Deep Brain Stimulation for Dystonia: Experience of a Moroccan University Hospital

BACKGROUND

Deep brain stimulation (DBS) is a well-established procedure that provides long-term symptom control of the third most common movement disorder: dystonia. In this study, we aim to report the experience of Ibn Rochd University Hospital in the treatment of dystonia using DBS of the globus pallidus internus, which represents an exceptional challenge for a developing country such as Morocco.

METHODS

Since 2013, we selected five eligible candidates for DBS surgery at the university hospital Ibn Rochd. A genetic assessment had been performed in four cases. Their motor and mental states were prospectively monitored using several validated scales, including Burke-Fahn-Marsden Dystonia Rating Scale, Mini Mental State Examination, 36-Item Short Form Survey, and Zarit scale.

RESULTS

Our sample had two clinical phenotypes of dystonia: isolated dystonia (in two patients) and combined dystonia (in three patients). Patients were aged 14 to 32 years, and their mean onset age ranged from 7 to 13 years with a mean progression duration of 9 years. Our results indicate successful treatment of patients with dystonia using DBS. Scores from the Burke-Fahn-Marsden Dystonia Rating Scale confirm improvements ranging from 40% to 95%. However, some potentially surgery-related complications could occur such as lead infection, which, in our experience, was reported in one case.

CONCLUSION

The experience of the university hospital Ibn Rochd regarding the use of DBS in treating dystonia was largely positive. However, the procedure faces challenges due to its complexity, specifically concerning its multidisciplinary nature, its genetic test costs, and the reluctance of pediatricians to get involved.

Tumoral calcinosis of unusual location in a chronic hemodialysis patient

Tumoral calcinosis is a rare cause of intratissular calcifications in hemodialysis patients with chronic renal failure. Its frequency is estimated between 0.5 and 7% of patients. We illustrate through a case of unusual localization diagnosed in our institution, the radiographic and scannographic aspect of this little known entity. A 40-year-old man, followed for hypertensive cardiopathy, in chronic renal failure for 12 years under hemodialysis, consulted for bilateral inguinal swellings evolving in a progressive and painless way. Biological investigations revealed hyperparathyroidism with increased phosphocalcic product. He was referred to us for radiological evaluation which revealed lesions in favor of bilateral pubo-inguinal tumor calcinosis. Tumoral calcinosis is a rare cause of intratissular calcifications in chronic renal failure patients undergoing hemodialysis. Pubic localization with infiltration and osteolysis of the symphysis pubis is very rare. Its main risk factors are the existence of hyperparathyroidism, an increase in phosphocalcic product and probably local traumatic factors. Tumoral calcinosis has a typical appearance on radiographs: amorphous, cystic and multilobulated calcifications of periarticular distribution. The CT scan allows a better delineation of the calcified mass. Its treatment remains controversial. The knowledge of osteoarticular manifestations of chronic hemodialysis patients, especially tumoral calcinosis by radiologists, allows to easily make the diagnosis and thus avoid invasive complementary explorations for the patient and to quickly institute an effective treatment.

Eccrine porocarcinoma: an extremely rare cutaneous tumor from a radiological point of view - case report and review of the literature

Eccrine porocarcinoma is a rare type of skin neoplasm. It represents less than 0.01% of all epithelial cutaneous tumors. Early diagnosis is the only way to minimize the mortality rate, given its aggressive nature and the high rate of local recurrence and metastasis. Clinical diagnosis is challenging and the confirmation is histological. Few studies have been published about the radiological features of eccrine porocarcinoma. We report a case of a localized eccrine porocarcinoma along with ultrasound, MRI features, and a review of the literature to highlight the role of imaging in the diagnosis and treatment plan.

