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sign previously observed in Wilson’s disease is drawn here, though with bright eyes, which to the best of our knowledge has not been described earlier in patients with MIE. We feel that metronidazole neurotoxicity may be added to the list of causes depicting such similarities.[4,5]
Tejendra Sukdeo Chaudhari, Hardeep Singh Malhotra, Ravindra Kumar Garg Department of Neurology, King George’s Medical University, Lucknow, Uttar Pradesh, India E-mail: [email protected]
References 1.
2. 3.
4. 5.
Rao DN, Mason RP. Generation of nitro radical anions of some 5-nitrofurans, 2- and 5-nitroimidazoles by norepinephrine, dopamine, and serotonin. A possible mechanism for neurotoxicity caused by nitroheterocyclic drugs. J Biol Chem 1987;262:11731-6. Evans J, Levesque D, Knowles K, Longshore R, Plummer S. Diazepam as a treatment for metronidazole toxicosis in dogs: A retrospective study of 21 cases. J Vet Intern Med 2003;17:304-10. Kim E, Na DG, Kim EY, Kim JH, Son KR, Chang KH. MR imaging of metronidazole-induced encephalopathy: Lesion distribution and diffusion-weighted imaging findings. AJNR Am J Neuroradiol 2007;28:1652-8. Hitoshi S, Iwata M, Yoshikawa K. Mid-brain pathology of Wilson’s disease: MRI analysis of three cases. J Neurol Neurosurg Psychiatry 1991;54:624-6. Kallollimath P, Nagappa M, Sinha S, Saini J, Bindu PS, Taly AB. Panda with “Bright eyes” in Wilson’s disease. Neurol India 2013;61:100-1.
Access this article online Quick Response Code:
Website: www.neurologyindia.com
dysarthria, right upper motor neuron facial palsy, and right hemiparesis (upper limb 2/5 and lower limb 4/5). Noncontrast computed tomographic bran scan was normal. Blood biochemistry and complete blood picture laboratory were normal. The tolulized red unheated serum test (TRUST) (1:16) and treponema pallidum hemagglutination assay (TPHA) test were positive. Human immunodeficiency virus serology was negative. On the 4th day of admission, his neurologic signs worsened and progressed to quadriplegia. Neurologic examination revealed severe dysarthria, dysphagia, and quadriplegia (left upper limb 4/5, left lower limb 3/5, right upper limb 2/5 and right lower limb 2/5). Magnetic resonance imaging demonstrated multiple acute infarcts involving scattered regions of the left cerebellar hemisphere and both side of the pons [Figure 1a and b]. Magnetic resonance-angiography revealed the absence of flow signal within the distal basilar artery, indicating an acute occlusion and a large saccular aneurysm in the middle artery was found [Figure 1c]. On day-5 cerebrospinal fluid (CSF) revealed 280 white blood cells/ul (26% lymphocytes), glucose 3.19 mmol/L, and protein 0.96 g/L. The CSF TRUST was positive (1:4). A diagnosis of meningovascular syphilis was made and was treated with intravenous penicillin G (4 million units every 4 h) for 2 weeks. Neurologic signs fluctuated in severity for the next 10 days after therapy was initiated, but later improved steadily. On day-20, follow-up computed tomographic-angiography revealed basilar artery occlusion with improved distal flow [Figure 1d]. The patient was discharged on day-21
PMID: *** DOI: 10.4103/0028-3886.132424
Received: 23-02-2014 Review completed: 18-03-2014 Accepted: 08-04-2014
Meningovascular syphilis with basilar artery occlusion: Case report and literature review Sir, A 45-year-old man known case of diabetes was admitted for new-onset occipital headache, right-sided weakness, dysarthria, and right facial droop. Examination revealed
Neurology India | Mar-Apr 2014 | Vol 62 | Issue 2
a
c
b
d
Figure 1: (a) Diffusion-weighted and (b) T2-weighted magnetic resonance images show multiple acute infarcts involving scattered regions of the left cerebellar hemisphere and both side of the pons. (c) Magnetic resonance-angiography shows absence of flow signal within the distal basilar artery (arrow) and a large saccular aneurysm (arrowhead) in the middle cerebral artery. (d) Follow-up computed tomographic angiography shows basilar artery occlusion with improved distal flow (arrow)
213
[Downloaded free from http://www.neurologyindia.com on Thursday, May 15, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Letters to Editor
and instructed to follow-up with primary physician in his local hospital. Neurosyphilis is known as “the great impostor” because of its wide range of clinical symptoms. Once a common disease, meningovascular syphilis has become rare since the advent of antibiotics. However, with the rise in the incidence of primary and secondary syphilis,[1] meningovascular syphilis may become a more common cause for stroke. In clinical practice, neurosyphilis as the cause of ischemic stroke is often not suspected. Diagnosis of neurosyphilis has therapeutic implication and nonor delayed institution of early appropriate treatment would result in more morbidity.[2] Most frequent clinical presentation of meningovascular syphilis is stroke presentation in the middle cerebral artery territory and vertebrobasilar artery and its branches are the second most commonly involved vessels. [3,4] Syphilis can cause the cause of aortic aneurysm, however cerebral aneurysm secondary to syphilitic vasculopathy has been reported rarely.[5] Clinical suspicion and early diagnosis and early institution appropriate treatment is important to reduce the morbidity associated with the disease.
