A Danish woman aged 28 years who had travelled in the Far East developed cerebral symptoms with headache and visual disturbances. Migraine was suspected. Subsequent CT scanning revealed multiple processes and metastases were suspected. As the patient had travelled in the Far East 1 1/2 years previously, she was examined for neurocysticercosis. This diagnosis was established and the patient was successfully treated with praziquantel. On account of increased travelling activity, the possibility of neurocysticercosis should be borne in mind when dealing with patients with cerebral symptoms and relevant travelling histories.
Reported is the first case of syringomyelia and syringobulbia associated with Arnold Chiari I malformation in a Malaysian child. The initial complaint was that of unilateral anhidrosis of the face. The chief presenting features were dissociated sensory loss, asymmetrical weakness of the left upper limb associated with subluxation of left shoulder and signs of upper motor neurone lesion in the left lower limb. One unusual feature was the presence of vesiculation followed by ulceration of the pinnae of both ears. Magnetic resonance imaging (MRI) of the posterior fossa and cervical and thoracic cord facilitated the diagnosis and was the most useful diagnostic procedure in this child.
The failed back surgery syndrome (FBSS) is a difficult diagnostic problem both clinically and radiologically. Forty-three patients were evaluated prospectively with magnetic resonance imaging (MRI) and forty-five scans were obtained. Fifteen patients (33%) showed recurrent disc prolapse; 15 (33%) patients postoperative epidural fibrosis; 8 (18%) both recurrent disc prolapse and epidural scarring; 4 (9%) patients spinal stenosis, 2 whom also had both epidural fibrosis and recurrent disc prolapse; 2 (4%) normal scans; 2 (4%) patients arachnoiditis and 1 (2%) patient postoperative pseudomeningocoele formation. Gadolinium-diethylenetriaminepenta-acetic acid (Gd-DTPA)-enhanced MRI was particularly helpful in differentiating recurrent disc prolapse and epidural fibrosis. Surgical findings in 11 patients were available. MRI correctly predicted recurrent disc prolapse in 6 patients, epidural fibrosis in 4 patients and spinal stenosis in 1 patient illustrating the value of this modality in the evaluation of FBSS.
A non-cyclic tetrameric structure has been suggested for calcichrome (calcion). This structure is consistent with its mass spectrum, proton NMR spectrum, elemental composition and complexing ability with polyaromatic hydrocarbons in water. The stability constants of the 1:1 complexes formed between calcichrome and seven polyaromatic hydrocarbons in water at room temperature have been measured.
We describe a patient with acute compression of the spinal cord by a spontaneous extra-dural haematoma. This rare condition is often misdiagnosed. We believe that an urgent MRI scan is indicated in patients presenting with progressive neurological deficit following spinal trauma. This allows the diagnosis of extra-dural haematoma to be made rapidly and for prompt decompression of the cord.
This survey covered male Singapore citizens born in 1974 who were medically screened at the age of 18 years before enlistment for compulsory military service. Suspected epileptics were referred to government hospitals for further management. Out of 20,542 men, there were 121 epileptics, giving a cumulative incidence of 5 per 1000 by age 18 years. We had information on 106 (87%) of these individuals and were able to interview them and review their hospital records. Seventy-three of the 106 (69%) epileptics had generalised seizures while 14 (13%) had refractory seizures. There was no statistically significant racial bias amongst these epileptics. Unprovoked afebrile seizures occurred early in these patients, half of whom had seizures onset before 7 years of age. Nine refractory epileptics had a history of febrile seizures, 4 of which were complex febrile seizures. Magnetic resonance imaging identified mesial temporal sclerosis in 2 patients and a hypothalamic lesion in 1 patient. Computed tomographic scans revealed focal cortical atrophy in 2 patients. Nine other patients had normal imaging studies. Nine out of 14 (64%) patients with refractory epilepsy had partial seizures; 4 (29%) had generalised seizures and 1 (7%) was unclassified. This is in contrast to the distribution of the entire cohort of epileptics studied. Two out of 9 patients with refractory partial seizures (gelastic epilepsy and mesial temporal sclerosis) had undergone surgery while 6 of the other 7 patients refused to consider surgery.
A case of germinoma originating in the basal ganglia and thalamus is presented. This tumour most commonly originates during childhood and adolescence, at pineal and suprasellar regions. In the early stages, the diagnosis of germinoma in the basal ganglion and thalamus is difficult because of its rarity and non-specific findings. The computed tomography (CT) and magnetic resonance imaging (MRI) findings though non-diagnostic, are discussed here. A few differential diagnoses had been discussed with radiological abnormality. Open biopsy done in this case proved to be two-cell pattern germinoma. Early detection of the tumour is desirable, since this tumour is highly sensitive to radio and chemotherapy and is potentially curable. Our patient was treated with combined chemotherapy and the response was well and no residual tumour or recurrence was seen on the repeated imaging modality, however his neurological deficits remained unchanged.
