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  • 1. KASTURI NEURO BULLETIN Volume 13: 9. EDITORIAL: Dear Colleagues and Friends, It is my immense pleasure to share some of the interesting cases with you. Now being the Unit Head of Neurology in PSG Hospitals, the responsibilities like setting Goals and shaping the Department etc., are increasing. In the midst of time, I will always try to be in touch with you through this bulletin. This Bulletin concentrates mainly on cases with MRI as its use is increasing in Neurological Diagnosis. The first article describes a case of trigeminal pain due to Demyelinating lesion. This was missed for several years as the patient did not undergo MRI evaluation earlier. A school girl got panicked as she was told some intracranial abnormality was present in her MRI and she stopped going to school. She was worried that she may need a neurosurgical intervention. With proper counseling about the benign nature of the lesion, we could make her life pleasurable. Again the third case is about trigeminal pain. This patient was misdiagnosed, as trigeminal neuralgia, but her clinical symptoms are totally different. An elongated styloid process causing constant retro mandibular pain was her problem. Paraplegia is pathetic. The patient has to depend on others for ADL. After suffering from paraplegia for several years, if anyone is asked to choose either to have few more years of life or to have both upper limbs working, it will be really a difficult situation. One such patient is described in here. 61 yrs old male was brought to the hospital with left focal seizures. The Physician does a CT for making a diagnosis. If the CT makes him more confused rather than making it clear, with several differential diagnoses like Encephalitis, Hemorrhagic Infarct, AVM, Cavernoma etc., the physician has to depend on senior’s expertise. Management of such kind of patient was described here. The last case is more of a practical problem. An old lady of left hemiplegia presented with increasing weakness and if her CT did not show any fresh lesions, where can you localize? Find the answer from the case report. We have organized a simple Neuro Quiz session from basic neurology to select candidates for sending them to a Quiz program. I am herewith enclosing a part of it for your casual answering. This contains 75 MCQs. Please send your answers before 1 st Nov, 2013, to me either by post or by e-mail. Amazing prizes are awaiting. I thank Dr. Thirumurthy, Dr.Balakrishnan and Dr. GnanaShanmugam for their contribution in preparing the questions. I once again welcome you to submit your interesting cases to Kasturi Neuro Bulletin just by E-mailing it to Those who like to support the Bulletin can send DD / Cheque in favor of “Kasturi Welfare Trust” to 89-A, East Lokamanya St, RS Puram, Coimbatore or pay directly through Karur Vysya Bank, RS Puram, Coimbatore, Account number 1122 1350 0000 2452. I do welcome your suggestions. With warm regards, Dr. B.Prakash, Editor. INSIDE THE ISSUE: 1. Use of MRI in Trigeminal Neuralgia 2 2. The role of Clinician in MRI interpretation 2 3. A case of Eagle’s syndrome 3 4. Limb or Life? 3 5. A case of temporal lobe lesion 4 6. A case of stroke on stroke 4 7.Supplement : Neuro Quiz – 75 Questions 5-8 6. For Internal Circulation only. Not for Sale.Supported by KASTURI WELFARE TRUST and SANOFI Dr.B.PRAKASH. MD.,DM(Neuro)., FAGE,. Professor & Chief (Unit IV) of Neurology (PSG H) KASTURI NEURO DIAGNOSTIC CENTRE 89-A, East Lokamanya Street, R.S.Puram. COIMBATORE – 2. Mob: 978 948 1179 E.Mail:
  • 2. USE OF MRI IN TRIGEMINAL PAIN THE ROLE OF CLINICIAN IN MRI INTERPRETATION INTRODUCTION: Usually Trigeminal neuralgia is idiopathic and MRI will be normal. The common finding in MRI is vascular loop pressing the trigeminal nerve. However other causes are not unusual. Mostly surgery is invasive and the patients tend to avoid / postpond it. CASE REPORT: 47 yrs old male was referred for right V2 V3 pain of six years duration. Two surgical interventions were attempted so far. He is on optimum dose of medications. No focal neurological deficits made out. MRI brain (fig-1) done, which showed T2 hyperintence signal in right middle cerebellar peduncle, suggesting focal demyelination. No other abnormalities noted. No vascular loop impingement. Hyper intense signals noted in FLAIR image is shown in (fig-2). No extra axial pathology (fig-3) made out. CONCLUSION: Even though the extra axial lesions are the common