Yao Yin-Dan, Hong Wen-Ke, Guan Li-Feng Department of Neurology, Ningbo No. 2 Hospital, Ningbo, China E-mail: [email protected]
References 1. 2. 3. 4. 5.
Chen XS, Yin YP, Wang QQ, Wang BX. Historical perspective of syphilis in the past 60 years in China: Eliminated, forgotten, on the return. Chin Med J (Engl) 2013;126:2774-9. Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG, et al. Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients. J Neurol Sci 2012;317:35-9. Flint AC, Liberato BB, Anziska Y, Schantz-Dunn J, Wright CB. Meningovascular syphilis as a cause of basilar artery stenosis. Neurology 2005;64:391-2. Feng W, Caplan M, Matheus MG, Papamitsakis NI. Meningovascular syphilis with fatal vertebrobasilar occlusion. Am J Med Sci 2009;338:169-71. Asdaghi N, Muayqil T, Scozzafava J, Jassal R, Saqqur M, Jeerakathil TJ. The re-emergence in Canada of meningovascular syphilis: 2 patients with headache and stroke. CMAJ 2007;176:1699-700. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.132427
Received: 17-01-2014 Review completed: 17-01-2014 Accepted: 08-04-2014
214
A giant falcine chondrosarcoma: Case report and literature review Sir, Parafalcine chondrosarcoma is extremely rare and may be difficult to differentiate preoperatively from falx meningioma. We report yet another such rare case. A 26-year-old male presented with a 3-week history of progressive headache and right hand numbness. Neurological examination revealed decrease in proprioception in the right hand. Cranial magnetic resonance imaging (MRI) revealed a well-marginated parafalx mass (9.4 × 6.4 × 6.0 cm) occupying bilateral frontal lobes and along the falx cerebri. It was hypointense on T1-weighted and hyperintense on T2-weighted images [Figure 1a] with no perilesional edema. Contrast-enhanced MRI scan showed a lobulated heterogeneously enhanced honeycomb lesion [Figure 1b]. Preoperative diagnosis was parafalcine meningioma and MR venography (MRV) showed oppression of superior sagittal sinus by the tumor [Figure 1c]. Total resection of the tumor was performed by bicoronal craniotomy. The lesion was hard, lobulated, gray-white, with a very firm cartilaginous consistency. The tumor and the dural attachment were totally removed. Regular follow-up MRI scans at 18 months showed no recurrence [Figure 1d]. She has recovered well and is able to run again. Microscopic examination revealed lobulated appearance with variable low to moderate cellularity composed primarily of individual cells separated by a basophilic matrix. Neoplastic chondrocytes had plump and hyperchromatic nuclei with few mitotic figures [Figure 2]. Immunohistochemical studies demonstrated positivity for S-100, which is consistent with the diagnosis of a cartilaginous tumor [Figure 3]. Chondrosarcomas are malignant tumors of cartilage and may arise from bone or soft tissues.[1] They account for 6% of skull = base neoplasms and 0.15% of all intracranial tumors.[2] Approximately 75% of all cranial chondrosarcomas occurs at the base of the skull and mostly in the middle cranial fossa.[3,4] The rare locations include the following: Choroid plexus, dura mater, and intraparenchymal. Only 61 cases of dural origin have been reported to date and of them only nine were classic low-grade type.[5-8] Skull-based chondrosarcomas are most commonly classic type,[3] but about 62% dural-based chondrosarcomas are mesenchymal variant. [5] The variants of parafalcine chondrosarcomas have a strong Neurology India | Mar-Apr 2014 | Vol 62 | Issue 2
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
sign previously observed in Wilson’s disease is drawn here, though with bright eyes, which to the best of our knowledge has not been described earlier in patients with MIE. We feel that metronidazole neurotoxicity may be added to the list of causes depicting such similarities.[4,5]
Tejendra Sukdeo Chaudhari, Hardeep Singh Malhotra, Ravindra Kumar Garg Department of Neurology, King George’s Medical University, Lucknow, Uttar Pradesh, India E-mail: [email protected]
References 1.
