Lumbar intramedullary spinal schistosomiasis presenting as progressive paraparesis: case report.

OBJECTIVE AND IMPORTANCE: Blood fluke infection or schistosomiasis affects up to 300 million people worldwide. Although infection of the hepatic and urogenital systems commonly occurs, central nervous system involvement is rare. When presenting in the spinal cord, schistosomiasis can be difficult to diagnose because it can present as mass lesion or transverse myelitis. We describe a patient with lumbar intramedullary spinal schistosomiasis who presented to a tertiary medical center in the United States and discuss the diagnosis and treatment of this rare disease. CLINICAL PRESENTATION: A 25-year-old Brazilian man presented with progressive, subacute, bilateral lower extremity motor and sensory deficits and disturbances in bladder function. Magnetic resonance imaging revealed a diffusely enhancing mass expanding the region of the conus medullaris. INTERVENTION: Laboratory investigation disclosed serum and cerebrospinal fluid eosinophilia. Ultimately, cerebrospinal fluid serology demonstrated the presence of Schistosoma mansoni. The patient was treated with praziquantel and steroids and made a marked recovery. CONCLUSION: The clinical and radiographic manifestations of spinal schistosomiasis can mimic those of intra-axial spinal tumors and transverse myelitis. To avoid unnecessary surgery or delay in treatment, the clinician must have knowledge of this type of presentation. The increasing volume of international travel and high prevalence of the disease worldwide increases the possibility that the practicing neurosurgeon in the United States may encounter this rare but treatable disease.

Spinal paraparesis due to leukemic meningitis in early-stage chronic lymphocytic leukemia.

Leukemic meningitis is a rare manifestation of chronic lymphocytic leukemia (CLL) and typically occurs in advanced stages. We report the case of a 71-year-old male in whom Binet A, Rai 1 stage CLL was diagnosed in June 2002. The stage called for a "watch and wait" strategy. Six months later the patient presented with paraparesis. Magnetic resonance imaging of the lumbar spine revealed no abnormalities. Lumbar puncture disclosed xanthochromic cerebrospinal fluid (CSF) with 1003 cells/microl, 95% atypical lymphocytes. Flow cytometry confirmed typical features of CLL. Intrathecal injections of methotrexate, cytosine arabinoside and corticosteroids did not substantially reduce the CSF cell count and failed to improve the neurological symptoms. Two weeks later the patient developed a pulmonary embolism complicated by fatal secondary pneumonia. Leukemic meningitis is a rare manifestation of CLL, especially in early stages. Selective spinal paraparesis as the first symptom of meningitis in CLL is even rarer and has been reported only once.

Tau protein in the cerebrospinal fluid is a marker of brain injury after aortic surgery.

BACKGROUND: Tau is a protein localized primarily in neurons, especially in the axonal compartment. Cerebrospinal fluid tau levels are elevated in acute stroke and head traumas. The purpose of this study is to elucidate the alterations of cerebrospinal fluid tau levels in patients with or without neurologic complication after aortic surgery. METHODS: Twenty-eight patients undergoing descending thoracic (n = 8) or thoracoabdominal (n = 20) aortic surgery were enrolled. Cerebrospinal fluid tau levels were measured before operation and at seven time points up to the 72nd postoperative hour, and were compared with cerebrospinal fluid S100B levels. RESULTS: Two patients developed brain infarction, including the one with paraplegia. In these patients, 20-fold to 100-fold tau elevation was observed, but S100B elevation was less evident in the patient without paraplegia. Three other patients developed spinal cord injury. Additional three patients suffered from temporary neurologic dysfunction of the brain. Tau levels in the latter three patients showed tenfold elevation and were higher than those in the three patients with spinal cord injury or those in the patients without neurologic complication up to 24 postoperative hours. The S100B levels were also higher in the three patients with temporary neurologic dysfunction of the brain than in the patients without neurologic complication at the conclusion of surgery. From 6 to 24 postoperative hours, they were higher in the three patients with spinal cord injury than in the patients without neurologic complication. CONCLUSIONS: These preliminary results suggest that cerebrospinal fluid tau levels reflect brain injury. Because tau levels may separate the patients with temporary neurologic dysfunction, they may serve as a useful marker of brain injury.

Reversal of paraparesis after thoracic aneurysm repair by cerebrospinal fluid drainage.

PURPOSE: To describe a case of reversal of delayed paraparesis, after an elective type I thoracoabdominal aortic aneurysm (TAAA) repair, via cerebrospinal fluid (CSF) drainage. CLINICAL FEATURES: A 75-yr-old woman developed paraparesis 13 hr after type I TAAA repair. The patient had been given combined regional and general anesthesia. There was no cerebrospinal fluid drain inserted at the time of surgery. The patient was hemodynamically stable throughout the procedure and was transported to the intensive care unit with trachea intubated and lungs ventilated. She demonstrated some initial lower limb paraparesis but had good recovery of limb function three hours after cessation of the epidural infusion. However, five hours and forty-five minutes after stopping the epidural, she was again paraparetic. Peripheral nerve injury, prolonged effects of epidural local anesthetic, and epidural hematoma were ruled out as precipitating factors. Cord ischemia was considered possible and a CSF catheter was inserted. Immediate improvement was seen upon catheter insertion and commencement of drainage, beginning with movement in the left toes and foot. Drainage was performed when the CFS pressure became > 15 mmHg. Motor function in the lower limbs continued to improve with each drainage extending to complete recovery after 40 hr. She was discharged home 11 days after surgery with no neurological deficit. CONCLUSION: Drainage of CSF was useful in treating a case of post-TAAA neurologic deficit.