KASTURI NEURO BULLETIN

Volume 13: 9.

EDITORIAL:

Dear Colleagues and Friends,

It is my immense pleasure to share some of the interesting cases with you. Now being the Unit Head of

Neurology in PSG Hospitals, the responsibilities like setting Goals and shaping the Department etc., are increasing. In

the midst of time, I will always try to be in touch with you through this bulletin.

This Bulletin concentrates mainly on cases with MRI as its use is increasing in Neurological Diagnosis.

The first article describes a case of trigeminal pain due to Demyelinating lesion. This was missed for several

years as the patient did not undergo MRI evaluation earlier.

A school girl got panicked as she was told some intracranial abnormality was present in her MRI and she

stopped going to school. She was worried that she may need a neurosurgical intervention. With proper counseling

about the benign nature of the lesion, we could make her life pleasurable.

Again the third case is about trigeminal pain. This patient was misdiagnosed, as trigeminal neuralgia, but her

clinical symptoms are totally different. An elongated styloid process causing constant retro mandibular pain was her

problem.

Paraplegia is pathetic. The patient has to depend on others for ADL. After suffering from paraplegia for several

years, if anyone is asked to choose either to have few more years of life or to have both upper limbs working, it will

be really a difficult situation. One such patient is described in here.

61 yrs old male was brought to the hospital with left focal seizures. The Physician does a CT for making a

diagnosis. If the CT makes him more confused rather than making it clear, with several differential diagnoses like

Encephalitis, Hemorrhagic Infarct, AVM, Cavernoma etc., the physician has to depend on senior’s expertise.

Management of such kind of patient was described here.

The last case is more of a practical problem. An old lady of left hemiplegia presented with increasing weakness

and if her CT did not show any fresh lesions, where can you localize? Find the answer from the case report.

We have organized a simple Neuro Quiz session from basic neurology to select candidates for sending them to a

Quiz program. I am herewith enclosing a part of it for your casual answering. This contains 75 MCQs. Please send

your answers before 1st

Nov, 2013, to me either by post or by e-mail. Amazing prizes are awaiting. I thank Dr.

Thirumurthy, Dr.Balakrishnan and Dr. GnanaShanmugam for their contribution in preparing the questions.

I once again welcome you to submit your interesting cases to Kasturi Neuro Bulletin just by E-mailing it to

prakashneuro@yahoo.co.in. Those who like to support the Bulletin can send DD / Cheque in favor of “Kasturi

Welfare Trust” to 89-A, East Lokamanya St, RS Puram, Coimbatore or pay directly through Karur Vysya Bank, RS

Puram, Coimbatore, Account number 1122 1350 0000 2452. I do welcome your suggestions. With warm regards,

Dr. B.Prakash,

Editor.

INSIDE THE ISSUE:

1. Use of MRI in Trigeminal Neuralgia 2

2. The role of Clinician in MRI interpretation 2

3. A case of Eagle’s syndrome 3

4. Limb or Life? 3

5. A case of temporal lobe lesion 4

6. A case of stroke on stroke 4

7.Supplement : Neuro Quiz – 75 Questions 5-8

6.

For Internal Circulation only. Not for Sale. Supported by KASTURI WELFARE TRUST and SANOFI

Dr.B.PRAKASH. MD.,DM(Neuro)., FAGE,.

Professor & Chief (Unit IV) of Neurology (PSG H)

KASTURI NEURO DIAGNOSTIC CENTRE

89-A, East Lokamanya Street, R.S.Puram.

COIMBATORE – 2. Mob: 978 948 1179

E.Mail: prakashneuro@yahoo.co.in

USE OF MRI IN TRIGEMINAL PAIN THE ROLE OF CLINICIAN IN MRI

INTERPRETATION

INTRODUCTION:

Usually Trigeminal neuralgia is

idiopathic and MRI will be normal. The

common finding in MRI is vascular loop

pressing the trigeminal nerve. However

other causes are not unusual. Mostly

surgery is invasive and the patients tend to

avoid / postpond it.

