3D steady-state MR cisternography in CSF rhinorrhoea

Purpose: To determine the utility of 3D steady-state MR cisternography in the demonstration and localisation of cerebrospinal fluid (CSF) leak in patients with clinically suspected CSF rhinorrhoea.

Material and Methods: Six consecutive patients with clinically suspected CSF rhinorrhoea were examined with routine MR evaluation and MR cisternography (MRC). All MR examinations included fast spin-echo (SE) T1WI in axial and sagittal planes, fast SE T2WI in axial and coronal planes and fluid attenuated inversion recovery (FLAIR) images in the axial plane. 3D evaluation was done using the CISS technique with 0.7-mm thickness in the sagittal and coronal planes. The site and extent of the defect, and any brain herniation detected on MRC were correlated with surgical findings.

Results: In the 6 patients who underwent surgical exploration and repair, intraoperative findings correlated with the defect revealed by MRC in all cases.

Conclusion: In clinically suspected CSF rhinorrhoea, MRC is highly accurate in localising the site and extent of CSF fistula and may be used as the first investigation due to its efficacy and non-invasive nature.

Imaging of parasitic infections of the central nervous system

Parasitic infections of the central nervous system (CNS) have increased over the last couple of decades, partly due to a drop in the living conditions of large populations in the world and the AIDS epidemic. Parasitic infections of the CNS are indolent and often life threatening, hence, an early diagnosis is imperative. While brain biopsy and laboratory analysis remain the gold standard for diagnosis, neuroimaging contributes significantly to diagnosis and follow-up. Imaging can demonstrate the extent of infection and complications and possibly, the type of parasitic infection when characteristic features are evident. The disappearance of the parasite or inflammation, gliosis, and/or calcification suggest a therapeutic response. The initial experience of the CT scan has been greatly enhanced by MRI which is currently the imaging modality of choice. This has been due to the greater tissue contrast resolution of MRI and its ability to detect subtle changes in the tissue parenchyma. Advanced techniques such as diffusion-weighted imaging (DWI), perfusion imaging (PI), MR angiography (MRA), and MR spectroscopy (MRS) have been used to improve the sensitivity for characterizing the type, viability, and burden of the parasites and the host tissue response. Additionally, it is possible to demonstrate the complications of the primary infection and those secondary to treatment, in some cases.

Comparative Study Evaluating the In Vivo Characteristics of Ruptured and Unruptured Aneurysms Using serial Digital Subtraction Angiography

Over the past decade preventive endovascular treatment is increasingly being considered for intracranial aneurysms irrespective of whether ruptured or unruptured. Few studies have dealt with in-vivo characteristics of intracranial aneurysms. We compare the angiographic morphology of ruptured and unruptured intracranial aneurysms using short interval serial DSA. 37 patients with intracranial aneurysms and who underwent at least two digital subtraction angiograms were included in the study. Based on the clinical presentation there were two subgroups of patients, Group A patients presenting acutely with Sub arachnoid haemorrhage (SAH) and Group B patients who had no clinical or imaging features suggestive of bleed. Clinical and serial angiographic data were correlated. Aneurysms in Group A (1.04 mm(3)) were significantly (p=0.010) smaller than in Group B (4.53 mm(3)). Aneurysms in group A showed increase in size and those in Group B showed a decrease in size (p=0.019). Hypertensive patients in both the groups showed a tendency for a decrease in the size of the aneurysms. Aneurysms having stasis at the time of initial angiogram had significantly reduced in size on follow up (p=0.013) at a faster rate (p=0.017). Presence of spasm in adjacent vessels was associated with increase in size of aneurysm on follow up in both Groups. There are significant differences between a ruptured aneurysm and an unruptured one. Ruptured aneurysms are small and show rapid increase in size. The presence of spasm increased the size of the aneurysm in the post rupture period and anti hypertensive medication and stasis were associated with decrease in size.

Chiari 1 malformations: an Indian hospital experience

INTRODUCTION

A consensus on the ideal surgical procedure for Chiari 1 malformation has not been achieved. The purposes of the study were to report on the experience of treating this condition in an Indian hospital, and to look into the management of this not too uncommon condition with a view to improve the treatment and prognosis.

METHODS

A retrospective case note study of all cases of Chiari 1 malformations operated over a ten-year period from 1989 to 1999 and followed-up for another two years, were analysed for clinical and radiological features. All patients who underwent posterior fossa decompression were included. Patients who underwent other procedures like shunts were excluded. The data obtained included clinical and radiological features.

RESULTS

A total of 51 cases were analysed. All patients had posterior fossa decompression with duroplasty in the majority. Many patients had a delayed improvement noticed during the follow-up period. Headache, neck pain and motor features showed an improvement in the majority of the patients but sensory deficits did not.

CONCLUSION

This study showed the effectiveness of posterior fossa decompression with duroplasty as a procedure, which benefited most patients with Chiari 1 malformations.

Stroke with supernumerary phantom limb: case study, review of literature and pathogenesis

OBJECTIVE

Constitute hypothesis for origin of supernumerary phantom limb (SPL) after stroke.

METHOD

Single case description, review of literature and formulation of hypothesis.

RESULTS

A 59-year-old lady was evaluated for complaints of left-sided hemiparesis and extra limbs attached to her left shoulder for the past 7 months. Neuropsychological assessment revealed left hemineglect with SPL, and profile suggested bilateral frontal, right parietotemporal and basal ganglia involvement. Magnetic resonance imaging brain scan showed gliotic cavity secondary to the old haematoma in right putamen with white matter changes in the right frontoparietotemporal lobes.