2. 3.
4. 5.
Rao DN, Mason RP. Generation of nitro radical anions of some 5-nitrofurans, 2- and 5-nitroimidazoles by norepinephrine, dopamine, and serotonin. A possible mechanism for neurotoxicity caused by nitroheterocyclic drugs. J Biol Chem 1987;262:11731-6. Evans J, Levesque D, Knowles K, Longshore R, Plummer S. Diazepam as a treatment for metronidazole toxicosis in dogs: A retrospective study of 21 cases. J Vet Intern Med 2003;17:304-10. Kim E, Na DG, Kim EY, Kim JH, Son KR, Chang KH. MR imaging of metronidazole-induced encephalopathy: Lesion distribution and diffusion-weighted imaging findings. AJNR Am J Neuroradiol 2007;28:1652-8. Hitoshi S, Iwata M, Yoshikawa K. Mid-brain pathology of Wilson’s disease: MRI analysis of three cases. J Neurol Neurosurg Psychiatry 1991;54:624-6. Kallollimath P, Nagappa M, Sinha S, Saini J, Bindu PS, Taly AB. Panda with “Bright eyes” in Wilson’s disease. Neurol India 2013;61:100-1.
Access this article online Quick Response Code:
Website: www.neurologyindia.com
dysarthria, right upper motor neuron facial palsy, and right hemiparesis (upper limb 2/5 and lower limb 4/5). Noncontrast computed tomographic bran scan was normal. Blood biochemistry and complete blood picture laboratory were normal. The tolulized red unheated serum test (TRUST) (1:16) and treponema pallidum hemagglutination assay (TPHA) test were positive. Human immunodeficiency virus serology was negative. On the 4th day of admission, his neurologic signs worsened and progressed to quadriplegia. Neurologic examination revealed severe dysarthria, dysphagia, and quadriplegia (left upper limb 4/5, left lower limb 3/5, right upper limb 2/5 and right lower limb 2/5). Magnetic resonance imaging demonstrated multiple acute infarcts involving scattered regions of the left cerebellar hemisphere and both side of the pons [Figure 1a and b]. Magnetic resonance-angiography revealed the absence of flow signal within the distal basilar artery, indicating an acute occlusion and a large saccular aneurysm in the middle artery was found [Figure 1c]. On day-5 cerebrospinal fluid (CSF) revealed 280 white blood cells/ul (26% lymphocytes), glucose 3.19 mmol/L, and protein 0.96 g/L. The CSF TRUST was positive (1:4). A diagnosis of meningovascular syphilis was made and was treated with intravenous penicillin G (4 million units every 4 h) for 2 weeks. Neurologic signs fluctuated in severity for the next 10 days after therapy was initiated, but later improved steadily. On day-20, follow-up computed tomographic-angiography revealed basilar artery occlusion with improved distal flow [Figure 1d]. The patient was discharged on day-21
PMID: *** DOI: 10.4103/0028-3886.132424
Received: 23-02-2014 Review completed: 18-03-2014 Accepted: 08-04-2014
Meningovascular syphilis with basilar artery occlusion: Case report and literature review Sir, A 45-year-old man known case of diabetes was admitted for new-onset occipital headache, right-sided weakness, dysarthria, and right facial droop. Examination revealed
Neurology India | Mar-Apr 2014 | Vol 62 | Issue 2
a
c
b
d
Figure 1: (a) Diffusion-weighted and (b) T2-weighted magnetic resonance images show multiple acute infarcts involving scattered regions of the left cerebellar hemisphere and both side of the pons. (c) Magnetic resonance-angiography shows absence of flow signal within the distal basilar artery (arrow) and a large saccular aneurysm (arrowhead) in the middle cerebral artery. (d) Follow-up computed tomographic angiography shows basilar artery occlusion with improved distal flow (arrow)
213
[Downloaded free from http://www.neurologyindia.com on Thursday, May 15, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Letters to Editor
and instructed to follow-up with primary physician in his local hospital. Neurosyphilis is known as “the great impostor” because of its wide range of clinical symptoms. Once a common disease, meningovascular syphilis has become rare since the advent of antibiotics. However, with the rise in the incidence of primary and secondary syphilis,[1] meningovascular syphilis may become a more common cause for stroke. In clinical practice, neurosyphilis as the cause of ischemic stroke is often not suspected. Diagnosis of neurosyphilis has therapeutic implication and nonor delayed institution of early appropriate treatment would result in more morbidity.[2] Most frequent clinical presentation of meningovascular syphilis is stroke presentation in the middle cerebral artery territory and vertebrobasilar artery and its branches are the second most commonly involved vessels. [3,4] Syphilis can cause the cause of aortic aneurysm, however cerebral aneurysm secondary to syphilitic vasculopathy has been reported rarely.[5] Clinical suspicion and early diagnosis and early institution appropriate treatment is important to reduce the morbidity associated with the disease.