CASE REPORT:

47 yrs old male was referred for

right V2 V3 pain of six years duration. Two

surgical interventions were attempted so

far. He is on optimum dose of medications.

No focal neurological deficits made out.

MRI brain (fig-1) done, which showed T2

hyperintence signal in right middle

cerebellar peduncle, suggesting focal

demyelination. No other abnormalities

noted. No vascular loop impingement.

Hyper intense signals noted in FLAIR image

is shown in (fig-2). No extra axial pathology

(fig-3) made out.

CONCLUSION:

Even though the extra axial lesions

are the common causes in Trigeminal

Neuralgia, we should not miss the unusual

demyelinating lesion as noted in our case.

Among the intra axial lesions,

demyelination is the most common

etiology.

INTRODUCTION:

MRI plays a vital role in the neurological

diagnosis and it has become almost mandatory

for most cases. However, if misinterpreted or

only relied on, it may mislead us.

CASE REPORT:

19 yrs old Ms.F, presented with severe

headache of 3 yrs duration. She was doing her

school final, but discontinued due to the daily

severe headache. She felt better only for few

hours on taking medications. She has nausea,

photophobia and sonophobia. Sunlight and

hunger aggravates her pulsating headache. She

was told her MRI was significantly abnormal.

Examination revealed no focal neurological

abnormalities. The clinical diagnosis was a

transformed migraine. A CT brain was done

during March’2011 and MRI with contrast, one

month later were reported that there was a

ruptured dermoid cyst. (Refer fig). A second

opinion from Senior Radiologist had revealed

the lesion was lipoma. The incidental finding

and the benign nature of the lesion was

explained to the pt. She was started on

migraine prophylaxis and is advised to attend

the classes. She had come for follow-up after

two months and was asymptomatic.

CONCLUSION:

It needs proper clinical assessment and

good radiological interpretation to make a

correct diagnosis, but the Clinician should spend

time with the patient to prevent unnecessary

anxieties.

1. Clinical Journal of pain – Jan 2002 Vol 18 (1) – 14 to 21

2. Acta Neuro Logica - March 82 Vol 65 (3), 182 to 189

Proc (Bayl Univ Med Cent). 2012 January; 25(1): 23–25. Am J Roentgenol. 1990;155 (4): 855-64

KNB 13: 9 -2

A CASE OF EAGLE’S SYNDROME

LIMB OR LIFE ?

INTRODUCTION:

Eagle’s Syndrome is a rare condition

in which elongated styloid process is

producing dysphagia, tinnitus, ear, face and

neck pain. Even though it is easily

diagnosed by ENT Surgeon and Dentist an

awareness of this syndrome is a must for

any clinician.

CASE REPORT:

A 24 years old female was referred

to us as right trigeminal neuralgia. She had

continuous retro mandibular pain, with

tinnitus. It is not electric shock like or

intermittent as like trigeminal neuralgia.

When the patient was asked to show the

site of the pain with her finger, she had

touched her right retro mandibular region

(fig-1), where she had tenderness too. No

neurological deficits made out. ENT

surgeon’s opinion obtained. She was

diagnosed to have right eagle’s syndrome

with an OPG x-ray (fig-2).The pictorial

representation was shown in fig-3.

DISCUSSION:

Eagle’s Syndrome is suspected when

the patient presents with retromandibular

pain, tinnitus or dysphagia. The treatment is

surgical Styloidectomy. The condition was

first described by Watt Weems Eagle in

1937.

INTRODUCTION:

It will be difficult to answer if anyone is

asked to have either functioning limb or to

undergo a life saving surgery.

