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 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

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

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