Diagnostic imaging of foot mycetomas: A report on two cases

Mycetomas caused by aerobic actinomycetes are called actinomycetomas. It is primarily localized in subcutaneous tissue but it can spread to different tissue planes including the skin, deep tissues and structures and eventually the bones. We report the cases of 2 patients referred for evaluation of soft tissue masses involving the foot. A 40-year-old male and a 25-year-old male, in both cases MRI was performed to assess the extension, which was later completed by a CT scan. MRI revealed a low intensity matrix that represents fibrosis containing multiple high intensity lesions corresponding to the mycetoma grains. Within some of the lesions a low-intensity focus was identified. This "dot-in-circle sign" on an MRI is a pathognomonic feature of mycetoma. The purpose of this work is to describe the characteristic MRI appearance of foot mycetoma.

Giant fibrous polyp issuing from the uterine cervix: A case report

Fibrous uterine polyps are very common in women during or after menopause, and less often seen in women of child-bearing age, with a maximum of frequency between 40, and 49 years. They can have various locations in the uterus depending on the patient's age, mostly the body, and fundus. We report a rare case of cervical localization of a pedicled fibrous polyp issuing from the cervix, in a 44-year-old female patient with 3 living children and a history of miscarriage, who had been presenting breakthrough bleeding, and pelvic pain for 3 months. It is essential to remind young radiologists of the different presentations of fibrous polyps, how to explore them better and when to fear malignancy and thus insist in a histologic study, in order to help clinicians to choose the most adequate treatment option.

Mirrored Appearance of Complete Common Mesentery Discovered on CT Scan for Crohn's Disease

Incomplete 90° intestinal rotation in a clockwise direction results in complete common mesentery being placed in a mirror image to and with a similar appearance to complete common mesentery. This rotation places the colon in the right half of the abdominal cavity and the small intestine in the left half of the abdominal cavity. We report the case of a 19-year-old patient with a history of cerebral palsy secondary to meningitis who presented with melaena and inflammatory anaemia. CT enterography was performed which showed regular, non-stenosing circumferential wall thickening of the sigmoid colon and rectosigmoid junction compatible with Crohn's disease, which was confirmed by pathophysiology. It also revealed transposition of the colon to the right hemi-abdomen and the small intestine to the left hemi-abdomen, the caecum to the right iliac fossa, and the third portion of the duodenum to the left of the mesenteric vessels.

LEARNING POINTS

Complete common mesentery in the mirror image is an anomaly of intestinal rotation, placing the colon in the right half of the abdomen and the small intestine in the left half of the abdomen.It can be asymptomatic and discovered incidentally during assessment for other conditions.

Massive Cerebral Air Embolism Causing Stroke Secondary to Pulmonary Tuberculosis

Cerebral air embolism due to pulmonary tuberculosis is an extremely rare cause of stroke. We report an unusual case of a presentation of cerebral air embolism likely due to pulmonary tuberculosis lesions during a severe cough. We discuss the relationship between the pulmonary tuberculosis and the occurrence of the cerebral air embolism. A 55-year-old man with lung tuberculosis suddenly experienced a nontraumatic loss of consciousness after a severe cough. The magnetic resonance imaging confirmed an ischemic stroke due to cerebral air embolism. The thoracic scan revealed tuberculosis with a parenchymatous cavity. Patients with intrapulmonary tuberculosis cavities should be strongly considered for surgical repair and should be warned about the risk of rupture of the cavity in the situation of increasing thoracic pressure.

How to cite this article: Bouaggad A, Moussaoui M, Abassi O, Hassen S, Essodegui F. Massive Cerebral Air Embolism Causing Stroke Secondary to Pulmonary Tuberculosis. Indian J Crit Care Med 2021;25(8):942–944.

[Leriche syndrome in a 20-year-old young woman: a case report]

Le syndrome de Leriche, ou syndrome d´oblitération aorto-iliaque, est une entité particulière d´artériopathie oblitérante des membres inférieurs qui consiste en une occlusion thrombotique du carrefour aorto-iliaque. Nous rapportons le cas d´une patiente âgée de 20 ans, sans antécédents pathologiques particuliers connus, qui s´est présentée avec un tableau d´ischémie aiguë des deux membres inférieurs. L´écho Doppler des membres inférieurs a retrouvé une diminution globale des flux artériels sans visualisation de matériel endoluminal. Ceci a motivé la réalisation d´un angioscanner des membres inférieurs qui a objectivé une thrombose artérielle étendue de l´aorte abdominale aux artères iliaques externes bilatérales. La patiente a par la suite bénéficié d´un pontage aorto-bi-iliaque avec une bonne évolution, ainsi que d´une démarche diagnostique étiologique à la recherche d´un éventuel terrain thrombogène.