MRI is now an important diagnostic tool in medical management. There are numerous safety issues to be considered by the clinicians prior to requesting an MRI examination for their patients. These include those related to the magnetic field, gradient magnetic fields, the patient and contrast medium. This paper discusses the dangers and necessary precautions essential to reduce the risk of untoward complications from MRI.
Matched MeSH terms: Magnetic Resonance Imaging/adverse effects*
Anomalous pancreatico-biliary junction (APBJ) is commonly associated with cystic dilatation of the bile ducts but recently, several cases without the cystic dilatation have been reported. We treated a young female patient with intractable back and epigastric pain of three months duration. The spine was normal on magnetic resonance imaging (MRI), but several lymph nodes were seen around the coeliac axis. An APBJ, a non-cystic biliary system, non-filling of the gallbladder and an irregular right margin of the bile duct were evident on endoscopic retrograde pancreatography (ERCP), which was highly suggestive of gallbladder (GB) malignancy. At surgery, the GB was hard with local infiltration of the bile duct. Numerous large para-aortic and supraduodenal lymph nodes were present and only a biopsy was possible. Details of the case are presented and the growing etiological importance of an APBJ, especially without cystic biliary dilatation in gallbladder carcinogenesis is discussed.
Lumbosacral nerve root avulsion is a rare clinical entity. Since the first description in 1955, only 35 cases have been reported. It is often associated with pelvic fractures and may be missed in the initial clinical examination as these patients usually present with multiple injuries. We present three such cases with clinical and radiological findings. These patients were involved in road traffic accidents. Two had fractures of the sacroiliac joint with diastasis of the symphysis pubis (Tile type C 1.2) and one had fractures of the public rami (Tile type B 2.1). All three had various degrees of sensory and motor deficit of the lower limbs. Lumbar myelogram shows characteristic pseudomeningoceles in the affected lumboscral region. Magnetic resonance (MR) imaging provides an additional non-invasive modality to diagnose this condition.
A recognized cause of incomplete or cancelled MRI examinations is anxiety and claustrophobic symptoms in patients undergoing MR scanning. This appears to be a problem in many MRI centres in Western Europe and North America, where it is said to be costly in terms of loss of valuable scan time, and has led to researchers suggesting several anxiety-reducing approaches for MRI. To determine the incidence of failed MRI examination among our patients and if there are any associations with a patient's sex, age and education level, we studied claustrophobia that led to premature termination of the MRI examination in the University Malaya Medical Centre (UMMC) in 3324 patients over 28 months. The incidence of failed MRI examinations due to claustrophobia in the UMMC was found to be only 0.54%. There are associations between claustrophobia in MRI with the patients' sex, age and level of education. The majority of those affected were male patients and young patients in the 25-45-years age group. The patients' education level appears to be the strongest association with failed MRI examinations due to claustrophobia, where the majority of the affected were highly educated individuals. Claustrophobia in MRI is more of a problem among the educated individuals or patients from a higher socio-economic group, which may explain the higher incidence in Western European and North American patients.
Matched MeSH terms: Magnetic Resonance Imaging/psychology*
Although intracerebral tuberculomas are common in countries where tuberculosis is still endemic, miliary tuberculosis with involvement of the central nervous system is exceptionally rare. We report two cases of pulmonary miliary tuberculosis with multiple intracerebral tuberculomas.
Video-EEG telemetry is often used to support the diagnosis of non-epileptic seizures (NES). Although rare, some patients may have both epileptic seizures (ES) and NES. It is crucially important to identify such patients to avoid the hazards of inappropriate anticonvulsant withdrawal. To delineate the electroclinical characteristics and diagnostic problems in this group of patients, we studied the clinical, EEG and MRI features of 14 consecutive patients in whom separate attacks, considered to be both NES and ES were recorded using video-EEG telemetry. Only two patients were drug-reduced during the telemetry. Most patients had their first seizure (ES or NES) in childhood (median age 7 years; range: 6 months-24 years); 8/14 patients were female. Brain MRI was abnormal in 10/14 patients. Interictal EEG abnormalities were present in all patients; 13/14 had epileptiform and 1/14 only background abnormalities. Over 70 seizures were recorded in these 14 patients: in 12/14 patients, the first recorded seizure was a NES (p < 0.001), and 7 of these patients had at least one more NES before an ES was recorded. Only 3/14 patients had more than 5 NES before an ES was recorded. Recording a small number of apparently NES in an individual by no means precludes the possibility of additional epilepsy. Particular care should be taken, and multiple (> 5) seizure recording may be advisable, in patients with a young age of seizure onset, interictal EEG abnormalities, or a clear, potential aetiology for epilepsy.
