Letters to Editor
4. 5. 6. 7. 8.
9.
Tallman MS, Kwaan HC. Reassessing the hemostatic disorder associated with acute promyelocytic leukemia. Blood 1992;79:543‑53. Drapkin RL, Gee TS, Dowling MD, Arlin Z, McKenzie S, Kempin S, et al. Prophylactic heparin therapy in acute promyelocytic leukemia. Cancer 1978;41:2484‑90. Bandyopadhyay S, Bandyopadhyay D. Acute Budd‑Chiari syndrome as an initial presentation of acute promyelocytic leukemia. J Cancer Res Ther 2010;6:567‑9. Lou Y, Mai W, Jin J. Simultaneous presentation of acute myocardial infarction and acute promyelocytic leukemia. Ann Hematol 2006;85:409‑10. Goldschmidt N, Gural A, Ben Yehuda D. Extensive splenic infarction, deep vein thrombosis and pulmonary emboli complicating induction therapy with all‑trans‑retinoic acid (ATRA) for acute promyelocytic leukemia. Leuk Lymphoma 2003;44:1433‑7. Chang H, Kuo MC, Shih LY, Wu JH, Lin TL, Dunn P, et al. Acute promyelocytic leukemia‑associated thrombosis. Acta Haematol 2013;130:1‑6. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.125281
Received: 15‑09‑2013 Review completed: 16‑09‑2013 Accepted: 04‑12‑2013
Post‑operative intradural tension pneumorrhachis Sir, sA 30‑year‑old male patient presented with progressive weakness of both lower limbs associated with numbness and no bladder/ bowel involvement. On examination, patient had asymmetric spastic paraparesis (power right 3/5 and left 4/5) with dissociate sensory loss, pain and temperature being more affected than touch/ vibration. Magnetic resonance imaging (MRI) whole spine revealed heterogeneously enhancing intradural intramedullary lesion at D1‑D2 level associated with holocord syrinx extending into the brainstem [Figure 1a]. Patient underwent C7‑D2 laminoplasty with gross total microsurgical excision. Intraoperatively tumor was greyish yellow with no abnormal vascularity. Tumor was suckable with no well‑defined tumor‑tissue interface. Patient was extubated and neurologically assessed. Motor power deteriorated after surgery. MRI revealed entrapped air at L3‑L4 level with reduction in size of syrinx [Figure 1b]. Computed tomography (CT) was done to confirm the diagnosis 664
a
b
c
Figure 1: (a) Pre-operative magnetic resonance imaging (MRI) Whole spine showing D2-7 intramedullary lesion with syrinx. (b) Post-operative MRI whole spine showing exision of lesion with laminotomy with pneumorachis at L2-3 level. (c) Post-operative computed tomography lumbar spinal spne showing the pneumo
and air was aspirated [Figure 1c]. Patient had sensory improvement after aspiration, however motor improvement was delayed. The term PR was primarily reported by Gordon in 1977 and the term coined 10 years later.[1] Most of the cases of PR are reported in association with traumatic brain injury. PR can be classified as internal (intradural) or external (extradural); and etiologically as traumatic, iatrogenic and non‑traumatic. [1,2] Extradural air is usually seen in association with penetrating injuries, whereas intradural air is seen in patients with severe traumatic brain injury or is iatrogenic.[1,2] Most of the cases of PR are asymptomatic and are detected on routine screening. Symptomatic tension PR is rare and only few cases are reported so far, most of which are posttraumatic. CT scan is the diagnostic modality of choice. Due to the rarity and the different etiologies and pathogenesis, no empiric guidelines for the treatment of PR exist. Hence the management of PR has to be individualized and frequently require multidisciplinary regime. Our patient had PR following intramedullary tumor excision. Presence of holocord syrinx and air getting entrapped during dural closure appears to be the likely cause of PR. Tension PR when present requires urgent intervention to prevent neurological deficits.