CONCLUSIONS

The conceptual framework of body schema can be used to classify many of the neurological disorders of body representation. Generation of SPL comes under the subtype of pathology of updating among the disorders of body schema. The continuous updating allows the body schema to modulate perceptual processing of objects according to their position in space. Brain areas classified as parts of motor system can, under pathological conditions (haemorrhage), influence body perception. So, when she used to move her arm, the representation of the estimated position was not updated by the motor commands. Sensory and motor information therefore becomes discrepant, and failure to integrate these two sources of information leads to loss of normal coherence, and the perceived shape of the body was altered by adding a SPL to accommodate the discrepancy.

Automated MRI parcellation study of regional volume and thickness of prefrontal cortex (PFC) in antipsychotic-naïve schizophrenia

OBJECTIVE

Prefrontal cortical dysfunction is considered to be critical in the pathogenesis of schizophrenia. However, structural magnetic resonance imaging (MRI) studies on the PFC have yielded inconsistent results because of various confounding factors.

METHOD

In this study we examined the volume and thickness abnormalities of the PFC in antipsychotic-naïve schizophrenia patients (n = 51) in comparison with age-, sex-, and handedness-matched (as a group) healthy comparison subjects (n = 47) using a newly described automated MRI parcellation analysis.

RESULTS

Schizophrenia patients showed i) significant volume deficits in bilateral lateral orbitofrontal and left medial orbitofrontal cortices as well as bilateral pars triangularis; and ii) significant thickness deficit in bilateral medial orbitofrontal cortices. Negative syndrome score had a significant negative correlation with the thickness of the left medial orbitofrontal cortex.

CONCLUSION

The study findings emphasize that prefrontal deficit in schizophrenia is differential and involves primarily the regions essential for 'social cognition'.

Intrathecal gadolinium-enhanced magnetic resonance cisternography in cerebrospinal fluid rhinorrhea: road ahead?

Accurate localization of cerebrospinal fluid (CSF) fistula in a patient with CSF rhinorrhea is challenging and often involves multiple imaging studies with associated expense and patient discomfort. Intrathecal contrast-enhanced computed tomography (CT) and unenhanced magnetic resonance (MR) cisternography using constructive interference in steady state (CISS-3D) sequences are currently being used in attempt to localize the leakage site but with varying degrees of success. Our purpose is to evaluate the utility of intrathecal gadolinium-enhanced MR cisternography (GdMRC) in patients with CSF rhinorrhea. Ten consecutive patients of CSF rhinorrhea (five spontaneous, four post-traumatic, and one post-operative) were evaluated with GdMRC. Nine of the patients underwent intrathecal contrast CT and CISS-3D examinations in addition. Each of studies was reviewed independently by three neuroradiologists blinded to results of other modalities. Surgery was planned after consensus and surgical correlation obtained in nine cases. The fistulous site was clearly demonstrated by using GdMRC in eight patients, CISS-3D in six, and intrathecal CT in three patients. The site of leakage was confirmed surgically in all the patients. One patient was found to be false negative both by intrathecal CT and GdMRC, and in one patient no fistulous site was demonstrated by any of the modalities and surgery was not offered. No adverse reaction was seen in any of the patients. GdMRC is a novel method of confirmation and localization of CSF fistula with potential for routine clinical application. Diagnosis and localization of fistulous site is better demonstrated due to its high-contrast resolution, absence of bony artifacts, and direct multi-planar imaging.

Neurohydatidosis

Early and non-invasive evaluation of hydatid infestation of brain and spine is of paramount importance, especially in endemic areas. We present a spectrum of imaging findings in neurohydatidosis with a brief review of literature.

Disappearing saccular intracranial aneurysms: do they really disappear?

SUMMARY

Evolution and natural history of cerebral aneurysms is a dynamic process. Spontaneous regression in size or complete disappearance of an aneurysm is a known phenomenon, more commonly noted in giant intracranial aneurysms. However, reappearance or regrowth of such aneurysms is rare with few anecdotal reports. We report a series of four cases including one giant aneurysm, which either disappeared or regressed on sequential angiograms. Regrowth or reappearance of two of these previously disappeared or regressed aneurysms was noted and endovascularly treated while the other two cases are being followed up. The decision to follow up was crucial considering the nature of the aneurysms to change in morphology under the influence of various hemodynamic factors.

Relaxation and susceptibility MRI characteristics in Hallervorden-Spatz syndrome

PURPOSE

To evaluate the imaging characteristics of the brain with respect to relaxation and susceptibility in Hallervorden-Spatz syndrome (HSS), a rare inherited neurodegenerative disorder (also referred to as neurodegeneration with brain iron accumulation).

MATERIALS AND METHODS

We reviewed 13 affected individuals who satisfied the inclusion criteria for HSS. Clinically, the patients were divided into two groups: early-childhood onset (age of onset before 10 years) and late-childhood onset (age of onset after 10 years). MRI was performed on 1.5T MR equipment. The imaging protocol included spin-echo (SE) T1-weighted (T1W), turbo spin-echo (TSE) T2W, and fluid attenuated inversion recovery (FLAIR) sequences in all patients. Susceptibility-weighted imaging (SWI) included a fast low-angle shot (FLASH) sequence in 10 patients and a blood oxygen level-dependent (BOLD) sequence in two patients.

RESULTS

All of the patients showed hyperintensity on T1WI and hypointensity on T2WI in the globus pallidi (GPs) bilaterally. Central or anteromedial hyperintensity was found in all but one patient. FLASH showed augmented hypointensity in 10 patients, and BOLD showed bilateral striatonigral abnormal pigmentation in two patients. MR spectroscopy (MRS) showed normal spectra in four patients, and a reduced NAA/Cho ratio in two.

CONCLUSION

MRI showed prominent signal abnormalities in the GP bilaterally in HSS. T1WI showed hyperintensity in all cases of HSS in addition to the "eye-of-the-tiger" sign on T2WI. SWI, FLASH, and BOLD demonstrated mineral deposition in the GP better than conventional imaging. Involvement of the striatonigral pathways was demonstrated for the first time on BOLD SWI.

