Tumefactive multiple sclerosis versus high grade glioma: A diagnostic dilemma.

Background: Tumefactive demyelinating lesions (TDL) share similar clinical features and magnetic resonance imaging (MRI) characteristics with high grade glioma (HGG). This study develops an approach to navigating this diagnostic dilemma, with significant treatment implications as the management of both entities is drastically different. Methods: A retrospective analysis of 41 TDLs and 91 HGG with respect to demographics, presentation and classical MRI characteristics was performed. A diagnostic pathway was then developed to help diagnose TDLs based on whole neuraxis MRI and cerebrospinal fluid (CSF) examination. Results: The diagnosis of TDL is more likely than HGG in younger females who present with subacute or chronic symptoms. MRI characteristics favoring TDL over HGG include smaller size, open rim enhancement, little or no associated edema or mass effect and the presence of a T2 hypointense rim. MRI of the whole neuraxis for detection of other lesions typical of multiple sclerosis (MS), in combination with a lumbar puncture (LP) showing positive CSF-specific oligoclonal bands (OCB), was positive in 90% of the TDL cohort. Conclusion: The diagnostic pathway, proposed on the basis of specific clinicoradiological features, should be followed in patients with suspected TDL. If MRI demonstrates other lesions typical of MS and LP demonstrates positive CSF-specific OCBs, then patients should undergo a short course of IV steroids to look for clinical improvement. Patients, who continue to deteriorate, do not demonstrate other lesions on MRI or where the LP is negative for CSF-specific OCB, should be considered for biopsy if safe to do so. This pathway will give the patients the best chance at neurological preservation.

Tumefactive multiple sclerosis versus high-grade glioma: A diagnostic dilemma.

BACKGROUND: Tumefactive demyelinating lesions (TDLs) share similar clinical features and MRI characteristics with high-grade glioma (HGG). This study develops an approach to navigating this diagnostic dilemma, with significant treatment implications as the management of both entities is drastically different. METHODS: A retrospective analysis of 41 TDLs and 91 HGG with respect to demographics, presentation, and classical MRI characteristics was performed. A diagnostic pathway was then developed to help diagnose TDLs based on whole neuraxis MRI and cerebrospinal fluid (CSF) examination. RESULTS: The diagnosis of TDL is more likely than HGG in younger females who present with subacute or chronic symptoms. MRI characteristics favoring TDL over HGG include smaller size, open rim enhancement, little or no associated edema or mass effect, and the presence of a T2 hypointense rim. MRI of the whole neuraxis for detection of other lesions typical of multiple sclerosis (MS), in combination with a lumbar puncture (LP) showing positive CSF-specific oligoclonal bands (OCB), was positive in 90% of the TDL cohort. CONCLUSION: The diagnostic pathway, proposed on the basis of specific clinicoradiological features, should be followed in patients with suspected TDL. If MRI demonstrates other lesions typical of MS and LP demonstrates positive CSF-specific OCBs, then patients should undergo a short course of IV steroids to look for clinical improvement. Patients who continue to deteriorate, do not demonstrate other lesions on MRI or where the LP is negative for CSF-specific OCB, should be considered for biopsy if safe to do so. This pathway will give the patients the best chance at neurological preservation.

Cavernous sinus embolisation prior to removal of penetrating foreign body in a 6-year-old child.

Transorbital penetrating foreign bodies are extremely rare in children and may penetrate the cavernous sinus or the underlying internal carotid artery. Parent vessel sacrifice and temporary balloon occlusion are feasible options for managing arterial injury during removal of the foreign body. Even in the absence of arterial injury, the ophthalmologist may encounter significant bleeding from the cavernous sinus deep in their operative field that is difficult to control. We present a case of a 6-year-old child with a stick penetrating the left superior orbit to enter the cavernous sinus but sparing the internal carotid artery. We describe the first reported experience of prophylactic coil embolisation of the cavernous sinus to minimise intraoperative bleeding during transorbital removal of a foreign body with an excellent clinical outcome.

Idiopathic intradural dorsal thoracic arachnoid cysts: A case series and review of the literature.

