal CSF profiles while oligoclonal bands were positive. Autoimmune profiles and serological tests for post-streptococcal infection as well as syphilis were negative. Thyroid function tests and serum ceruloplasmin were within normal limits. Levo-Dopa, clonazepam and sodium valproate had been prescribed and the clinical syndrome was gradually improved.

Avaliação da doença de Parkinson pela ressonância magnética / Evaluation of Parkinsonïs disease using magnetic resonance imaging

OBJETIVO: Avaliar a doença de Parkinson pela ressonância magnética. MATERIAIS E MÉTODOS: De outubro de 1999 a outubro de 2002, foram estudados 42 pacientes com parkinsonismo, por meio de um aparelho de ressonância magnética de 1,5 T. Os pacientes foram divididos em dois grupos: grupo com doença de Parkinson (n = 26) e grupo com síndrome parkinsoniana atípica (n = 16), sendo os resultados comparados com um grupo controle (n = 18). Foram avaliadas as seguintes variáveis: espessura da pars compacta do mesencéfalo, grau de hipointensidade de sinal no putâmen, grau de atrofia cerebral, lesões no mesencéfalo, lesões na substância branca e a presença de lesão na borda póstero-lateral do putâmen. A análise estatística dos dados foi realizada, com a utilização do programa SPSS. RESULTADOS: A média de idade foi de 58,2 anos nos grupos com doença de Parkinson e controle, e 60,5 anos no grupo com síndrome parkinsoniana atípica. Os pacientes com doença de Parkinson e síndrome parkinsoniana atípica apresentaram redução da espessura da pars compacta e maior grau de hipointensidade de sinal no putâmen. O grau de atrofia cerebral foi maior nos pacientes com síndrome parkinsoniana atípica. As lesões no mesencéfalo e na substância branca foram semelhantes entre os grupos. O sinal hiperintenso na borda póstero-lateral do putâmen foi um achado pouco freqüente na população estudada, mas sugestivo de atrofia de múltiplos sistemas. CONCLUSÃO: Desta forma, a ressonância magnética detectou alterações morfológicas cerebrais que podem auxiliar no diagnóstico por imagem das síndromes parkinsonianas.

OBJECTIVE: The objective of this study was to evaluate the magnetic resonance imaging findings in patients with Parkinson's disease. MATERIALS AND METHODS: In the period from October 1999 to October 2002, 42 patients with parkinsonism were investigated using a 1.5 T MR equipment. Patients were divided into two groups: patients with Parkinson's disease (n = 26) and patients with atypical Parkinsonian syndrome (n = 16). The results were compared with a control group (n = 18). The following variables were evaluated: thickness of the mesencephalon compact pars, hypointense signal in the putamen, degree of brain atrophy, lesions in the mesencephalon, lesions in the white matter, and the presence of lesions in the posterior-lateral edge of the putamen. Statistical data analysis was carried out using the SPSS program. RESULTS: The mean age was 58.2 years for the Parkinson's disease and control groups, and 60.5 years for the atypical Parkinsonian syndrome group. Patients with Parkinson's disease and atypical Parkinsonian syndromes presented decreased thickness of the compact pars and a higher degree of signal hypointensity in the putamen. Cerebral atrophy was more prominent in the patients with atypical Parkinsonian syndrome. Lesions in mesencephalon and white matter were similar in both groups. The frequency of hyperintense signal in the posterior-lateral edge of the putamen was low within the studied population, although that could suggest multiple-system atrophy. CONCLUSION: Magnetic resonance imaging allows the detection of brain morphological changes that may help in the diagnosis of Parkinsonian syndromes.

Megalencephalic leukoencephalopathy with subcortical cysts: MRI and proton spectroscopic features.

Megalencephalic leukoencephalopathy with subcortical cysts (MLC) is a rare, recently described disease. It is characterized clinically by a large head, mild neurological symptoms and a remarkably slow course of functional deterioration. The MRI is characterized by 'swollen white matter' and large symmetrical cystic changes in the cerebral hemispheres. MLC should be considered in the differential diagnosis of children with megalencephaly and leukoencephalopathy. We report a child with this disease and discuss the MRI and MRS features.

Neurocysticercosis presenting as midbrain syndrome.

Brainstem is infrequently involved in patients with neurocysticercosis, usually, it occurs in association with disseminated form of neurocysticercosis. We are reporting two cases who had large multiple cysticercus lesions and presented as acute midbrain syndrome. The diagnosis of neurocysticercosis was established by presence of characteristic granulomatous extraaxial lesions around the midbrain, and in cerebral parenchyma, along with strongly positive ELISA for cysticercal antigen in cerebrospinal fluid as well as in serum. Both patients responded well to corticosteroids. However, repeat follow-up CT scan income case did not show significant alteration in the size of the lesion.