Middle meningeal arteriovenous fistula and its spontaneous closure. A case report and review of the literature

SUMMARY

Middle meningeal artery pseudo-aneurysms and arteriovenous fistulas are usually post-traumatic, although occasional iatrogenic cases have been reported. The treatment has been obliteration of the fistula by surgical or endovascular means. Spontaneous closure of fistula is uncommon. We report a case of non-traumatic middle meningeal arteriovenous fistula in a patient with alcoholism, which resolved spontaneously without treatment.

Clinicoradiological features of tuberculous meningitis in patients over 50 years of age

BACKGROUND AND AIMS

Tuberculous meningitis (TBM) is a debilitating form of CNS tuberculosis with a high morbidity and mortality in spite of treatment. The diagnosis is based on clinical, radiological and laboratory features. The classical CT features of basal exudates, hydrocephalus, infarcts and granulomas have been mostly reported in younger individuals. Our aim was to study imaging features of TB meningitis in adults over the age of 50 years.

MATERIALS AND METHODS

Clinical, imaging and laboratory features of 53 adult patients over the age of 50 years (sixth to eighth decades) were studied retrospectively. Diagnosis of TBM was based on clinical and laboratory features.

RESULTS

Imaging features were the conspicuous absence of typical features of TBM (ie, basal meningeal enhancement, hydrocephalus, infarcts/granulomas were seen in only a minority of patients).

CONCLUSIONS

CT features of TBM in elderly patients were few, atypical and non-contributory for diagnosis, probably because of age related immune senescence. Strong clinical suspicion and correlation with laboratory findings is necessary for early diagnosis.

Restricted diffusion in Canavan disease

INTRODUCTION

Canavan disease is a megalencephalic leukodystrophy due to deficiency of the enzyme aspartoacylase. Proton MR spectroscopy finding of elevated N-acetyl-L: -aspartate is considered diagnostic of Canavan disease.

CASE REPORT

We report a case of Canavan disease, which showed restricted diffusion in diffusion-weighted imaging and discuss the cause of it.

T2 relaxometry of ring lesions of the brain

AIM

To differentiate two common aetiologies of "ring lesions," tuberculomas and cysticercal cysts, using T2 relaxometry.

MATERIALS AND METHODS

Fifty-five ring-enhancing lesions of the brain (32 cysticercal cysts; 23 tuberculomas) in 27 patients with focal seizures were studied for T2 relaxation times.

RESULTS

The mean T2 relaxation times of cysticercal cysts was 617 ms (range 305-1365 ms; SD 272.2) and that of tuberculomas 161 ms (range 83-290 ms; SD 60.3; 95% confidence).

CONCLUSION

T2 relaxometry is a simple, reliable and valuable non-invasive magnetic resonance imaging (MRI) technique to differentiate between intracranial cysticercal cysts and tuberculomas, and may be incorporated in routine diagnostic protocols.

Quantitative magnetic resonance techniques in the evaluation of intracranial tuberculomas

PURPOSE

To evaluate intracranial tuberculomas using quantitative magnetic resonance (MR) techniques such as T2 relaxometry, magnetization transfer (MT), and diffusion-weighted imaging (DWI).

MATERIAL AND METHODS

Thirty-three patients with intracranial tuberculomas (histologically confirmed in 22) were evaluated using proton density/T2-weighted, T1-weighted (with and without MT), and echo-planar diffusion-weighted imaging sequences. T2 relaxation times, MT ratios (MTR), and apparent diffusion coefficient (ADC) values were calculated from the center of the lesion, the periphery, perilesional edema, and contralateral normal white matter. The mean and standard deviation values of each variable were calculated and correlated using Pearson's test (P = 0.05).

RESULTS

The measured mean values of T2 relaxation time, MTR, and ADC in the center of lesions were 155.5 ms, 14.1, and 1.27 x 10(-3) mm(2)/s, respectively, compared to 117 ms, 23.72, and 0.74 x 10(-3) mm(2)/s in normal white matter, and a T2 relaxation time of 187.45 ms in normal gray matter. Significant inverse correlations were noted between T2 relaxation values and MTR (P<0.001) and between MTR and ADC (P = 0.046). Significant positive correlation was seen between T2 relaxation and ADC values (P = 0.03).

CONCLUSION

Intracranial tuberculomas are characterized by relatively short T2 relaxation times (compared to normal gray matter), decreased MTR, and mostly no restriction of diffusion. A combination of these quantitative parameters could be of help in the noninvasive diagnosis of tuberculomas.

Diffusion-weighted imaging and proton MR spectroscopy in the characterization of acute disseminated encephalomyelitis

INTRODUCTION

Acute disseminated encephalomyelitis (ADEM) is usually a monophasic illness characterized by multiple lesions involving gray and white matter. Quantitative MR techniques were used to characterize and stage these lesions.

METHODS

Eight patients (seven males and one female; mean age 19 years, range 5 to 36 years) were studied using conventional MRI (T2- and T1-weighted and FLAIR sequences), diffusion-weighted imaging (DWI) and proton magnetic resonance spectroscopy (MRS). Apparent diffusion coefficient (ADC) values and MRS ratios were calculated for the lesion and for normal-appearing white matter (NAWM). Three patients were imaged in the acute stage (within 7 days of the onset of neurological symptoms) and five in the subacute stage (after 7 days from the onset of symptoms).