Zinner Syndrome

Zinner syndrome is a developmental anomaly of the urogenital tract. This condition is defined by the triad of unilateral renal agenesis, ipsilateral seminal vesicle cyst and ipsilateral ejaculatory duct obstruction. The syndrome is due to malformation of the mesonephric duct during embryogenesis. The condition used to be rare but is now frequently encountered due to the advent of MRI and CT. MRI confirms the diagnosis by revealing the seminal vesicle cyst and its contents, and the ejaculatory duct obstruction, while CT confirms renal agenesis. We report the case of a young patient with Zinner syndrome.

LEARNING POINTS

Zinner syndrome consists of the triad of renal agenesis, seminal vesicle cyst and ejaculatory duct obstruction.Any insult during embryogenesis of the mesonephric duct in men can result in Zinner syndrome.Pelvic MRI is the gold standard to confirm the diagnosis of Zinner syndrome.

Spontaneous vertebral artery dissection in an elder patient: a case report

Vertebrobasilar artery dissection (VBD) is a rare cause of posterior ischemic strokes. It is more likely to occur in young patients with a history of traumatism or hereditary connective tissue disorders. Spontaneous VBD is rare, especially in elder patients. This paper aims to report the case of an old patient that presented with a posterior ischemic stroke due to a spontaneous vertebral artery dissection (SVAD), linked to atherosclerosis. The diagnosis of SVAD was made by Magnetic resonance imaging (MRI) which is the gold standard technique to diagnose this pathology in a short time so the patient could receive adequate treatment.

[Post traumatic pseudoaneurysm of the external carotid]

Le pseudo-anévrisme provient d'une solution de la continuité de la paroi artérielle, secondaire à l'inflammation, un traumatisme ou des causes iatrogènes telles que la chirurgie, une biopsie percutanée ou un drainage. Nous rapportons un cas d'un patient de 37 ans, venant consulter pour constatation d'une tuméfaction cervicale évoluant progressivement suite à un traumatisme cervical pénétrant survenu 8 mois auparavant. L'échographie doppler complétée par un angioscanner a confirmé le diagnostic de pseudo-anévrisme de l'artère carotide externe gauche. Le diagnostic de pseudo-anévrisme est plus aisé avec le développement considérable de l'imagerie en coupe et de l'angiographie.

[Rare localization of aneurysmal bone cyst in the sphenoid bone]

Le kyste osseux anévrysmal est une tumeur bénigne pouvant toucher tous les os du corps. Rare au niveau de la base du crane, il siège habituellement au niveau des os longs. Nous rapportons l'observation clinique d'un homme de 44 ans suivi depuis 9 mois pour une masse du basisphenoide étiquetée à tort comme un macroadénome invasif à prolactine et pour lequel il fut mis sous traitement (agonistes dopaminergiques). Nous avons redressé le diagnostic en évoquant le kyste osseux anévrysmal du sphénoïde de par son aspect radiologique en IRM quasi pathognomonique.

[Osteoid osteoma: about a case]

Osteoid osteoma is a benign primary bone tumor. This tumor is relatively frequent, accounting for 12% of all benign bone tumors and about 2-3% of all bone tumors. We report a new case of osteoid osteoma confirmed histologically. A 30-year old patient was referred for evaluation of chronic ankle pain. Front and lateral radiographs of the ankle showed a heterogeneous lesion located in the neck of the talus without soft tissue abnormalities. The CT scan of the ankle showed a nodular, hypodense lesion located in the neck of the talus with a limited osteosclerotic reaction.

[Pregnancy and extra-gastrointestinal stromal tumor: an exceptional association]

Extra-gastrointestinal stromal tumors (EGIST) are rare entities. The coexistence of a gastrointestinal stromal tumor and pregnancy is exceptional. We describe a case of this association, three years after the first diagnosis of EGIST made during exploratory laparotomy for abdominal-pelvic mass. We report the diagnostic difficulties and management of pregnancy on recurrence of EGIST tumor.

