Solitary cerebral parenchymal cysticercosis: a prospective comparative study with computed tomography and magnetic resonance imaging.

AIM: To present a prospective series of 86 patients with solitary cerebral cysticerci who underwent both contrast computed tomography (CT) and contrast magnetic resonance imaging (MRI), and to correlate and compare the imaging findings using these two modalities. MATERIALS AND METHODS: Lesion characteristics, staging of the cyst and perilesional hypodensity on CT and hyperintensity on MRI were analyzed, and the lesion was described with regard to the appearance of the scolex, cyst fluid, cyst wall and the perilesional area. RESULTS: Patients were largely children and adolescents (mean age 17.4 years, range 6-52) with 52.3% males. MRI was performed, on average, 10.7 days after CT. MRI was more sensitive than plain CT scan in detecting cysticercal lesions (P = 0.003), but there was no statistically significant difference between contrast CT and MRI. None of the patients were detected with an alternative disease on serial MRI. No cyst showed significant mass effect. Non-contrast CT was less sensitive than either contrast CT or MRI in detecting the scolex (P = 0.011), but no difference was seen between the latter two modalities. Qualitative imaging characteristics of the cysticercus on MRI and CT scan are described. All cysts were round in shape, with an average diameter of <10 mm, and maximum diameter of 19 mm. CONCLUSION: In the present prospective series, contrast CT was nearly as sensitive as MRI in detecting solitary cerebral cysticerci. Thus, in highly resource-limited settings contrast CT may be sufficient for the diagnosis and management of neurocysticercosis.

HHH regime for arteritis secondary to TB meningitis: a prospective randomized study.

BACKGROUND: Tuberculous meningitis (TBM) is a fairly common, debilitating disease and is often complicated by arteritis resulting in brain infarction. Few treatment regimes specifically address this condition. Hypervolemia-hypertension-hemodilution (HHH) regime is known to be effective for treatment of vasospasm complicating subarachnoid hemorrhage. We studied the efficacy of HHH regime in patients with TBM with arteritis using a prospective, randomized study design. PATIENTS AND METHODS: Patients diagnosed to have TB meningitis by clinical, CSF, and imaging findings were evaluated for arteritis, which was recognized by presence of focal neurologic deficits with or without corresponding focal hypodensities on brain CT scan. Patients with deficits of < 96 h were randomized to HHH or conservative treatment. All patents received four-first-line anti-TB drugs and Inj.dexamethasone. HHH therapy was administered over 3-9 days. Neurologic status and modified Rankin score were noted serially and at discharge. RESULTS: Seven patients received HHH and 5, conservative treatment. All had hemiparesis with power 0-3/5. Median GCS was worse in HHH group (11 vs. 13). In the HHH group, 6/7 improved in motor power, and 5/7 in sensorium. In the control group, 3/5 improved in motor power and 3/5 in sensorium. Four patients died in each group. CONCLUSION: HHH therapy is safe and may be beneficial in the management of patients with infective arteritis secondary to TBM. Further study in a larger group with improved monitoring of cerebral circulation is indicated.

Hypertrophic cranial pachymeningitis in countries endemic for tuberculosis: diagnostic and therapeutic dilemmas.

Hypertrophic cranial pachymeningitis (HCP) is an uncommon disorder with few studies correlating clinical, imaging and histopathological features. The aim of this study was to describe clinical and laboratory observations and therapeutic options of patients with HCP. Eleven patients with HCP (M:F 6:5; age range, 23-52 years) were evaluated over 10 years. Etiology was ascertained by MRI and laboratory tests and confirmed by biopsy of meninges and/or brain (7), nasal mucosa (1), mediastinal lymph node (1), muscle (2) or conjunctiva (2). Salient clinical features were headache (7), multiple cranial neuropathies (8), visual disturbances (6), seizures (2) and hemiparesis (2). Abnormal tests included: rapid erythrocyte sedimentation rate (3), positive serum venereal disease testing (1), chest CT abnormalities (4/6) and positive Mantoux test (2/5). Cerebrospinal fluid changes (10/11) revealed the following: cell count 0-47/mm(3); protein 14-95 mg/mL; and glucose of 44-79 mg/mL. Contrast MRI revealed a variable extent of thickened dura mater in all patients. Histopathology (n=11) confirmed chronic inflammation (100%) and provided specific etiology in six (vasculitis [2], sarcoidosis [2], tuberculosis [1], Wegener's granulomatosis [1]). Treatment included steroids only (4), anti-tubercular therapy with steroids (5), penicillin (1) and cyclophosphamide and plasmapheresis (1). During follow-up (27.0+/-26.3 months) there was significant recovery (9/9). On serial imaging (4), the lesion remained the same in three and resolved partially in one patient. HCP, despite frequently posing diagnostic and therapeutic challenges, has favorable outcome when treated appropriately.