RESULTS

ADC values in NAWM were in the range 0.7-1.24 x 10(-3) mm/s2 (mean 0.937 +/- 0.17 mm/s2). ADC values of ADEM lesions in the acute stage were in the range 0.37-0.68 x 10(-3) mm/s2 (mean 0.56 +/- 0.16 mm/s2) and 1.01-1.31 x 10(-3) mm/s2 (mean 1.24 +/- 0.13 mm/s2) in the subacute stage. MRS ratios were obtained for all patients. NAA/Cho ratios were in the range 1.1-3.5 (mean 1.93 +/- 0.86) in the NAWM. NAA/Cho ratios within ADEM lesions in the acute stage were in the range 0.63-1.48 (mean 1.18 +/- 0.48) and 0.29-0.84 (mean 0.49 +/- 0.22) in the subacute stage. The ADC values, NAA/Cho and Cho/Cr ratios were significantly different between lesions in the acute and subacute stages (P < 0.001, P < 0.027, P < 0.047, respectively). ADC values were significantly different between lesions in the acute (P < 0.009) and subacute stages (P < 0.005) with NAWM. In addition, NAA/Cho and Cho/Cr ratios were significantly different between lesions in the subacute stage and NAWM (P < 0.006, P < 0.007, respectively).

CONCLUSION

ADEM lesions were characterized in the acute stage by restricted diffusion and in the subacute stage by free diffusion and a decrease in NAA/Cho ratios. Restricted diffusion and progressive decrease in NAA/Cho ratios may help in staging the disease.

MRI volumetric and 31P MRS metabolic correlates of caudate nucleus in antipsychotic-naïve schizophrenia

OBJECTIVE

To examine the volumetric and metabolic correlates of caudate nucleus in antipsychotic-naïve schizophrenia patients in comparison with healthy controls.

METHOD

Twelve antipsychotic-naïve schizophrenia patients and 13 healthy controls underwent (31)P magnetic resonance spectroscopy of basal ganglia. Magnetic resonance imaging volume of caudate nuclei was measured using scion image software.

RESULTS

Patients had significantly smaller caudate volume than healthy controls. Phosphocreatine (PCr)/total phosphorous and PCr/total adenosine tri-phosphate ratios of both caudate nuclei were significantly lower in patients than controls. Significant negative correlation was found between the left caudate volume and left PCr/total phosphorus ratio in the patients. Age at onset of psychosis had i) significant negative correlation with right and left caudate volumes and ii) significant positive correlation with left PCr/total phosphorus ratio.

CONCLUSION

The metabolic and volumetric abnormalities of caudate nucleus in antipsychotic-naïve schizophrenia patients support neurodevelopmental etiopathogenesis.

Altered structure and expression of RB1 gene and increased phosphorylation of pRb in human vestibular schwannomas

Tumor-specific alterations at the RB1 gene locus in 30 human vestibular schwannomas including 10 NF2 and 20 sporadic cases were analysed. Southern blot analysis of DNA from these samples revealed loss of heterozygosity (LOH) at the RB1 locus in 6 of 24 informative cases (25%) compared to normal blood DNAs from the same patients. Northern blot analysis showed normal size RB1 mRNA in all the tumor samples. However, there was a 2-5-fold increase in the level of expression of the RB1 gene in all the tumor samples compared to the WI38 cell line which was used as control. Western blot analysis of the RB1 protein, pRb showed a 2.5-5-fold increase in the level of total pRb as compared to normal WI38 cell line. Sixty five to seventy five percent of the total pRb were in phosphorylated form in most tumors. The LOH at the RB1 gene locus suggests genetic instability in these patients. Further, increased levels of RB1 mRNA, total pRb and the phosphorylated form of pRb suggests that RB1 gene in these tumors may have anti-apoptotic function. These results suggest that the RB1 gene has a major role in the development of human vestibular schwannomas.

Relevance of occlusion test in endovascular coiling of posterior cerebral artery (p2 segment) aneurysms

SUMMARY

P2 segment aneurysms are located on the posterior cerebral artery (PCA) between the junction of the posterior communicating artery with the PCA and the quadrigeminal cisternal part of the PCA. We reviewed our experience with endovascular coiling in such aneurysms. Clinical and pre-procedural data from four patients, referred for endovascular treatment of P2 segment aneurysms, were retrospectively studied for factors influencing post-interventional neurological deficits caused by ischemia of the PCA distal territory. Balloon occlusion was done in three patients and patient tolerance was assessed using clinical and anatomic criteria. Embryologic and anatomic features of the PCA were reviewed. Balloon occlusion test and endovascular coiling of aneurysms was possible in three patients. Control angiogram after embolization showed elimination of aneurysms from the circulation and the distal PCA filled through leptomeningeal anastomoses. One patient deteriorated due to aneurysmal rupture soon after the balloon occlusion test and coiling could not be done. In the other three patients post-intervention CT and MRI images showed PCA territory infarcts in spite of demonstration of good collateral circulation distal to the occluded PCA. In conclusion, P2 aneurysms can be effectively treated by endovascular coiling without a balloon occlusion test. While the balloon occlusion test does not contribute to clinical decision-making it may be associated with potential morbidity and mortality.

Basal ganglia high-energy phosphate metabolism in neuroleptic-naive patients with schizophrenia: a 31-phosphorus magnetic resonance spectroscopic study

OBJECTIVE

This study used 31-phosphorus magnetic resonance spectroscopy ((31)P MRS) to investigate basal ganglia abnormalities in neuroleptic-naive patients with schizophrenia.

METHOD

Nineteen schizophrenia patients and 31 age- and sex-matched healthy comparison subjects underwent (31)P MRS.

RESULTS

The phosphocreatine/total phosphorus and phosphocreatine/total ATP ratios in both basal ganglia were significantly lower in patients.

CONCLUSIONS

Schizophrenia patients showed features of increased metabolism in the basal ganglia consistent with impaired activity of the frontostriatal pathways.