Jasmit Singh, Hrushikesh Kharosekar1, Vernon Velho Departments of Neurosurgery, and 1Grant Medical College, Sir JJ Group of Hospitals, Mumbai, Maharashtra, India E‑mail: [email protected]
Neurology India | Nov-Dec 2013 | Vol 61 | Issue 6
Letters to Editor
References 1 2
Sang-Don Kim, Jin-Sung Kim, Ju-Yong Seong, Young-Geun Choi, Ik-Seong Park, Min-Woo Baik, Traumatic Pneumorrhachis, J Kor Neurotraumatol Soc 2007;3:113-115. Oertel MF, Korinth MC, Reinges MH, Krings T, Terbeck S, Gilsbach JM. Pathogenesis, diagnosis and management of pneumorrhachis. Eur Spine J 2006;15 Suppl 5:636‑43. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.125284
Figure 1: Clinical photograph of a 7-year-old female child shows right conjunctival chemosis and congestion, and lower lid inflammatory swelling predominantly involving the lateral half of the right eyelid
Received: 20‑10‑2013 Review completed: 28‑10‑2013 Accepted: 04‑12‑2013
Extraocular muscle cysticercosis mimicking as pseudotumor orbit: A clinical dilemma Sir, In India, 78% of the cases of ocular cysticercosis have been reported from Andhra Pradesh and Puducherry.[1] Extraocular orbital cysticercosis is very uncommon, despite the frequency of ocular and brain involvement.[2] Sometimes, as in our case, it is very difficult to differentiate extraocular muscle cysticercosis from orbital pseudotumor. A 7‑year‑old female child presented with 2‑month complaints of right sided headache, periocular pain and redness of eye. The onset was insidious with gradual progression. The pain was aggravated by movement of the eyeball. Lateral ocular movement was restricted. Examination revealed right sided conjunctival congestion and chemosis and inflammatory swelling of right lower lid [Figure 1]. Laboratory investigations revealed raised erythrocyte sedimentation rate (54 mm at the end of 1 h) and peripheral eosinophilia (800 cells/cubic mm). Serology test (ELISA) for anti‑cysticercal antibodies (IgG) was positive. B‑scan ocular ultrasonography of right eye revealed a well‑defined cystic lesion with an eccentric mural nodule. Pericystic soft‑tissue inflammation and edema was also seen. Right lateral rectus muscle was not delineated separately [Figure 2]. Magnetic resonance imaging orbit revealed fusiform enlargement of right lateral rectus muscle. The expanded muscle Neurology India | Nov-Dec 2013 | Vol 61 | Issue 6
Figure 2: B-scan ocular ultrasonography of right eye reveals a welldefined cystic lesion with clear content (arrowheads) and a highly reflective pinhead lesion within it representing the scolex (thin arrow). Pericystic soft tissue inflammation and edema present (asterisk). Right lateral rectus muscle could not be delineated separately
contained a sharply circumscribed cyst with a small mural nodule. The inflamed extraocular muscle and the adjacent soft‑tissue together produced an inflammatory pseudomass indenting the posterolateral aspect of right globe. The inflammatory changes were best observed on fat‑suppressed T2‑weighted image. On diffusion‑weighted image, pericystic tissue showed multiple areas of reduced diffusivity suggesting inflammatory mass with abscess formation; the cyst per se did not show diffusion restriction. There was no involvement of brain parenchyma [Figure 3]. Based on imaging findings, radiological diagnosis of extraocular orbital cysticercosis of right lateral rectus muscle with formation of inflammatory pseudomass was suggested. Patient was started on systemic steroids and albendazole and was given for 6 weeks. On the 3rd day, patient started showing improvement. Pain and fever subsided and ocular motility improved. Serial B‑scan ocular ultrasonography demonstrated complete resolution of the cyst and inflammatory mass over a period of 6 weeks. 665
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.
4. 5. 6. 7. 8.
9.
Tallman MS, Kwaan HC. Reassessing the hemostatic disorder associated with acute promyelocytic leukemia. Blood 1992;79:543‑53. Drapkin RL, Gee TS, Dowling MD, Arlin Z, McKenzie S, Kempin S, et al. Prophylactic heparin therapy in acute promyelocytic leukemia. Cancer 1978;41:2484‑90. Bandyopadhyay S, Bandyopadhyay D. Acute Budd‑Chiari syndrome as an initial presentation of acute promyelocytic leukemia. J Cancer Res Ther 2010;6:567‑9. Lou Y, Mai W, Jin J. Simultaneous presentation of acute myocardial infarction and acute promyelocytic leukemia. Ann Hematol 2006;85:409‑10. Goldschmidt N, Gural A, Ben Yehuda D. Extensive splenic infarction, deep vein thrombosis and pulmonary emboli complicating induction therapy with all‑trans‑retinoic acid (ATRA) for acute promyelocytic leukemia. Leuk Lymphoma 2003;44:1433‑7. Chang H, Kuo MC, Shih LY, Wu JH, Lin TL, Dunn P, et al. Acute promyelocytic leukemia‑associated thrombosis. Acta Haematol 2013;130:1‑6. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.125281
Received: 15‑09‑2013 Review completed: 16‑09‑2013 Accepted: 04‑12‑2013
Post‑operative intradural tension pneumorrhachis Sir, sA 30‑year‑old male patient presented with progressive weakness of both lower limbs associated with numbness and no bladder/ bowel involvement. On examination, patient had asymmetric spastic paraparesis (power right 3/5 and left 4/5) with dissociate sensory loss, pain and temperature being more affected than touch/ vibration. Magnetic resonance imaging (MRI) whole spine revealed heterogeneously enhancing intradural intramedullary lesion at D1‑D2 level associated with holocord syrinx extending into the brainstem [Figure 1a]. Patient underwent C7‑D2 laminoplasty with gross total microsurgical excision. Intraoperatively tumor was greyish yellow with no abnormal vascularity. Tumor was suckable with no well‑defined tumor‑tissue interface. Patient was extubated and neurologically assessed. Motor power deteriorated after surgery. MRI revealed entrapped air at L3‑L4 level with reduction in size of syrinx [Figure 1b]. Computed tomography (CT) was done to confirm the diagnosis 664
a
b
c
Figure 1: (a) Pre-operative magnetic resonance imaging (MRI) Whole spine showing D2-7 intramedullary lesion with syrinx. (b) Post-operative MRI whole spine showing exision of lesion with laminotomy with pneumorachis at L2-3 level. (c) Post-operative computed tomography lumbar spinal spne showing the pneumo
and air was aspirated [Figure 1c]. Patient had sensory improvement after aspiration, however motor improvement was delayed. The term PR was primarily reported by Gordon in 1977 and the term coined 10 years later.[1] Most of the cases of PR are reported in association with traumatic brain injury. PR can be classified as internal (intradural) or external (extradural); and etiologically as traumatic, iatrogenic and non‑traumatic. [1,2] Extradural air is usually seen in association with penetrating injuries, whereas intradural air is seen in patients with severe traumatic brain injury or is iatrogenic.[1,2] Most of the cases of PR are asymptomatic and are detected on routine screening. Symptomatic tension PR is rare and only few cases are reported so far, most of which are posttraumatic. CT scan is the diagnostic modality of choice. Due to the rarity and the different etiologies and pathogenesis, no empiric guidelines for the treatment of PR exist. Hence the management of PR has to be individualized and frequently require multidisciplinary regime. Our patient had PR following intramedullary tumor excision. Presence of holocord syrinx and air getting entrapped during dural closure appears to be the likely cause of PR. Tension PR when present requires urgent intervention to prevent neurological deficits.