Two cases of cerebral arterial gas embolism (CAGE) occurred after a decompression incident involving five maintenance crew during a cabin leakage system test of a Hercules C-130 aircraft. During the incident, the cabin pressure increased to 8 in Hg (203.2 mm Hg, 27 kPa) above atmospheric pressure causing intense pain in the ears of all the crew inside. The system was rapidly depressurized to ground level. After the incident, one of the crew reported chest discomfort and fatigue. The next morning, he developed a sensation of numbness in the left hand, with persistence of the earlier symptoms. A second crewmember, who only experienced earache and heaviness in the head after the incident, developed retrosternal chest discomfort, restlessness, fatigue and numbness in his left hand the next morning. Both were subsequently referred to a recompression facility 4 d after the incident. Examination by the Diving Medical Officer on duty recorded left-sided hemianesthesia and Grade II middle ear barotrauma as the only abnormalities in both cases. Chest X-rays did not reveal any extra-alveolar gas. Diagnoses of Static Neurological Decompression Illness were made and both patients recompressed on a RN 62 table. The first case recovered fully after two treatments, and the second case after one treatment. Magnetic resonance imaging (MRI) of the brain and bubble contrast echocardiography performed on the first case 6 mo after the incident were reported to be normal. The second case was lost to follow-up. Decompression illness (DCI) generally occurs in occupational groups such as compressed air workers, divers, aviators, and astronauts. This is believed to be the first report of DCI occurring among aircraft's ground maintenance crew.
A novel Hendra-like paramyxovirus named Nipah virus (NiV) was the cause of an outbreak among workers from one abattoir who had contact with pigs. Two patients had only respiratory symptoms, while 9 patients had encephalitis, 7 of whom are described in this report. Neurological involvement was diverse and multifocal, including aseptic meningitis, diffuse encephalitis, and focal brainstem involvement. Cerebellar signs were relatively common. Magnetic resonance imaging scans of the brain showed scattered lesions. IgM antibodies against Hendra virus (HeV) were present in the serum of all patients. Two patients recovered completely. Five had residual deficits 8 weeks later.
A rare case of diffuse malignant peritoneal mesothelioma in a 71 year-old Malay man with no previous history of asbestos or radiation exposure is described. The clinical manifestation was a large abdominal mass. At laparotomy he was found to be in the advanced stage of the disease. The tumour was not resectable and patient was sent home. He gradually deteriorated and died three months after diagnosis was made. The magnetic resonance imaging (MRI) features of peritoneal mesothelioma which has not been previously reported are described.
Nonchromaffin paragangliomas are unusual tumours arising from widely distributed paraganglionic tissues probably of neural crest origin. In the head and neck region they are usually seen as carotid body or jugulotympanic tumours. Other rarely reported sites in the head and neck region are the orbit, nose and larynx. This report deals with a case of sinonasal paraganglioma which was initially treated with surgery and radiotherapy. Twenty two years later the tumour recurred and showed a rapid growth due to malignant transformation which we believe is late effect of radiotherapy. The clinical features, histopathology and role of radiotherapy in sinonasal paragangliomas together with a review of the medical literature have been discussed.
Here the first case in the literature of both mesenchymal hamartoma and malignant mesenchymoma occurring in a 6-year-old male child, at different times and at different sites in the liver, and also the possible malignant transformation of a mesenchymal hamartoma is reported. The tumor developed from a lesion in the right lobe that was overlooked initially during a left lateral segmentectomy at 18 months of age for a mesenchymal hamartoma. Malignant mesenchymoma is a rare and aggressive tumor. The origin of this tumor is not well understood. There has been no direct support to the hypothesis that malignant mesenchymoma may be the malignant counterpart of mesenchymal hamartoma. The authors provide clinical and histopathologic evidence in our case that suggests the possibility of malignant mesenchymoma arising from a mesenchymal hamartoma. This case emphasizes the need for complete removal of mesenchymal hamartoma and the need for long-term follow-up to detect multifocal lesion or malignant transformation.
In an arthroscopic-MRI correlation study of acute injuries to the knee it was found that anterolateral meniscocapsular separations of the lateral aspect of the knee were missed on MRI reporting. Eighty sports-related injuries of the knee were seen by experienced orthopaedic surgeons at the University of Malaya Medical Centre and at the National Sports Centre, Malaysia from January 1996 to July 1997. Fifty of the patients were suspected to have meniscal tears that were either lateral or medial on clinical examination and they were sent for MRI. Many of these patients were tertiary referrals. Magnetic resonance imaging examinations in 27 of the 50 patients were reported as not showing any intrasubstance or obvious meniscocapsular tears, but arthroscopy performed on them revealed anterolateral meniscocapsular tears of the lateral meniscus of varying degrees in nine of these patients. In retrospect the tears could be seen on MRI, and a pattern to the tears was noted and classified as follows. Type 0, normal; type 1, torn inferior or superior meniscocapsular attachment; type 2, both meniscofemoral and meniscotibial ligaments torn but with minimal separation of meniscus and capsule by fluid or synovitis; and type 3, marked separation of meniscus and capsule by fluid (> 3 mm). Ten patients who did not undergo arthroscopy for various personal and financial reasons underwent MRI which showed type 1 and type 2 tears, and were treated conservatively. These patients were all asymptomatic after 4-6 weeks with regard to clinical signs, suggesting a lateral meniscal tear. Magnetic resonance imaging therefore does reveal minor degrees of meniscocapsular tears anterolaterally when one understands the normal anatomy in this region.