CASE REPORT:

45/M had a fall from height during

Oct’2007 and sustained multiple fractures and

burst Atlas (Jefferson #) shown in fig-1. He had

fracture D3-D4 causing paraplegia. A CT brain

done at that time showed a right parietal

hypodense lesion?contusion. The patient learnt

to live with paraplegia. He presented to us by

June’13 with 3 episodes of seizures. The CT

report was Rt parietal Glioma. He was given

AED, antiedema measures steroids and advised

surgery, But he was not willing as there is a

chance of developing left hemiplegia over

paraplegia. A tapering steroid course was

given. Meanwhile he developed LRI and the

steroid was stopped. He got re-admitted for

recurrence of serial seizures. No fresh

neurological deficits. No increase in the size of

tumor. The importance of undergoing surgical

excision was insisted, but the patient got

discharged AMA.

CONCLUSION:

It is difficult to decide for the pt

whether or not to undergo surgery which may

lead to weakness of left limb, leaving him to live

with only Rt UL. This may not give a meaningful

life. We had advised surgery for protection of

life. But this may add only years to the life at

the expense of quality of life.

1. Journal .Neuro Radiology Vol 34 (5) 344 to 345

2. Journal.Maxilo fascial surgery Vol 41(2) 162 to 166

1. Neurol Clin. 1995 Nov;13(4):847-59.

2. Jou of Cl Oncology, 20, 8 (April 15), 2002

KNB 13: 9 -3

A CASE OF TEMPORAL LOBE

LESION A CASE OF STROKE ON STROKE

INTRODUCTION:

Temporal lesions when presenting with

seizures may be confusing, especially if imaging

modalities do not give a proper diagnosis.

CASE REPORT:

By Aug’13, a 60/M, presented to a local

hospital with acute confusional state and left

focal seizures. He has DM, HT & renal

impairment. His CT showed left temporal

resolving bleed with edema, on which varying

diagnoses like AVM / Cavernoma etc., were

made (fig-1). He was treated with anti epileptics

and discharged. Later MRI brain was done

which was reported as left temporal neoplasm.

He was having right LL marching parasthesia

without any focal neurological deficits. A

detailed EEG with additional leads showed

epileptic focus at left temporal region (fig-2). A

repeat MRI with MRS with 1.5 Tesla machine,

confirmed 5x2.5x2 cm left medial temporal low

grade glioma (fig-3). He was admitted, anti-

epileptic drugs and other doses were adjusted.

The crawling sensation totally subsided. Blood

Sugar and Blood Pressure brought under

control.

CONCLUSION:

Initial presentation of low grade glioma

may be seizures, altered sensorium or

confusional state. For correct diagnosis of intra

cranial lesions, high quality MRI scans cannot be

compromised. Non contrast CT, lower Tesla MRI

can be utilized for screening purpose only.

INTRODUCTION:

If a patient develop a stroke on a

preexisting stroke, it will be possible to make

a clinical diagnosis, only if the area and/or

pathology of two strokes are different.

Suppose a patient with right MCA infarct,

develop again right MCA infarct, it will be

difficult to make a correct diagnosis of site,

size of the lesion. It will also be difficult to say

whether the second stroke is organic.

CASE REPORT:

50/F, a known case of DM/HT/DCM

had left hemiplegia by Sep’12 (fig 1). She

improved over a period of 2 wks, and she

could gradually walk in a circumduction gait

without support. She had Rt CCA intraluminal

thrombus with severe LV dysfunction. Her CT

showed moderate sized Rt MCA infarct.

During Aug’13, she had worsening of left

hemiparesis which could not be assessed

correctly. A repeat CT showed almost the

same findings as that of old infarct(fig2). 90%

occlusion in Rt CCA was noted. MRI brain

revealed two small foci of high parietal infarct

(hyperintense in DWI) within the old infarct

(fig 3). She received a course of Heparin,

improved to some extent and discharged.

CONCLUSION:

Diffusion weighted images are more

helpful in diagnosing acute infarct even if it

occurs within the region of old infarct.