Spectrum of epilepsy in tuberous sclerosis

Tuberous sclerosis (TS) is an autosomal dominant disease that affects the brain, skin, eye, heart and kidney. The diagnostic criteria for tuberous sclerosis complex (TSC) have recently been revised. There are relatively few Indian studies on this disorder. Twenty-six patients diagnosed as having TS over a period of 18 years are being reported. The onset of seizures ranged from infancy to adolescence. The patterns of epilepsy encountered were generalized tonic clonic seizures (13), complex partial seizures (10), simple partial seizures (9) and myoclonic jerks (4) including infantile spasms (3). Patients often had more than one seizure type. Nineteen patients were mentally subnormal. Cutaneous manifestations were facial angiofibroma i.e. adenoma sebaceum (20), shagreen patches (7), hypopigmented macules (6), ash leaf spots (4), café-au-lait spots (2), facial hypoplasia (2) and periungual fibromas (1). One patient each had retinal phakoma and renal angiomyolipoma. CT scan revealed sub-ependymal calcifications (12), parenchymal tubers (3), cerebral edema (3) and cortical atrophy (1). One patient had enhancement of peri-ventricular sub-ependymal lesions on MRI. Anticonvulsants prescribed were phenobarbitone (20), diphenyl hydantoin (14), carbamazepine (8), sodium valproate (4), benzodiazepines (4), ACTH (2), prednisone (1), mysoline (1) and vigabatrin (1). Most patients were on combinations of anti-convulsants and response to therapy was usually not very satisfactory. However, the child treated with vigabatrin did well.

MRI and in vivo proton MR spectroscopy in a racemose cysticercal cyst of the brain

Racemose cysticercal cyst is the subarachnoid manifestation of the larvae of Taenia solium. On MRI the cysts may resemble other cystic masses. We report the magnetic resonance spectroscopy (MRS) features of a case on in vivo proton spectroscopy and discuss its role in the diagnosis of intracranial cysts of parasitic aetiology.

Megalencephalic leukoencephalopathy with subcortical cysts: MRI and proton spectroscopic features

Megalencephalic leukoencephalopathy with subcortical cysts (MLC) is a rare, recently described disease. It is characterized clinically by a large head, mild neurological symptoms and a remarkably slow course of functional deterioration. The MRI is characterized by 'swollen white matter' and large symmetrical cystic changes in the cerebral hemispheres. MLC should be considered in the differential diagnosis of children with megalencephaly and leukoencephalopathy. We report a child with this disease and discuss the MRI and MRS features.

Neurological soft signs in never-treated schizophrenia

OBJECTIVE

Studies of Neurological Soft Signs (NSS) in schizophrenia are confounded by handedness, inconsistent methodology, and prior treatment with neuroleptics. The study objective is to examine NSS in never-treated schizophrenia.

METHOD

We examined the NSS in treatment-naïve schizophrenia patients (n = 21) and age, sex, education, and handedness matched normal controls (n = 21) using the modified Neurological Evaluation Scale with good inter-rater reliability.

RESULTS

Schizophrenia patients had significantly more NSS than normals. No significant correlation was found between illness duration and NSS.

CONCLUSION

Higher neurological signs in never-treated patients and their lack of association with illness duration suggest neurodevelopmental etiopathogenesis of schizophrenia.

Measuring the corpus callosum in schizophrenia: a technique with neuroanatomical and cytoarchtectural basis

BACKGROUND

Corpus Callosum (CC) abnormalities have been described in schizophrenia. Review of CC measurement methods in schizophrenia reveals inconsistency and lack of neuroanatomical basis.

AIMS

The aims of the study are to describe a new CC measurement method with valid a neuroanatomical and cytoarchitectural basis and to demonstrate inter-rater reliability for the same.

SETTINGS AND DESIGN

The study was performed in the National Institute of Mental Health & Neurosciences, Bangalore, India. Ours is a cross-sectional study in which both the first author and senior neuroradiologist were blind to clinical details.

MATERIAL AND METHODS

We report a reliable, semi-automated CC measuring technique with a neuroanatomical and cytoarchitectural basis tested in a group of 16 never-treated schizophrenia patients using 1-mm thick, objectively defined midsagittal MRI section. Measurement on coded slices using scion image software ensured elimination of rater bias.

STATISTICAL ANALYSIS USED

The statistical analysis used for assessing inter-rater reliability is intraclass correlation coefficient analysis.

RESULTS

The intraclass correlation coefficients for the CC measurements were as follows: CC Area = 0.93; Anterior CC area = 0.84; Area of body of the CC = 0.83; Area of CC isthmus = 0.65; Area of CC splenium = 0.88; maximum antero-posterior distance of CC = 0.96.

CONCLUSION

Measurements showed good inter-rater reliability. The methodology demonstrated in our study is simple, relevant, reliable and can be used for future schizophrenia research.

Reduced Caudate Volume in Never-Treated Schizophrenia : Evidence for Neuro developmental Etiopathogenesis

BACKGROUND

Evidence suggests that caudate nucleus abnormalities have a role in schizophrenia. Structural brain imaging studies on caudate size in schizophrenia are inconclusive due to confounding factors.

METHODS

In this study, caudate volume was measured on coronal Magnetic Resonance Images (I -mm) in consenting 15 never-treated schizophrenia (DSM-IV) patients and 15 age, sex, handedness, education and socioeconomic status matched controls using semi-automated Scion image software.

RESULTS

Multivariate analysis revealed significantly smaller caudate volume in patients than controls after controlling for intracranial area (df = 2,27; F = 5.4; p = 0.028). Separate univariate analysis showed that right (df = 2,27; F = 5.4; p = 0.028) and left (df = 2,27; F = 5.2; p = 0.031) caudate were significantly smaller in patients than controls after controlling for intracranial area. Illness duration did not correlate significantly with either right (r = - 0.13; p = 0.65) or left (r = - 0.10; p = 0.7) caudate volume.

DISCUSSION

Significantly smaller caudate nucleus in patients with never-treated schizophrenia suggests that some aspect of the disease process of schizophrenia influences the caudate nucleus. In conclusion, smaller caudate volume in never treated schizophrenia with lack of correlation between illness duration and caudate size supports neuro developmental etiopathogenesis in schizophrenia.