Dysmyelinating neuropathy in benign form of megalencephalic leukoencephalopathy with subcortical cysts: a novel observation from south India.

A 37-year-old gentleman presented with macrocephaly since early childhood and progressive impairment of motor and cognitive functions. Magnetic resonance imaging revealed extensive white matter involvement and frontotemporal subcortical cysts. Absent ankle jerk and abnormal nerve conduction study raised a possibility of associated peripheral neuropathy. Sural nerve biopsy was suggestive of dysmyelinating neuropathy. This report serves to expand the clinical spectrum of this rare leukodystrophy.

Intracranial metastasis from a glandular variant of atrial myxoma.

BACKGROUND: Intracranial metastases from atrial myxoma producing symptomatic mass lesions are very rare with only ten examples reported in the literature. We report a patient with multiple metastases from a cardiac myxoma which had an unusual histopathology mimicking an adenocarcinoma. CLINICAL PRESENTATION: A 35 year old man presented with left facio-brachial focal motor seizures unresponsive to antiepileptic drugs and these episodes preceded the symptoms of cardiac myxoma. The seizures worsened a year following resection of the cardiac myxoma. The MRI of the brain revealed multiple lesions of heterogeneous intensity, partly solid and cystic situated in the right fronto-parietal, left temporal and occipital lobes. FINDINGS: Right fronto-parietal craniotomy revealed lesions with haemorrhagic, calcified areas and a large cystic component was decompressed. Histological examination of the lesions in the brain demonstrated prominent glandular differentiation, identical in morphology to the primary cardiac lesion of a glandular variant of atrial myxoma. CONCLUSION: This report highlights the rare presentation of atrial myxoma with intracranial metastases and reviews previously reported examples. This is only the second case report of a glandular variant of atrial myxoma with metastases to the brain. A pathologist, unaware of this unusual variant of primary atrial myxoma, may mistake the intracranial lesion for a metastatic adenocarcinoma.

T2 relaxometry of ring lesions of the brain.

AIM: To differentiate two common aetiologies of "ring lesions," tuberculomas and cysticercal cysts, using T2 relaxometry. MATERIALS AND METHODS: Fifty-five ring-enhancing lesions of the brain (32 cysticercal cysts; 23 tuberculomas) in 27 patients with focal seizures were studied for T2 relaxation times. RESULTS: The mean T2 relaxation times of cysticercal cysts was 617 ms (range 305-1365 ms; SD 272.2) and that of tuberculomas 161 ms (range 83-290 ms; SD 60.3; 95% confidence). CONCLUSION: T2 relaxometry is a simple, reliable and valuable non-invasive magnetic resonance imaging (MRI) technique to differentiate between intracranial cysticercal cysts and tuberculomas, and may be incorporated in routine diagnostic protocols.

Quantitative magnetic resonance techniques in the evaluation of intracranial tuberculomas.