1. www. 191.9, 192.8, M9450/3 2. Neu ind mar-Apr, 2012.60(2), 243

Neurology. 1997 Apr;48(4):891-5.

medpagetoday.com/Neurology/Strokes/14475

KNB 13: 9 -4

1.Common site of Neuro fibroma

a.Extradural

b.Intramedullary

c.Extramedullary

d.Intraventricular

2.Contrast enhancing paediatric neoplasm

a.Choroid Plexus Papilloma

b.Giant cell astrocytoma

c.Medullo blastoma

d.All the above

3.Blood product Methemoglobulin seen in MRI

after one week of intracerbral haemorrhage is

a.Hypermagnetic

b.Paramagnetic

c.Diamagnetic

d.Conramagnetic

4.Pengiun sign in MRI is seen in

a.Parkinson’s disease

b..Multiple system atrophy

c. Progressive Supranuclear Palsy

d.Olivo Ponto Cerebellar Atrophy

5.Cortical ribbon sign in MRI is seen in

a. CNS HIV

b. CJD

c. SCA

d. Rabies

6.Frontal horn dilatation in CT scan is seen in

Huntington’s Chorea

a.True

b.False

7.Correct the jumbled letters of VALDREN

SHELTOR ZAP; degenerative disorder (NBIA)

which is not often used now a days

8.Unilateral temporal T2 hyperintensity seen in

a.Glioma

b.HSE

c.Infarct

d.All of the above

9.Match diagnosis and the needed skull Xray

1 Pituitary lesion a.Down’s view

2.Basilar invagination b.Lateral view

3.CP angle lesion c.AP view

4.Eagle’s syndrome- d.Open mouth

10.To differentiate between post operative

gliosis and recurrence of glioma the scan

advised is

a.MRI b.fMRI

c.PET d.SPECT

11.Shouldering in Myelogram is a feature of

a.Neurofibroma

b.Disc Prolapse

c.Pott’s spine

d.Spinal AVM

12.Non contrast CT scan may miss

a.Low grade glioma

b.CVT

c.Tuberculoma

d.All of the above

13.In routine MRA, the contrast agent used is

a.Iodine

b.Gadolinium

c.Non ionic contrast agent

d.None of the above

14.MRI sequence for diagnosing acute infarct is

a.FLAIR b.T1 & T2

c.DWI d. PWI

15. The location of tumor in intracranial NF is

a.Pons b.IV Ventricle

c.CP angle d.Pituitary

16.16 yrs old girl presented with Writer’s

cramp, she has a ring in her eye. The likely

diagnosis is

a.Parkinsonism

b.Wilson Disease

c.Hypothyroidism

d.Neurocysticercosis

17.60 yrs old male presented with large Rt MCA

Stroke seen in CT. The immediate action is

a.Thrombolysis b.Heparin

c.Decompression d.Ecospirn

18. The findings noted in CECT of CVT is

a. Eye of Tiger sign

b. SDH

c. Hyperdense MCA sign

d. Empty delta sign

Supplement to Kasturi Neuro Bulletin 13:9 - Mini Neuro Quiz

Editor’s Decision is final.

19. The prognosis of the Pontine bleed is

a.Poor b.Good

20. The likely diagnosis of enumerous ring

enhancing lesions by MRI is

a.Sarcoidosis

b.Secondaries

c.AV Malformation

d.Neurocystecercosis

21. Hypohalamo- hypophyseal fibres are

formed by the axons of

a. Supraoptic b. Paraventricular

c. Both d. None

22. Midbrain structure which projects to the

corpus striatum is

a. Pyramidal tract

b.Medial Longitudinal Fasciculus

c.Medial Geniculate Body

d.Substantia Nigra

23. A lesion of subthalamus results in

a.Chorea b. Athetosis

c.Hemiballismus d.Dystonia

24. Which lobe is directly above the tentorium?

a. Parietal lobe b. Temporal lobe

c. Cerebellum d. Occipital lobe

25. Which part of brainstem region is in the

tentorial region

a. Pons b. Medulla

c. Hypothalamus d. Midbrain

26. Myelin sheaths are formed by

a. Oligodendrocytes

b.Schwann cells

c.Both

d.None

27. Role of arachnoid granulation is to

a. Produce CSF

b. Stain CSF

c. Transfer CSF to venous system

d. Transfer CSF to lymphatic.