Functional MR imaging of hand motor cortex in a case of persistent mirror movement

Persistent mirror movements are unwanted movements restricted to muscles homologous to those moved intentionally on the opposite body half. It is rarely observed and the functional MRI findings in a case of persistent mirror movement are described.

CT features of intracranial metastases of unknown primaries

Intracranial metastases of central nervous system are relatively common in patients with systemic cancer. Computed tomography (CT) scans of 60 patients of intracranial metastatic disease of unknown primaries, at the time of surgery, were retrospectively analyzed. These patients primarily presented with neurological dysfunction. They were operated upon for various reasons and histopathological diagnosis was obtained. There were 39 male and 21 female patients, with age range of 18 to 74 years. The common clinical symptoms were raised intracranial pressure without lateralization, acute onset hemiplegia and seizures. Multiple cranial nerve palsies were observed in 4 patients. Histopathologically the intracranial lesions consisted of metastatic adenocarcinoma (32 cases) or metastatic squamous cell carcinoma (28 cases). Among cases of adenocarcinoma, CT revealed solitary lesions in 17 and multiple lesions in 13 cases. Two had extraaxial deposition in the region of petrous apex. Out of squamous cell carcinomas, 17 lesions were solitary, while 10 were multiple and one had extraaxial deposition in the region of petrous apex. This study is unique as it consisted of CT features of intracranial metastases of unknown primary malignant disease elsewhere in the body.

MRI in subacute combined degeneration of spinal cord: a case report and review of literature

A 56 year old man presented with acute onset posterior column and lateral spinothalamic tract dysfunction over a period of 15 days. MRI showed diffuse hyperintensity on T2WI involving the posterior columns. A diagnosis of subacute combined degeneration (SCD) of the spinal cord was considered and confirmed by laboratory findings. The patient showed complete recovery on B12 therapy. MRI lesion also compeletely resolved.

Thoracic cord compression due to ossified hypertrophied ligamentum flavum

Ossified ligamentum flavum is increasingly appreciated as an important cause of thoracic myeloradiculopathy. Fifteen patients with age ranging from 30-61 years were studied. Fourteen presented with spastic paraparesis, and radiculopathy was the only complaint in one patient. Routine skiagrams and myelograms showed non-specific changes. Baseline CT and CT myelogram, however, documented the ossification of ligamentum flavum comprehensively. MRI was done in three patients. Multiple levels of the disease were seen in two cases. Four patients had ossified posterior longitudinal ligament. Thickened ligamentum flavum should be considered as an important cause of thoracic cord compression.

Solitary pulmonary metastasis from intracranial meningiothelial meningioma

Although known, histologically proven pulmonary metastasis from a benign intracranial meningioma is exceedingly rare. We report a case of meningiothelial meningioma producing a solitary pulmonary deposit.

Pure word deafness in two patients with subcortical lesions

We report two patients with pure word deafness (PWD) with tumour in the III ventricle region with obstructive hydrocephalus. A diagnosis of PWD was made in these two patients in view of impaired verbal comprehension in the presence of adequate hearing, intact acoustic stapedius reflex and well preserved environmental sound perception. Return of verbal comprehension following the radiation therapy observed is probably due to the reduction of the tumour mass and the release of thalamocortical auditory pathways from its compressive effect. Our findings support the hypothesis of the presence of discrete auditory pathways for mediation of verbal and non-verbal stimuli independently.

Intracranial haemorrhage resulting from unsuspected choriocarcinoma metastasis

A retrospective analysis of clinicopathological data of 10 patients with clinically unsuspected cerebral metastatic choriocarcinoma was carried out. All patients were young adult females. History of preceding pregnancy/abortion was forthcoming in 5 cases but none had a prior history of abnormal gestation. Features of raised intracranial tension followed by hemiparesis were the commonest presenting symptoms. A clinicoradiologic diagnosis of intracerebral haemorrhagic mass, either primary or secondary to tumour bleed, cortico-venous thrombosis or arteriovenous malformation, was entertained in 8 out of 10 cases. In other two cases, ring enhancing lesions prompted the diagnosis of granulomatous masses. Eight patients were operated upon, of whom two died after short hospital stay, and were autopsied. All had haemorrhagic masses noted at surgery/autopsy. Accurate diagnosis of metastatic choriocarcinoma was established only by histologic examination of these haemorrhages. This report emphasizes the importance of considering metastatic choriocarcinoma as an important differential diagnosis of haemorrhagic intracerebral lesions in women of child bearing age group. Measurement of serum/CSF level of HCG in suspected cases helps to implement early therapy. The diagnostic value of histopathologic examination of surgically resected blood clots in determining aetiology of intracerebral haemorrhagic masses is highlighted.

Intracranial infective aneurysms: angiographic evaluation with treatment

Infective intracranial aneurysms are relatively uncommon. They develop due to septic embolisation of the vasa vasorum or lumen of the artery, with resultant focal arteritis and necrosis, leading to aneurysm formation. They are an important cause for intracranial haemorrhage. Six cases of infective aneurysms are described. A focus of infection could be detected in all the patients. Surgery was done in three cases, out of which two patients made significant recovery, while one patient died in the immediate postoperative period. Out of the three cases, treated conservatively with antibiotic therapy, there was total resolution on follow up angiogram in two, while one patient was lost to follow up.