Jasmit Singh, Hrushikesh Kharosekar1, Vernon Velho Departments of Neurosurgery, and 1Grant Medical College, Sir JJ Group of Hospitals, Mumbai, Maharashtra, India E‑mail: [email protected]
Neurology India | Nov-Dec 2013 | Vol 61 | Issue 6
Letters to Editor
References 1 2
Sang-Don Kim, Jin-Sung Kim, Ju-Yong Seong, Young-Geun Choi, Ik-Seong Park, Min-Woo Baik, Traumatic Pneumorrhachis, J Kor Neurotraumatol Soc 2007;3:113-115. Oertel MF, Korinth MC, Reinges MH, Krings T, Terbeck S, Gilsbach JM. Pathogenesis, diagnosis and management of pneumorrhachis. Eur Spine J 2006;15 Suppl 5:636‑43. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.125284
Figure 1: Clinical photograph of a 7-year-old female child shows right conjunctival chemosis and congestion, and lower lid inflammatory swelling predominantly involving the lateral half of the right eyelid
Received: 20‑10‑2013 Review completed: 28‑10‑2013 Accepted: 04‑12‑2013
Extraocular muscle cysticercosis mimicking as pseudotumor orbit: A clinical dilemma Sir, In India, 78% of the cases of ocular cysticercosis have been reported from Andhra Pradesh and Puducherry.[1] Extraocular orbital cysticercosis is very uncommon, despite the frequency of ocular and brain involvement.[2] Sometimes, as in our case, it is very difficult to differentiate extraocular muscle cysticercosis from orbital pseudotumor. A 7‑year‑old female child presented with 2‑month complaints of right sided headache, periocular pain and redness of eye. The onset was insidious with gradual progression. The pain was aggravated by movement of the eyeball. Lateral ocular movement was restricted. Examination revealed right sided conjunctival congestion and chemosis and inflammatory swelling of right lower lid [Figure 1]. Laboratory investigations revealed raised erythrocyte sedimentation rate (54 mm at the end of 1 h) and peripheral eosinophilia (800 cells/cubic mm). Serology test (ELISA) for anti‑cysticercal antibodies (IgG) was positive. B‑scan ocular ultrasonography of right eye revealed a well‑defined cystic lesion with an eccentric mural nodule. Pericystic soft‑tissue inflammation and edema was also seen. Right lateral rectus muscle was not delineated separately [Figure 2]. Magnetic resonance imaging orbit revealed fusiform enlargement of right lateral rectus muscle. The expanded muscle Neurology India | Nov-Dec 2013 | Vol 61 | Issue 6
Figure 2: B-scan ocular ultrasonography of right eye reveals a welldefined cystic lesion with clear content (arrowheads) and a highly reflective pinhead lesion within it representing the scolex (thin arrow). Pericystic soft tissue inflammation and edema present (asterisk). Right lateral rectus muscle could not be delineated separately
contained a sharply circumscribed cyst with a small mural nodule. The inflamed extraocular muscle and the adjacent soft‑tissue together produced an inflammatory pseudomass indenting the posterolateral aspect of right globe. The inflammatory changes were best observed on fat‑suppressed T2‑weighted image. On diffusion‑weighted image, pericystic tissue showed multiple areas of reduced diffusivity suggesting inflammatory mass with abscess formation; the cyst per se did not show diffusion restriction. There was no involvement of brain parenchyma [Figure 3]. Based on imaging findings, radiological diagnosis of extraocular orbital cysticercosis of right lateral rectus muscle with formation of inflammatory pseudomass was suggested. Patient was started on systemic steroids and albendazole and was given for 6 weeks. On the 3rd day, patient started showing improvement. Pain and fever subsided and ocular motility improved. Serial B‑scan ocular ultrasonography demonstrated complete resolution of the cyst and inflammatory mass over a period of 6 weeks. 665
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.