28. Floor of IV ventricle is associated with

a. Medulla b. Pons and Medulla

c. Pons, Medulla and Cerebellum

d. Midbrain, Pons & Medulla

29. Ligaments attach between the exit and

entrance of ventral and dorsal roots following

each spinal nerve

a.Pial b.Dura

c.Collagen d.Flavii

30. Spinal C8 root, exits between the vertebrae

a. C6-C7 b. C7-C8

c. C7-T1 d. T1-T2

31. Cauda equina is formed by the dorsal and

ventral roots of _____ segments of spinal cord

a.Lumbar b.Sacral

c.Lumbosacral d.Coccygeal

32. Safest point to sample CSF is between

a. C7-T1 b. L1-L2

c. D12 – L1 d. L3-L4

33. In syringomyelia (expansion of central

canal) there will damage to the

a. Spinothalamic tract

b.Spino reticular tract

c. Corticospinal tract

d. All of the above

34. The vessel lateral to the chiasm is

a. Anterior cerebral artery

b. Middle cerebral artery

c. Posterior communicating artery

d. Internal cerebral artery

35. Central retinal artery is the branch of

a.Internal Carotid

b.External Carotid

c.Ophthalmic

d.Choroidal

36. Area of the medulla containing the spinal

nucleus of trigeminal nerve is supplied by

a. Anterior inferior cerebellar artery

b. Posterior inferior cerebellar artery

c. Superior cerebellar artery

d. Vertebral artery

37. Which limb of internal capsule contain

cortical approach

a. Anterior limb

b. Posterior limb

c. Both

d. Neither

38. Ganglionic ICH occur due to rupture of

a. Lenticulostriate A

b. Posterior Communicating A

c. Anterior Cerbral A

d. Internal cerebral Vein

39. The reception of the saccula and

semicircular canals are examples of

a. Chemoreception

b. Nociception

c. Mechanoception

d.Osmoreception

40. Incidence of post stroke seizure is > 30%

a. True b. False

41. Olivo cerebellar axons terminate in the

cerebellum by

a. Mossy fibers b. Climbing fibers

c. Basket cell axons d. None

42. Tumours originating from Schwann cells of

VIII Cr.N compress which cranial nerve?

a. IX & X b. VII

c. V d. VI

43. Tendon, joints, muscle spindle and skin are

innervated by axons whose cell bodies are in

a.Pyramidal tract b.Muscle Spindle

c.Spinal AHC d.Neurons

44. Most devastating effects are produced by

sudden occlusion of origin of

a. MCA b. ACA

c. VA d. PCA

45. Which vessels supply the speech area

commonly?