Neurogenic heterotopic ossification : a diagnostic and therapeutic challenge in neurorehabilitation

Heterotopic ossification (HO) is an important cause of restriction in range of movements and secondary motor disability following neurotrauma, orthopaedic interventions and burns. It has not received focussed attention in non-traumatic neurological disorders. In a prospective study of 377 patients, on medical problems in neurological rehabilitation setting, 15 subjects (3.97%) had neurogenic heterotopic ossification. Their clinical diagnosis was: transverse myelitis (7), neurotuberculosis (4), traumatic myelopathy (2) and stroke (2). Hip (10), knee (4) and elbow joints (1) were involved. The risk factors included urinary tract infection (15), spasticity (6), pressure sores (13) and deep venous thrombosis (DVT) (6). The initial diagnosis was often other than HO and included DVT (3), haematoma (2) and arthritis (2). ESR and serum alkaline phosphatase levels were elevated in all but one subject. The diagnosis of HO was established using X-rays, CT Scan and three-phase bone scan. Following treatment with non-steroidal anti-inflammatory drugs, the range of motion improved in only four patients. HO resulted in significant loss of therapy time during rehabilitation. High index of suspicion about this complication is necessary for early diagnosis and prompt intervention.

Ect and t(2) relaxometry: a static walter proton magnetic resonance imaging study

The aim of the study was to detect brain oedema with electroconvulsive therapy (ECT). Magnetic resonance imaging (MRI) T(2) relaxation time which is an indicator of brain water was measured one day prior to the first ECT and at two hours after second ECT in five depressive patients prescribed right unilateral (RUL) ECT. MRI T(2), relaxation time was measured in hippocampus (He) and thalamus (Th) bilaterally No significant change in T(2) relaxation time following ECT occurred in any of the four regions. EC T did not produce any detectable brain oedema and hence the treatment may be considered safe. The study needs to be replicated in a larger sample and also in bilateral (BL) ECT patient group.

Open and minimally open lips schizencephaly

Two patients with isolated schizencephaly, a very rare congenital anomaly of the brain, who presented with epilepsy are presented. According to imaging morphology, there are two types of schizencephaly, 'open lip' and 'minimally open lip'. These two cases emphasize that while MRI is superior to CT in the diagnosis of congenital brain anomalies, schizencephaly can be diagnosed by its characteristic CT features.

Profile of neurologic disorders associated with HIV/AIDS from Bangalore, south India (1989-96)

One hundred patients (95 males, 5 females, mean age at presentation 31.6 +/- 9.4 yr) with various neurological disorders associated with HIV infection during 1989-1996 were evaluated at NIMHANS, Bangalore. Eighty patients belonged to group I associated with opportunistic neuroinfections and 20 to group II--non infectious neurological disorders. Cryptococcal meningitis either alone (n = 31) or associated with tuberculous meningitis (n = 6) was the most common (46.3%) followed by neurotuberculosis either alone (n = 24) or with cerebral toxoplasmosis (n = 4) accounting for 35 per cent. Other opportunistic neuroinfections included cerebral toxoplasmosis, herpes zoster, fulminant pyogenic meningitis and neurosyphilis. Clinical characteristics, diagnostic clues, their laboratory and radiological profiles and problems encountered in diagnosis and management of these opportunistic infections are highlighted. In group II (19 males and one female; mean age of 32.6 +/- 9.4 yr), two patients had cortical dementia, three acute brain stem involvement, two epilepsy and one had features suggestive of progressive multifocal leukoencephalopathy. Two patients of group I during follow up developed cortical dementia. Six had peripheral nervous system involvement similar to Guillain-Barre syndrome. Sixty six patients (63 of group I and 3 of group II) progressed to AIDS, 33 patients from group I and one patient from group II succumbed to the disease. With the rapid increase in the incidence of HIV/AIDS and an increase in the neurological manifestations of HIV/AIDS it is important to recognise the magnitude of the problem for health planning in India.

Early onset cerebellar ataxia with retained tendon reflexes (EOCA) and olivopontocerebellar atrophy (OPCA): a computed tomographic study

Computed tomographic (CT) studies in olivopontocerebellar atrophies (OPCA) and 'early onset cerebellar ataxia with retained tendon reflexes (EOCA)' are few and vary widely in methodology and criteria for cerebellar and brainstem atrophy. In this prospective study, CT scan observations on 26 patients (EOCA-11, OPCA-15) were compared with 31 controls using qualitative and quantitative assessment of cisterns, ventricles and atrophy of brain. Vermian and/or cerebellar hemispheric (predominantly anterior) atrophy was present in 80.8% and both were equally common. Cerebral cortical atrophy (26.9%) and leukoariosis (15.4%) were less frequently seen. Statistically significant atrophy of pons, brachium pontis, cerebellum and midbrain was noted in patient group. No significant differences were observed between EOCA and OPCA groups. Evidence of atrophy did not correlate with either the duration of illness or the severity of cerebellar ataxia in both the groups. The severity of brainstem atrophy in 14 patients with and 12 patients without abnormal brainstem auditory evoked response did not differ significantly. This study highlights the methodology of CT evaluation for brainstem and cerebellar atrophy, draws attention to cerebral atrophy and emphasizes the lack of significant differences in CT morphology between OPCA and EOCA patients.

Evaluation of posttraumatic vasospasm, hyperaemia, and autoregulation by transcranial colour-coded duplex sonography

Serial transcranial colour-coded duplex sonography (TCCS) was performed on 24 adult patients with severe head injury (GCS 8 or less). Flow velocities were obtained from the middle cerebral artery (MCA) and extracranial internal carotid artery (EICA). An autoregulation study was done using the transient hyperaemic response test, evidence of vasospasm (V-MCA greater than 100 cm/s and Lindegaard ratio more than 3) was found in nine patients (37%). Two of these developed non-contusion-related infarction and two others contusion-related infarction. This was significant (p < 0.05). Vasospasm started around day 2, reaching maximum around day 4 and persisting until the second week. Vasospasm was significantly associated with a poor outcome (p < 0.05). There was no correlation between the extent of SAH as seen on CT and vasospasm. Evidence of hyperaemia were observed in two patients (8%) and impaired autoregulation in seven patients (29%). Impaired autoregulation was significantly associated with development of hyperaemia (p < 0.05). TCCS studies permit a non-invasive evaluation of cerebral haemodynamics that will help in the management of head injured patients.