Idiopathic granulomatous mastitis: a report of twenty cases

INTRODUCTION

Idiopathic granulomatous mastitis is a benign lesion of the mammary gland characterised by the presence of non-infectious inflammatory breast lesions limited to the lobules.

OBJECTIVE

We report twenty cases of idiopathic granulomatous mastitis (IGM) with a discussion of epidemiology, clinical and diagnostic features, treatment and progress of this pathological entity.

MATERIALS AND METHODS

A retrospective study of twenty cases compiled from a ten-year period, from 952 pathological anatomy examinations carried out to investigate various breast pathologies.

RESULTS

The patients had a mean age of 45.5 years. Clinical examinations revealed a tumefaction measuring between 2.5 and 18 cm in diameter. The mean size was 5.5 cm. Mammography showed nodular lesions and sonography demonstrated hypoechoic nodules. On histological examination there was a granulomatous inflammatory infiltrate of epithelioid and giant cells, without caseation necrosis, made up of lymphocytes, plasma cells and neutrophils. Microbiology investigations were negative. Lesion involvement was principally lobulocentric. Surgical excision of the lesions was combined with corticosteroid therapy in twelve cases, with non-steroidal anti-inflammatory drugs in another four and with antibiotic therapy in four cases. The patients made good progress in the short-term.

DISCUSSION AND CONCLUSION

IGM is a rare entity. It poses a problem of differential diagnosis because it clinically resembles other forms of mastitis. The diagnosis can be made with certainty on histological studies. The treatment is medical alongside surgical excision. The prognosis of this disease remains favourable.

[Cushing's syndrome due to a pulmonary carcinoid]

Cushing paraneoplasic syndrome is a rare cause of hypercorticism. We report a case of 35 year-old man presenting with Cushing's syndrome characterized by severe signs of hypercorticism and hypokalemia. Endocrine investigations were suggestive of an hypercortisolism linked to an ectopic adrenocorticotropic (ACTH) secretion, both at baseline (mean ACTH levels=275 pg/ml, urinary free cortisol excretion=3.898 mmol/24 h) and after pharmacodynamic testing (lack of inhibition of ACTH by dexamethasone). Thoracic tomodensitometric examination revealed a 15 mm tumor corresponding to a neuroendocrine pulmonary carcinoid with positive immunostaining for chromogranin A. Postoperative ACTH measurement was undetectable, plasma cortisol and free urinary cortisol were also decreased after tumor resection suggesting complete tumor removal. This case report illustrates the characteristics of paraneoplasic Cushing syndrome due to ACTH secreting pulmonary neuroendocrine carcinoid.

[Primary lymphoma of the thyroid gland]

Malignant primary lymphoma of the thyroid gland is a rare disease generally occurring women in the 6(th) or 7(th) decade of life. The principal clinical sign is giant goiter rapidly leading to sings of compression, raising the question of differential diagnosis with anaplastic cancer. The radiological findings in our patient were suggestive of malignancy due to the locoregional invasion. Immunohistochemistry study of the surgical specimen was required to reach the definitive diagnosis of thyroid gland primary lymphoma. Diagnosis of malignant primary lymphoma of the thyroid gland made at the stage of extensive locoregional extension compromises prognosis. Our patient died after one session of chemotherapy.

Imagerie des angiomyolipomes du rein : à propos de neuf cas

PURPOSE

To report the radiological polymorphism of angiomyolipoma (AML).

MATERIAL AND METHODS

[corrected] A retrospective series of eight cases of AML explored by US and CT scan. The diagnosis was radiological in seven cases and histopathological in one case.

RESULT

Five cases of AML were discovered fortuitously. The tuberous sclerosis of Bourneville disease (TSB) was noted in five cases. The cverage age was 37 years with female predominance noted in seven cases. The AML were multiple in half cases all of thein had TSB. The tumoral size ranged from 0.5 cm and 20 cm. The US showed an homogenous hyperechogenique mass in six cases and heterogenous in two cases. The CT scan showed polymorph parenchymal lesions. The fatty component was detected in seven cases. An intratumoral bleeding was noted in one case.