BACKGROUND: Spinal intradural arachnoid cysts (SIAC) are cerebrospinal fluid (CSF) filled sacs formed by arachnoid membranes and may be either idiopathic or acquired. Idiopathic cysts represent a separate entity and their aetiology remains uncertain. By far the most difficult differential diagnosis is distinguishing between idiopathic anterior spinal cord herniation (IASCH) and dorsal thoracic intradural arachnoid cysts (TIAC), due to their similarity in radiological appearance. Cine-mode (SSFP) is emerging as a novel technique in the diagnosis and operative planning of SIAC. METHOD: Retrospective analysis of patients with idiopathic TIACs that were surgically managed at Royal North Shore Hospital and North Shore Private Hospital between November 2000 and November 2015. RESULTS: Ten patients were included in this study. Age ranged from 20 to 77years with a mean age of 60years and a female preponderance. The most common clinical features were progressive gait ataxia and lower limb myelopathy. Radicular pain tends to improve following surgery, however gait ataxia may not. DISCUSSION: While there are circumstances in which the distinction between dorsal thoracic intradural arachnoid cysts and idiopathic anterior spinal cord herniation are radiologically obvious, in cases where the appearances are less clear, cine-mode SSFP MRI imaging can provide an invaluable tool to differentiate these pathologies and lead the clinician towards the correct diagnosis and management. The mainstay of surgical management for dorsal TIACs is laminectomy and cyst excision or fenestration. Surgery for gait ataxia should be aimed towards preventing deterioration, while maintaining the potential for symptomatic improvement, whereas surgery for radicular pain should be curative.

Transtympanic Facial Nerve Paralysis: A Review of the Literature.

Facial nerve paralysis because of penetrating trauma through the external auditory canal is extremely rare, with a paucity of published literature. The objective of this study is to review the literature on transtympanic facial nerve paralysis and increase physician awareness of this uncommon injury through discussion of its clinical presentation, management and prognosis. We also aim to improve patient outcomes in those that have sustained this type of injury by suggesting an optimal management plan. In this case report, we present the case of a 46-year-old white woman who sustained a unilateral facial nerve paresis because of a garfish penetrating her tympanic membrane and causing direct damage to the tympanic portion of her facial nerve. On follow-up after 12 months, her facial nerve function has largely returned to normal. Transtympanic facial nerve paralysis is a rare injury but can have a favorable prognosis if managed effectively.

Lumbosacral transitional vertebrae and its prevalence in the Australian population.

Study Design Retrospective cohort study. Objective Lumbosacral transitional vertebrae (LSTV) are a common congenital anomaly, and they can be accurately identified on anteroposterior (AP) radiographs of the lumbosacral spine. This study attempts to determine the prevalence of this congenital anomaly and to increase awareness among all clinicians to reduce the risk of surgical and procedural errors in patients with LSTV. Methods A retrospective review of 5,941 AP and lateral lumbar radiographs was performed. Transitional vertebrae were identified and categorized under the Castellvi classification. Results The prevalence of LSTV in the study population was 9.9%. Lumbarized S1 and sacralized L5 were seen in 5.8 and 4.1% of patients, respectively. Conclusion LSTV are a common normal variant and can be a factor in spinal surgery at incorrect levels. It is essential that all clinicians are aware of this common congenital anomaly.

Intracranial subdural empyema: a 10-year case series.

BACKGROUND: Intracranial subdural empyema (ISDE) is a pyogenic infection located in the space between the dura and arachnoid mater. Early diagnosis, prompt initiation of antimicrobial therapy, and surgical drainage are essential to reduce morbidity and mortality. This case series analyzes the presentation and management of ISDE in Queensland, Australia, over a 10-year period. METHODS: Thirty-six patients with ISDE were treated at Gold Coast University Hospital, Princess Alexandra Hospital, Townsville Hospital, and Royal Brisbane Hospital. The patients' medical records were analyzed to ascertain patient demographics, etiology, presentation, and management. RESULTS: A slight male preponderance occurred in the cohort of 36 patients with ISDE. The most common source of infection was a neurosurgical procedure, followed by sinusitis and otogenic sources. Headache, fever, and altered sensorium were the most common clinical triad of symptoms, present in 19 (53%) patients. Craniotomy was performed as the initial surgical procedure in 28 (88%) of the 32 patients who required surgery. Seizure prophylaxis was given to 25 (69%) patients, with 8 (32%) of those patients having seizures during their hospitalizations despite this therapy. Five (14%) patients required readmission and a second craniotomy because of failed resolution of the ISDE. CONCLUSION: Altered sensorium, fever, vomiting, and headache should alert the clinician to the possibility of ISDE. A history of neurosurgery, sinusitis, otitis media, or skull trauma increases the likelihood of this differential. Management includes sensitive antibiotic therapy and surgical drainage. Compared with burr hole, craniotomy is associated with less recurrence of ISDE.