Mild encephalitis with reversible lesion in the splenium (MERS) is a clinicoradiological syndrome presenting as a solitary lesion in the central portion of the splenium of the corpus callosum (SCC) with a radiological finding of restricted diffusion and low apparent diffusion coefficient (ADC) values. Complete resolution of the lesion on follow-up imaging and full clinical recovery are the hallmarks of this syndrome, even with only supportive therapy. MERS is usually associated with normal Cerebrospinal fluid (CSF) findings and an excellent prognosis, even without corticosteroid therapy. Magnetic resonance imaging (MRI) is the ideal modality for initial diagnosis and follow-up. Not many cases of this uncommon clinicoradiological syndrome with transient elevation of CSF proteins have been reported. In the subsequent sections, we present a case report of this unusual clinicoradiological entity with raised CSF protein. We also elaborate on possible differential diagnoses and the syndrome’s proposed pathophysiology.

Brain ; pathology ; Humans ; Hyponatremia ; complications ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Myelinolysis, Central Pontine ; diagnosis ; etiology ; pathology ; physiopathology ; therapy ; Osmolar Concentration ; Osmosis ; Osmotic Pressure ; Risk Factors ; Time Factors

Spinal dermoid tumors are rare, benign, slow growing tumors. These tumors may become acutely symptomatic after rupture or infection. Excision of the lesion with long term close follow-up studies is required for the management of these lesions. We present a very rare case of ruptured conus medullaris dermoid cyst in a 22-year-old male presented with urinary retention and low back pain. Magnetic resonance imaging scan with contrast reveals a lesion in the cauda equina inseparable from conus medullaris with fat droplets within the central spinal canal extending up to the medulla. Patient was operated with laminectomy and near complete excision of the lesion was done. Patient's low back pain was relieved following surgery. However patient had persistent urinary incontinence and on clean intermittent self-catheterization. Histopathology was suggestive of dermoid cyst.
Cauda Equina ; Conus Snail ; Dermoid Cyst ; Humans ; Laminectomy ; Low Back Pain ; Magnetic Resonance Imaging ; Male ; Rupture ; Spinal Canal ; Spinal Cord ; Urinary Incontinence ; Urinary Retention

Filum terminale arteriovenous fistula (FTAVF) presenting as a cause of failed back surgery syndrome is a rare entity. We report a 48-year-old male patient who presented with clinical features of a conus medullaris/cauda equina lesion. He had upper and lower motor neuron signs in both the lower limbs with autonomic dysfunction. The patient was misdiagnosed and was operated twice earlier for lumbar canal stenosis and disc prolapse. After reviewing his clinical and radiological findings a diagnosis of FTAVF was made. He underwent surgery and there was a significant improvement in his neurological functions. We discuss the case and review the literature on FTAVF's.
Arteriovenous Fistula* ; Cauda Equina* ; Constriction, Pathologic ; Conus Snail ; Diagnosis ; Failed Back Surgery Syndrome ; Humans ; Lower Extremity ; Male ; Middle Aged ; Motor Neurons ; Prolapse

This article on Asian Spine Journal was initially published without the word 'Canal' in the title.

We present a case of 24-year-old male presented with low back pain radiating to the left lower limb, tingling numbness and weakness of 6 months duration. Magnetic resonance imaging scan with contrast reveals an extradural mass at lumbosacral region. Patient was operated with laminectomy and complete excision of the lesion was done. Patient's radicular pain relieved following the surgery and weakness also improved. Histopathology was suggestive of non-Hodgkin's lymphoma. Patient received chemotherapy which was followed by radiotherapy. Primary Non-Hodgkin's lymphoma of the lumbosacral spinal epidural tissue is an uncommon lesion. Lymphoma involves the central nervous system in 5-11% of cases either at presentation of the disease or during its course. The spinal epidural tissue is involved primarily in 0.1-3.3% of cases with spinal cord compression being the commonest presentation. Excision of the lesion followed by chemotherapy and radiotherapy is required to achieve cure.
Central Nervous System ; Humans ; Hypesthesia ; Laminectomy ; Low Back Pain ; Lower Extremity ; Lumbosacral Region ; Lymphoma ; Lymphoma, Non-Hodgkin ; Magnetic Resonance Imaging ; Male ; Spinal Cord Compression ; Young Adult