CONCLUSION

The radiological feature of AML is variable, related to tumoral size. It's typical when a tumor of kidney contains fat. An association with TSB is a supplementary argument of diagnosis.

[Malignant stromal tumors of the small intestine: report of 9 cases]

PURPOSE

Analysis of imaging features of malignant stromal tumors of the small bowel and review of literature.

MATERIAL AND METHODS

9 cases of malignant stromal tumor of the small bowel with histological proof were imaged at US (8 cases), small bowel series (9 cases) and CT scan (3 cases).

RESULTS

There were 6 cases of leiomyosarcoma and 3 cases of malignant schwannoma. Tumors involved the jejunum in 3 patients, the ileum in 4 patients, and the duodenum in 2 patients. The main clinical presentation was an abdominal mass (8 cases), which appeared heterogeneous and hypoechoic with eccentric lumen at US confirming its GI origin (7 cases). Small bowel series showed a bulky cavitary mass opacified via a thin fistula (7 cases), an ileo-ileal intussusception (1 case) and enlarged duodenal lumen (1 case). CT performed in 3 cases showed an intraperitoneal mass with soft-tissue density. A communication with the GI tract was noted in 1 case, and in another case, it showed an intestinal intussusception. US guided biopsy performed in 3 cases provided diagnosis in 2 cases (malignant schwannoma, leiomyosarcoma). Tumor growth was exophytic in 8 cases and dumbbell-shaped in 1 case.

CONCLUSION

The imaging features of malignant stromal tumors of the small bowel are similar. It varies with the type of tumor growth and its size. The diagnosis may be suggested based on imaging features.

[Upper esophageal duplication. Apropos of a case disclosed by respiratory distress]

The authors report a new case of cystic oesophageal duplication, discovered in a 10-month-old infant. This case is unusual because of its site: thoraco-cervical, and its acute clinical manifestations: respiratory depression. A surgical resection was performed after Barium swallow, chest X-ray and ultrasonography. Surgery ensured rapid clinical improvement. Pathology confirmed the diagnosis of cystic oesophageal duplication.

[Late perforation of pre-sternal coloplasty: echocardiography diagnosis]

The authors report a previously non described case of late rupture of a presternal colon esophagoplasty in a patient with history of caustic ingestion. The role of sonography was the diagnosis of the rupture due to presternal position of the coloplasty.

[Contribution of ultrasonography in thyroid diseases. Apropos of 100 cases]

Thyroid disease is a very common disease, essentially affecting women, and raises diagnostic and therapeutic problems. The objective of this study was to specify the value of ultrasonography in the diagnosis and aetiological orientation of these lesions, based on a retrospective study of 100 patients. The results of ultrasonography were compared to the histological results. The aetiologies detected were dominated by benign lesions, particularly adenomas (56 cases), dystrophic goitres (32 cases) and cancers (7 cases). Ultrasonography allowed the detection of clinically impalpable nodules with no isotope scan signs in 11% of cases. The ultrasonographic appearance of benign nodules was variable. Solitary nodules were detected in 63 cases. They were hyperechoic in 15 cases, isoechoic in 8 cases, cystic in 9 cases, and mixed in 31 cases. A peripheral clear halo was revealed in 25 cases and macrocalcifications were present in 17 cases. Malignant lesions were visualized in 7 cases and were solitary in 5 cases. Solitary lesions had a hypoechoic echostructure in 1 case, an isoechoic echostructure in 2 cases and a mixed echostructure in 2 cases. The margins were poorly demarcated in 3 cases, and circumscribed without peripheral halo in 2 cases. Cervical lymphadenopathy was detected in 2 cases. Graves' disease, diagnosed in 2 patients, showed a diffuse hypoechoic appearance of the entire thyroid gland. Ultrasonography is a sensitive morphological method for the diagnosis of thyroid lesions. A detailed and precise analysis of the ultrasound signs of the lesion can suggest that benign or malignant nature of the lesion, which can be completed by Doppler-ultrasound and especially ultrasound-guided needle biopsies.