a. Right MCA b. Left MCA

c. Left PCA d. Rt &Lt PCA

46.In uncal herniation, which portion of

brainstem is compressed

a.Midbrain b.Upper Pons

c.Lower Pons d.Medulla

47. In right frontal lobe infarct, eye balls will

look towards

a. Right Side b.Left Side

c.Upwards d.Downwards

48. in cerebellar herniation , which portion of

brainstem is compressed

a.Midbrain b.Upper Pons

c. Medulla d. None

49.IV fluid to be avoided in increased

intracranial pressure

a. Normal Saline

b. 3% saline

c. 5% dextrose

d. 5% dextrose in normal saline

50.Which of the following is not associated

with cytotoxic brain edema

a. Brain Tumor

b.Ischemic Stroke

c.Hepatic encephalopathy

d.Hypoxic encephalopathy

51.Which of the following is the first line

investigation in a patient with suspected

subarachnoid hemorrhage

a. Lumbar puncture b. CT brain

c. MRI brain d.EEG

52. Hemorrhage in which portion of brain

warrant urgent surgical evacuation

a. Pons b. Basal ganglia

c. Cerebellum d. Frontal lobe

53.Which of the following is most commonly

the cause of spinal epidural abscess

a.Lumbar puncture

b.Osteomyelitis

c. Penetrating trauma

d. Hematogenous spread

54. Which of the following drug is used in the

management of Guillaine Barre syndrome

a. Interferon alpha

b. IV immunoglobulin

c. IV methyl prednisolone

d. Oral prednisolone

55. With regards to headache which is not a

red flag

a. Fever

b. Rapidity of onset

c. Age >75years

d. Duration > 4 days

56.Which of the following is the only

thrombolytic agent approved for the

management of acute ischemic stroke

a. streptokinase b. alteplase

c. tenecteplase d. urokinsae

57.All of the following imaging features

favours tuberculous meningitis except

a. Basal exudates b. Abscess

c. Vasculitis d. Tuberculoma

58. Loading dose of phenytoin for management

of status epilepticus is

a. 5mg/kg b. 10mg/ kg

c. 15mg/kg d. 30mg/kg

59. Which portion of brain is preferentially

involved in Herpes Simplex Encephalitis

a. Frontal lobe b. Parietal lobe

c. Temporal lobe d. Occipital lobe

60.Which of the following is not the feature of

Neuroleptic Malignant Syndrome

a. fever b. altered sensorium

c. movement disorder d. hemiparesis

61.Empirical antibiotic therapy for bacterial

meningitis is

a. Ceftriaxone + Vancomycin

b. Ampicillin + Gentamycin

c. Ampicillin

d. Ampicillin + Vancomycin

62. BP reduction in acute ischemic stroke is not

warranted in

a. Carotid Dissection b. Associated MI

c. BP > 140/100 d.Thrombolysis plan

63. In which of the following situation, Heparin

is indicated in ischemic stroke

a. All Ischemic Strokes

b. Cardio Embolic Stroke

c. Carotid Artery Stroke

d. Lateral Medullary Stroke

64. All the following is associated with

increased CSF lymphocyte count except

a. Acute Pyogenic Meningitis

b. Partly Treated Pyognic Mengts

c. Tuberculous Meningitis

d. Fungal Meningitis

65. Drug preferred to treat psychosis in

parkinson’s disease a. Haloperidol b. Chlorpromazine

c. Quetiapine d. Trifluperazine

66. Starting AED therapy is indicated in all of

the following conditions, except

a. Abnormal neurological examination

b. Focal Seiz with todds paralysis

c. Single provoked Seizures

d. Abnormal EEG

67. Therapeutic concentration of serum

Phenytoin is

a.10-20 ug/ml b.20-30 ug/ml

c.30-40 ug/ml d.40-50 ug/ml

68.Checking Sr. AED is indicated for

a. Drug Toxicity b. Compliance

c. Sr. level Assessment d. All

69. First AED introduced was

a.Phenobarbitone b.Bromide

c.Phenytoin d.Primidone

70.All AEDs act at sodium channel except

a.Phenytion b.Carbamazepine

c.Oxcarbamazepine d.Gabapentin

71. All are side effects of topiramate except

a.Sedation b.Glaucoma

c.Renal stone d.Weight gain

72. % of patient who do not respond to

treatment with single AED

a.33 b.25 c.66 d.75

73. Drug of choice for absence seizure

a.Valproate b.Carbamazepine

c.Phenytoin d.Oxcarbazepine

74.All are seizure inducing AED, except

a.Phenytoin b.Valproic acid

c.Phenobarbitone d.Primidone

75. Oxcarbazepine is better than CBZ in the

following

a. Rash is less common

b. Hyponatremia is less common

c. Better pt tolerability

d. All of the above

I thank our neuro team (Dr.Thirumurthy, Dr.Balakrishnan, &Dr.Gnanshanmugam) in preparing and permitting the Q&A to present to you