PURPOSE: To evaluate intracranial tuberculomas using quantitative magnetic resonance (MR) techniques such as T2 relaxometry, magnetization transfer (MT), and diffusion-weighted imaging (DWI). MATERIAL AND METHODS: Thirty-three patients with intracranial tuberculomas (histologically confirmed in 22) were evaluated using proton density/T2-weighted, T1-weighted (with and without MT), and echo-planar diffusion-weighted imaging sequences. T2 relaxation times, MT ratios (MTR), and apparent diffusion coefficient (ADC) values were calculated from the center of the lesion, the periphery, perilesional edema, and contralateral normal white matter. The mean and standard deviation values of each variable were calculated and correlated using Pearson's test (P = 0.05). RESULTS: The measured mean values of T2 relaxation time, MTR, and ADC in the center of lesions were 155.5 ms, 14.1, and 1.27 x 10(-3) mm(2)/s, respectively, compared to 117 ms, 23.72, and 0.74 x 10(-3) mm(2)/s in normal white matter, and a T2 relaxation time of 187.45 ms in normal gray matter. Significant inverse correlations were noted between T2 relaxation values and MTR (P<0.001) and between MTR and ADC (P = 0.046). Significant positive correlation was seen between T2 relaxation and ADC values (P = 0.03). CONCLUSION: Intracranial tuberculomas are characterized by relatively short T2 relaxation times (compared to normal gray matter), decreased MTR, and mostly no restriction of diffusion. A combination of these quantitative parameters could be of help in the noninvasive diagnosis of tuberculomas.

Restricted diffusion in Canavan disease.

INTRODUCTION: Canavan disease is a megalencephalic leukodystrophy due to deficiency of the enzyme aspartoacylase. Proton MR spectroscopy finding of elevated N-acetyl-L: -aspartate is considered diagnostic of Canavan disease. CASE REPORT: We report a case of Canavan disease, which showed restricted diffusion in diffusion-weighted imaging and discuss the cause of it.

Clinicoradiological features of tuberculous meningitis in patients over 50 years of age.

BACKGROUND AND AIMS: Tuberculous meningitis (TBM) is a debilitating form of CNS tuberculosis with a high morbidity and mortality in spite of treatment. The diagnosis is based on clinical, radiological and laboratory features. The classical CT features of basal exudates, hydrocephalus, infarcts and granulomas have been mostly reported in younger individuals. Our aim was to study imaging features of TB meningitis in adults over the age of 50 years. MATERIALS AND METHODS: Clinical, imaging and laboratory features of 53 adult patients over the age of 50 years (sixth to eighth decades) were studied retrospectively. Diagnosis of TBM was based on clinical and laboratory features. RESULTS: Imaging features were the conspicuous absence of typical features of TBM (ie, basal meningeal enhancement, hydrocephalus, infarcts/granulomas were seen in only a minority of patients). CONCLUSIONS: CT features of TBM in elderly patients were few, atypical and non-contributory for diagnosis, probably because of age related immune senescence. Strong clinical suspicion and correlation with laboratory findings is necessary for early diagnosis.

Middle meningeal arteriovenous fistula and its spontaneous closure. A case report and review of the literature.

SUMMARY: Middle meningeal artery pseudo-aneurysms and arteriovenous fistulas are usually post-traumatic, although occasional iatrogenic cases have been reported. The treatment has been obliteration of the fistula by surgical or endovascular means. Spontaneous closure of fistula is uncommon. We report a case of non-traumatic middle meningeal arteriovenous fistula in a patient with alcoholism, which resolved spontaneously without treatment.

Spontaneous resolution of bilateral superior ophthalmic vein and cavernous sinus thrombosis. A case report.

Superior ophthalmic vein thrombosis is uncommon, and bilateral superior ophthalmic vein thrombosis is rarer still. The resolution of bilateral superior ophthalmic vein thrombosis takes a long time. The spontaneous resolution of bilateral superior ophthalmic vein thrombosis is not known and not reported in the literature so far. Here we present MRI of bilateral superior ophthalmic vein thrombosis and its spontaneous resolution.

Vertebral body signal changes in spinal cord infarction: histopathological confirmation.

Spinal cord infarctions are rare. They are difficult to diagnose clinically and remain undiagnosed even after extensive investigations. Magnetic Resonance (MR) features include hyperintensity of the cord on T2W images. Few cases of spinal cord infarction associated with vertebral body infarction are reported in the literature. We describe another five cases of spinal cord infarction with histopathological confirmation of the vertebral body signal changes. MR examinations of five patients who presented with acute spontaneous spinal cord syndrome were reviewed. Abnormal MR features of the spinal cord included signal changes within the parenchyma, best demonstrated on T2W images. These cord changes were associated with vertebral body T2 hyperintensity in all the patients and in one patient, the computed tomography guided biopsy of vertebral body lesion reported infarction. MR is sensitive to detect spinal cord infarctions and associated vascular and bony changes. The associated signal abnormalities in the bone marrow are a corroborative sign in the diagnosis of spinal cord infarction which was proved by histopathology.