Cavernous-venous malformation of brain stem--report of a case and review of literature

BACKGROUND

Because of improved imaging techniques, the association of cavernous and venous malformations is now being seen more often in neurosurgical practice. However, only a few cases have been subjected to surgery. Surgical excision of the cavernous malformation, sparing the venous component, has been the method of choice advocated by most authors. This, however, is not possible when the components are intimately associated with each other. It thus becomes important to predict the surgical outcome in such lesions, especially when they are located in an eloquent area. A surgically excised case of cavernous-venous malformation in the dorsal pontomedullary region is presented here; the histology confirmed the intimate association of both components. The relevant literature is also discussed.

CASE DESCRIPTION

This 20-year-old male presented with episodic vomiting, giddiness, and persistent cerebellar signs over a six-year period. Neuroimaging studies-computed tomography scan/magnetic resonance imaging (CT/MRI) were suggestive of a cavernous malformation. MRI also showed a draining vein close to the lesion. Following total excision, histopathology confirmed the intimate association of both cavernous and venous malformations. The patient made an uneventful recovery. MRI at follow up confirmed total excision.

CONCLUSIONS

The presence of venous channels draining into a lesion that otherwise appears to be a cavernous malformation may indicate an intimately associated venous component. Selective surgical excision of the cavernous component may be difficult in such cases. Surgical outcome, though favorable in this case, will be difficult to comment upon unless more such cases are reported. This may be of greater significance in lesions located in eloquent areas.

Palatal tremor, progressive multiple cranial nerve palsies, and cerebellar ataxia: a case report and review of literature of palatal tremors in neurodegenerative disease

We describe a patient with an unusual clinical presentation of progressive multiple cranial nerve palsies, cerebellar ataxia, and palatal tremor (PT) resulting from an unknown etiology. Magnetic resonance imaging showed evidence of hypertrophy of the inferior olivary nuclei, brain stem atrophy, and marked cerebellar atrophy. This combination of progressive multiple cranial nerve palsies, cerebellar ataxia, and PT has never been reported in the literature. We have also reviewed the literature of PT secondary to neurodegenerative causes. In a total of 23 patients, the common causes are sporadic olivopontocerebellar atrophy (OPCA; 22%), Alexander's disease (22%), unknown etiology (43.4%), and occasionally progressive supranuclear palsy (4.3%) and spinocerebellar degeneration (4.3%). Most patients present with progressive cerebellar ataxia and approximately two thirds of them have rhythmic tremors elsewhere. Ear clicks are observed in 13% and evidence of hypertrophy of the inferior olivary nucleus in 25% of the patients. The common neurodegenerative causes of PT are OPCA/multiple system atrophy, Alexander's disease, and, in most of them, the result of an unknown cause.

Posterior circulation abnormalities in moyamoya disease : a radiological study

Moyamoya disease (MMD) is an uncommon entity outside Japan. Though the clinical and radiological features are well described, involvement of the posterior circulation has not been highlighted. Out of 10 patients of MMD studied, the posterior circulation was involved in 9 (3 bilateral, 6 unilateral). The P1 segment was most commonly affected. Interestingly, no infarcts were seen in the territory of the posterior circulation in any patient. Five patients showed recent haemorrhages on scan. It was thalamic haemorrhage in four and subarachnoid in one patient. The posterior circulation is frequently involved in MMD as evident on angiography. However, ischaemic events of the posterior circulation are not frequent, as the posterior circulation acts as collateral pathway for the diseased anterior circulation till later stages of the disease.

CSF rhinorrhoea from unusual site : report of two cases

CSF rhinorrhoea is associated with high morbidity and mortality. Bone and dural defects may result from trauma or enlarging 'pitholes' or breach in lateral recess of sphenoid sinus. Unless surgically corrected, they tend to cause meningitis and rhinorrhoea. Unusually delayed rhinorrhoea is a diagnostic problem.

Heterotopic ossification in non-traumatic myelopathies

Heterotopic ossification (HO) is an important complication of spinal cord and brain injuries but is rarely reported among patients with non-traumatic myelopathies. In a prospective study on medical problems seven (6.04%) among the 114 subjects with non-traumatic myelopathies had heterotopic ossification. All of them had involvement of hip joints. The co-morbid conditions were: urinary tract infection, seven; spasticity, three; pressure sores, five; and deep venous thrombosis, one. The initial diagnosis was often other than heterotopic ossification. Erythrocyte sedimentation rate and serum alkaline phosphatase levels were elevated in all subjects. Following rest and non-steroidal anti-inflammatory drugs, the range of motion improved in two patients. Heterotopic ossification can occur in patients with non-traumatic myelopathies and has risk factors and clinical features similar to patients with traumatic spinal cord injury. A high index of suspicion about this complication is necessary for early diagnosis and prompt intervention.

Sparganosis of brain and spinal cord: unusual tapeworm infestation (report of two cases)

Among the diseases due to cerebral parasitism, those caused by sparganum mansoni, the larval form of Spirometra mansoni, are very rare. We report two cases, one involving the frontoparietal area in a 38-year-old male and presenting as a mass lesion and another in a 10-year-old girl, presenting with paraparesis due to mid-thoracic compressive mass lesion. Pathological examination of the resected lesion revealed the characteristic plerocercoid larva, spargana, enclosed in acute inflammatory exudate, resembling an abscess. Postoperative recovery was good, suggesting that the best treatment for cerebral or spinal sparganosis mansoni is surgical excision. Serological tests for diagnosis were not carried out in these cases, since parasitic infection was not suspected. Although generally the role of immunodiagnosis is limited due to rarity of the condition, in endemic areas such tests may be useful in preoperative diagnosis.