Yao Yin-Dan, Hong Wen-Ke, Guan Li-Feng Department of Neurology, Ningbo No. 2 Hospital, Ningbo, China E-mail: [email protected]
References 1. 2. 3. 4. 5.
Chen XS, Yin YP, Wang QQ, Wang BX. Historical perspective of syphilis in the past 60 years in China: Eliminated, forgotten, on the return. Chin Med J (Engl) 2013;126:2774-9. Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG, et al. Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients. J Neurol Sci 2012;317:35-9. Flint AC, Liberato BB, Anziska Y, Schantz-Dunn J, Wright CB. Meningovascular syphilis as a cause of basilar artery stenosis. Neurology 2005;64:391-2. Feng W, Caplan M, Matheus MG, Papamitsakis NI. Meningovascular syphilis with fatal vertebrobasilar occlusion. Am J Med Sci 2009;338:169-71. Asdaghi N, Muayqil T, Scozzafava J, Jassal R, Saqqur M, Jeerakathil TJ. The re-emergence in Canada of meningovascular syphilis: 2 patients with headache and stroke. CMAJ 2007;176:1699-700. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.132427
Received: 17-01-2014 Review completed: 17-01-2014 Accepted: 08-04-2014
214
A giant falcine chondrosarcoma: Case report and literature review Sir, Parafalcine chondrosarcoma is extremely rare and may be difficult to differentiate preoperatively from falx meningioma. We report yet another such rare case. A 26-year-old male presented with a 3-week history of progressive headache and right hand numbness. Neurological examination revealed decrease in proprioception in the right hand. Cranial magnetic resonance imaging (MRI) revealed a well-marginated parafalx mass (9.4 × 6.4 × 6.0 cm) occupying bilateral frontal lobes and along the falx cerebri. It was hypointense on T1-weighted and hyperintense on T2-weighted images [Figure 1a] with no perilesional edema. Contrast-enhanced MRI scan showed a lobulated heterogeneously enhanced honeycomb lesion [Figure 1b]. Preoperative diagnosis was parafalcine meningioma and MR venography (MRV) showed oppression of superior sagittal sinus by the tumor [Figure 1c]. Total resection of the tumor was performed by bicoronal craniotomy. The lesion was hard, lobulated, gray-white, with a very firm cartilaginous consistency. The tumor and the dural attachment were totally removed. Regular follow-up MRI scans at 18 months showed no recurrence [Figure 1d]. She has recovered well and is able to run again. Microscopic examination revealed lobulated appearance with variable low to moderate cellularity composed primarily of individual cells separated by a basophilic matrix. Neoplastic chondrocytes had plump and hyperchromatic nuclei with few mitotic figures [Figure 2]. Immunohistochemical studies demonstrated positivity for S-100, which is consistent with the diagnosis of a cartilaginous tumor [Figure 3]. Chondrosarcomas are malignant tumors of cartilage and may arise from bone or soft tissues.[1] They account for 6% of skull = base neoplasms and 0.15% of all intracranial tumors.[2] Approximately 75% of all cranial chondrosarcomas occurs at the base of the skull and mostly in the middle cranial fossa.[3,4] The rare locations include the following: Choroid plexus, dura mater, and intraparenchymal. Only 61 cases of dural origin have been reported to date and of them only nine were classic low-grade type.[5-8] Skull-based chondrosarcomas are most commonly classic type,[3] but about 62% dural-based chondrosarcomas are mesenchymal variant. [5] The variants of parafalcine chondrosarcomas have a strong Neurology India | Mar-Apr 2014 | Vol 62 | Issue 2
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