BACKGROUND AND AIMIntravenously-administered tissue plasminogen activator (IV-TPA) induces thrombolysis and remains the only FDA-approved therapy for acute ischaemic stroke. IV-TPA thrombolysis has been approved recently in Singapore for acute stroke. Continuous exposure of clot to 2-MHz pulsed-wave transcranial Doppler (TCD) ultrasound during IV-TPA infusion is known to augment thrombolysis. We aimed to determine the feasibility, safety and efficacy of ultrasound-assisted thrombolysis in acute ischaemic stroke in Singapore.

SUBJECTS AND METHODSConsecutive patients with acute ischaemic stroke due to intracranial arterial-occlusions were treated with standard IV-tPA and continuously monitored with 2-MHz TCD according to the CLOTBUST-trial protocol. Arterial recanalisation was determined with Thrombolysis in Brain Ischemia (TIBI) flow-grading system. Safety and efficacy of ultrasoundassisted thrombolysis were assessed by rates of symptomatic intracranial haemorrhage (sICH) and functional recovery at 1 month, respectively.

RESULTSFive consecutive patients (mean age 58 years, 3 men and 3 of Chinese ethnicity) were included. Mean time elapsed between symptom onset and presentation to emergency room was 98 minutes (range, 50 to 135 minutes) while the mean time interval between symptom onset to IV-TPA bolus was 144 minutes (range, 125 to 180 minutes). Partial or complete recanalisation with reduction in the stroke severity was noted in 4 out of the 5 patients during IV-TPA infusion (mean change in NIHSS = 4 points; range 2 to 8 points). None of our patients developed sICH while 4 patients demonstrated good functional outcome at 1 month.

CONCLUSIONSOur preliminary study demonstrates the feasibility, safety and efficacy of ultrasound-assisted thrombolysis in acute ischaemic stroke in Singapore. Continuous TCD-monitoring during IV-TPA infusion provides real-time information, enhances thrombolysis and improves functional outcomes in acute ischaemic stroke.

Aged ; Brain Infarction ; diagnostic imaging ; Female ; Fibrinolytic Agents ; administration & dosage ; Humans ; Infusions, Intravenous ; Male ; Middle Aged ; Thrombolytic Therapy ; methods ; Tissue Plasminogen Activator ; administration & dosage ; Ultrasonography, Interventional ; methods

INTRODUCTIONTranscranial Doppler (TCD) is an established tool for the non-invasive assessment of cerebral blood flow. Since TCD results vary with the skills and experience of the sonographer, it requires validation against contrast angiography. We evaluated the diagnostic accuracy of TCD against computed tomography angiography (CTA) and the feasibility of the latter as an additional screening tool in our acute ischaemic stroke patients.

MATERIALS AND METHODSOur stroke unit manages about 700 patients annually. Acute stroke patients undergo TCD for vascular assessment of major arteries of the circle of Willis. Randomly selected acute stroke patients with significant stenosis on TCD underwent high-resolution cranial CTA with multidetector helical scanner. CTA was performed within 24 hours of TCD and images were interpreted by a neuroradiologist blinded to TCD findings. An independent neurosonologist reevaluated TCD if CTA findings were contradictory. Additional information by either modality was also noted.

RESULTSFifteen patients (12 men, mean age 61 +/- 15years) with cerebral ischaemia and moderate (>50%) stenosis in > or =1 large intracranial arterial segment on routine TCD were evaluated by CTA. Compared with 21 segments of significant stenosis on CTA, TCD showed 16 true-positive, 3 false-positive and 5 false-negative results (sensitivity: 76.2%, positive predictive value: 84.2%). In 3 cases, TCD showed findings complementary to CTA (real-time embolisation, collateral flow patterns, evidence of distal M2 branch occlusion).