Unilateral Moyamoya Phenomenon Due to MCA Occlusion in a Child Presenting with Intracerebral Hemorrhage.

SUMMARY: Spontaneous middle cerebral artery (MCA) occlusion leading to moyamoya phenomenon is different from classical moyamoya disease. Previous studies have reported such phenomena in adults with ischemic lesions, except for a solitary case in a child.We report a case of a ten-year old girl who presented with a deep intracerebral hematoma and a normal ipsilateral middle cerebral artery on initial evaluation by CT. Subsequently, on follow-up angiography, the ipsilateral MCA was occluded with evidence of unilateral basal lenticulostriate and transdural collateral supply causing a 'moyamoya' phenomenon. This report discusses a rare and interesting disease from the perspective of 'moyamoya' phenomenon and angiogenesis.

Neurological manifestations of Ehlers-Danlos Syndrome.

Ehlers-Danlos Syndrome (EDS) is more identified for its cutaneous features but its neurological manifestations have not received the focused attention. Four patients of Ehlers-Danlos Syndrome (EDS) with neurological manifestations were evaluated for phenotypic data. These four men were from three families and two had consanguineous parentage. The mean age at onset and presentation of neurological symptoms were 10.5 years and 19 years respectively. Patient 1 presented with bilateral optic atrophy, sensorineural deafness, cerebellar ataxia and neuropathy. Patient 2 had marfanoid habitus, chorea and cerebellar ataxia. Patient 3 had action and percussion myotonia, wasting and weakness of sternocleidomastoid and distal limb muscles. Patient 4 had action myotonia, mirror movements of both hands and neuropathy. MRI of brain showed right parietal polymicrogyria. Neuroaxis involvement at multiple levels in EDS may have prognostic significance.

Relevance of occlusion test in endovascular coiling of posterior cerebral artery (p2 segment) aneurysms.

SUMMARY: P2 segment aneurysms are located on the posterior cerebral artery (PCA) between the junction of the posterior communicating artery with the PCA and the quadrigeminal cisternal part of the PCA. We reviewed our experience with endovascular coiling in such aneurysms. Clinical and pre-procedural data from four patients, referred for endovascular treatment of P2 segment aneurysms, were retrospectively studied for factors influencing post-interventional neurological deficits caused by ischemia of the PCA distal territory. Balloon occlusion was done in three patients and patient tolerance was assessed using clinical and anatomic criteria. Embryologic and anatomic features of the PCA were reviewed. Balloon occlusion test and endovascular coiling of aneurysms was possible in three patients. Control angiogram after embolization showed elimination of aneurysms from the circulation and the distal PCA filled through leptomeningeal anastomoses. One patient deteriorated due to aneurysmal rupture soon after the balloon occlusion test and coiling could not be done. In the other three patients post-intervention CT and MRI images showed PCA territory infarcts in spite of demonstration of good collateral circulation distal to the occluded PCA. In conclusion, P2 aneurysms can be effectively treated by endovascular coiling without a balloon occlusion test. While the balloon occlusion test does not contribute to clinical decision-making it may be associated with potential morbidity and mortality.

MRI and in vivo proton MR spectroscopy in a racemose cysticercal cyst of the brain.

Racemose cysticercal cyst is the subarachnoid manifestation of the larvae of Taenia solium. On MRI the cysts may resemble other cystic masses. We report the magnetic resonance spectroscopy (MRS) features of a case on in vivo proton spectroscopy and discuss its role in the diagnosis of intracranial cysts of parasitic aetiology.

Functional MR imaging of hand motor cortex in a case of persistent mirror movement.

Persistent mirror movements are unwanted movements restricted to muscles homologous to those moved intentionally on the opposite body half. It is rarely observed and the functional MRI findings in a case of persistent mirror movement are described.