[Orbital hydatid cyst. Apropos of a case]

The authors report a new case of orbital hydatid cyst diagnosed in 3 year old children who had presented an insidious exophtalmia explored by CT Scan. The authors recall the CT Scan features of the orbital hydatid cyst and the contribution of the others imaging methods.

[Appendiceal mucocele. Apropos of 6 cases]

Appendicular mucocele is a rare lesion presenting a combination of several histological lesions. It generally ruptures into the peritoneum and rarely into the retroperitoneum. The objective of this study was to examine the various radiological appearances of appendicular mucocele and to report three cases of mucocele which ruptured into the retroperitoneum. This retrospective series of 6 cases of histologically confirmed appendicular mucocele was collected by the Central Radiology Department of Ibn Rochd University Hospital in Casablanca. The mean age of the patients was 61.6 years (33 years-77 years) and the sex ratio was 4/2. A plain abdominal X-ray and ultrasonography were performed in all patients. Five patients were examined by CT scan and two underwent a barium enema. Five out of six mucoceles ruptured: into the peritoneal cavity in 2 cases with gelatinous ascites and into the retroperitoneum in 3 cases. The plain abdominal X-ray showed a mass in the right flank, which was calcified in 2 cases. Ultrasonography and CT scan were suggestive of the diagnosis of appendicular mucocele in only two cases. The case of non ruptured mucocele consisted of a clearly delimited, thin-walled collection. A loculated effusion with scalloping on the liver was observed in the two cases of gelatinous ascites. In the three cases of mucocele rupturing into the retroperitoneum, ultrasonography and CT scan showed a loculated retroperitoneal collection. This collection extended into the right psoas in 2 out of 3 cases. Gelatinous ascites is the usual complication of appendicular mucocele; but in rare cases of mucocele of a retrocaecal appendix, the mucus may enter the retroperitoneum.

[Percutaneous treatment of abdominal collections. Apropos of 135 cases]

The authors reviewed 135 abdominal collections, collected at the Radiologic Central Service over four years. The average age of the patients was 40 years. The abscesses sit especially in the liver (54 cases) and the psoas muscle (43 cases). The percutaneous management was guided by ultrasonography in all the cases. The results were successful in 74%. Only 15 cases needed surgical therapy. The literature results are similar. The authors underline the percutaneous treatment interests, its efficacy, its complications and their therapy.

[Renal hydatid cyst of uncommon aspect. Apropos of a case]

The authors report an unusual ultrasonographic aspect of hydatic cyst of kidney. They point out the importance of computed tomography in atypic hydatid cysts. Semiologic analysis of ultrasonographic and scanographic patterns, leads usually to the diagnosis of atypic hydatid cyst, in addition with serologic examination.

[Ultrasonography in the diagnosis and treatment of psoas abscess. Apropos of a study with 30 patients]

The abscess of psoas are more often secondary to a loco-regional cause. The authors report a series of 42 abscess of psoas in 30 patients during 3 years. It concerns 16 men and 14 women witch a mean age of 35 years. The abscess was secondary to a spondylodiscis in 25 patients and primary in 5 patients. The size of the abscess was upper 5 cm with a variable ultrasound structure: liquid in 33 cases, hypoechogenic in 9 cases. All patients underwent a percutaneous treatment guided by ultrasonography. A single or multiple evacuation puncture with 16 Gauge needle were performed for 40 abscess. Complementary percutaneous drainage with 14 french drain was used in 3 cases. In 2 other cases, the percutaneous drainage was used firstly. The bacteriological study of puncture liquid isolated the germ in 8 cases. Evaluation has been assessed in only 29 cases. The recovery was reached in 12 abscess on 15 which were treated by a single puncture. In 10 abscess on 13 treated by multiple puncture; and in 4 abscess an 5 managed by drainage. The results demonstrate the accuracy of single or multiple drainage puncture associated with adapted antibiotherapy in the management of abscess.