CONCLUSIONTCD in our neurovascular laboratory shows a satisfactory agreement with cranial CTA in evaluating patients with cerebral ischaemia. TCD can provide additional real-time dynamic findings complementary to information provided by CTA.

Aged ; Brain Ischemia ; diagnosis ; Cerebral Angiography ; Female ; Humans ; Male ; Middle Aged ; Pilot Projects ; Singapore ; Tomography, X-Ray Computed ; Ultrasonography, Doppler, Transcranial

PURPOSE: Celiac disease is a common non-communicable disease with varied presentations. Purpose of this study was to find the duodeno-endoscopic features in celiac disease and to compare duodeno-endoscopic and histological findings between typical and atypical celiac disease in children. METHODS: Hospital based observational study was conducted at Sir Padampat Mother and Child Health Institute, Jaipur from June 2015 to May 2016. Patients were selected and divided in two groups- typical and atypical celiac disease based upon the presenting symptoms. Upper gastrointestinal endoscopy and duodenal biopsy was performed for serology positive patients. Results were analysed using appropriate statistical test of significance. RESULTS: Out of 101 enrolled patients, 47.5% were male. Age ranged from 1 to 18 years. Study showed that 54.5% were typical and 45.5% were atypical. Patients presenting with atypical symptoms were predominantly of older age group. On endoscopy, scalloping, mosaic pattern, reduced fold height and absent fold height; and in histology, advanced Marsh stage were significantly higher in the typical group. CONCLUSION: Awareness of atypical presentations as well as duodeno-endoscopic features may have considerable practical importance for the diagnosis of celiac disease in children. Scalloping, mosaic pattern, reduced fold height and nodularity are main endoscopic markers of celiac disease in children. Endoscopic markers of duodenal mucosa may be important in early diagnosis of celiac disease, in children subjected to endoscopy for atypical presentations or indication other than suspected celiac disease.
Biopsy ; Celiac Disease* ; Child Health ; Child* ; Diagnosis ; Early Diagnosis ; Endoscopy ; Endoscopy, Gastrointestinal ; Humans ; Male ; Mothers ; Mucous Membrane ; Observational Study ; Pectinidae ; Wetlands

BACKGROUND: Aberrant myeloid antigen (MA) co-expression and high expression of CD34 antigen on the blasts of acute lymphoblastic leukemia (ALL) patients are independently reported to have a role in pathogenesis and prognosis. This study was conducted to determine whether these two parameters are related. METHODS: A total of 204 cases of ALL were included in an analysis of blast immunophenotypic data. CD34 expression was categorized as low when less than 50% of blasts were CD34-positive (CD34low) and as high when 50% or more were CD34-positive (CD34high). RESULTS: Of 204 cases of ALL, 163 and 41 were of B-cell origin (B-ALL) and T-cell origin (T-ALL), respectively. Of all cases, 132 (64.7%) showed co-expression of MA and among these, 101 (76.51%) were CD34high, while the remaining 31 (23.48%) were CD34low. Of 72 cases without MA co-expression, 25 (34.72%) were CD34high and 47 (67.25%) were CD34low. Furthermore, of 163 cases of B-ALL, 111 showed co-expression of MA and 84 of these were CD34high. Of 52 cases of B-ALL without MA expression, 22 were CD34high. Among 41 cases of T-ALL, 21 co-expressed MA, 17 of which were CD34high. Moreover, all 20 cases of T-ALL without co-expression of MA were CD34low. These differences were statistically significant. CONCLUSION: We observed a strong correlation between aberrant MA expression and CD34high expression on the blasts of ALL. We hypothesize that these different patient subsets may represent unique prognostic characteristics.
Antigens, CD34 ; B-Lymphocytes ; Flow Cytometry ; Humans ; Immunophenotyping ; Precursor Cell Lymphoblastic Leukemia-Lymphoma* ; Precursor T-Cell Lymphoblastic Leukemia-Lymphoma ; Prognosis ; T-Lymphocytes ; Tertiary Care Centers*