causes in Trigeminal Neuralgia, we should not miss the unusual demyelinating lesion as noted in our case. Among the intra axial lesions, demyelination is the most common etiology. INTRODUCTION: MRI plays a vital role in the neurological diagnosis and it has become almost mandatory for most cases. However, if misinterpreted or only relied on, it may mislead us. CASE REPORT: 19 yrs old Ms.F, presented with severe headache of 3 yrs duration. She was doing her school final, but discontinued due to the daily severe headache. She felt better only for few hours on taking medications. She has nausea, photophobia and sonophobia. Sunlight and hunger aggravates her pulsating headache. She was told her MRI was significantly abnormal. Examination revealed no focal neurological abnormalities. The clinical diagnosis was a transformed migraine. A CT brain was done during March’2011 and MRI with contrast, one month later were reported that there was a ruptured dermoid cyst. (Refer fig). A second opinion from Senior Radiologist had revealed the lesion was lipoma. The incidental finding and the benign nature of the lesion was explained to the pt. She was started on migraine prophylaxis and is advised to attend the classes. She had come for follow-up after two months and was asymptomatic. CONCLUSION: It needs proper clinical assessment and good radiological interpretation to make a correct diagnosis, but the Clinician should spend time with the patient to prevent unnecessary anxieties. 1. Clinical Journal of pain – Jan 2002 Vol 18 (1) – 14 to 21 2. Acta Neuro Logica - March 82 Vol 65 (3), 182 to 189 Proc (Bayl Univ Med Cent). 2012 January; 25(1): 23–25. Am J Roentgenol. 1990;155 (4): 855-64 KNB 13: 9 -2
  • 3. A CASE OF EAGLE’S SYNDROME LIMB OR LIFE ? INTRODUCTION: Eagle’s Syndrome is a rare condition in which elongated styloid process is producing dysphagia, tinnitus, ear, face and neck pain. Even though it is easily diagnosed by ENT Surgeon and Dentist an awareness of this syndrome is a must for any clinician. CASE REPORT: A 24 years old female was referred to us as right trigeminal neuralgia. She had continuous retro mandibular pain, with tinnitus. It is not electric shock like or intermittent as like trigeminal neuralgia. When the patient was asked to show the site of the pain with her finger, she had touched her right retro mandibular region (fig-1), where she had tenderness too. No neurological deficits made out. ENT surgeon’s opinion obtained. She was diagnosed to have right eagle’s syndrome with an OPG x-ray (fig-2).The pictorial representation was shown in fig-3. DISCUSSION: Eagle’s Syndrome is suspected when the patient presents with retromandibular pain, tinnitus or dysphagia. The treatment is surgical Styloidectomy. The condition was first described by Watt Weems Eagle in 1937. INTRODUCTION: It will be difficult to answer if anyone is asked to have either functioning limb or to undergo a life saving surgery. CASE REPORT: 45/M had a fall from height during Oct’2007 and sustained multiple fractures and burst Atlas (Jefferson #) shown in fig-1. He had fracture D3-D4 causing paraplegia. A CT brain done at that time showed a right parietal hypodense lesion?contusion. The patient learnt to live with paraplegia. He presented to us by June’13 with 3 episodes of seizures. The CT report was Rt parietal Glioma. He was given AED, antiedema measures steroids and advised surgery, But he was not willing as there is a chance of developing left hemiplegia over paraplegia. A tapering steroid course was given. Meanwhile he developed LRI and the steroid was stopped. He got re-admitted for recurrence of serial seizures. No fresh neurological deficits. No increase in the size of tumor. The importance of undergoing surgical excision was insisted, but the patient got discharged AMA. CONCLUSION: It is difficult to decide for the pt whether or not to undergo surgery which may lead to weakness of left limb, leaving him to live with only Rt UL. This may not give a meaningful life. We had advised surgery for protection of life. But this may add only years to the life at the expense of quality of life. 1. Journal .Neuro Radiology Vol 34 (5) 344 to 345 2. Journal.Maxilo fascial surgery Vol 41(2) 162 to 166 1. Neurol Clin. 1995 Nov;13(4):847-59. 2. Jou of Cl Oncology, 20, 8 (April 15), 2002 KNB 13: 9 -3
  • 4. A CASE OF TEMPORAL LOBE LESION A CASE OF STROKE ON STROKE INTRODUCTION: Temporal lesions when presenting with seizures may be confusing, especially if imaging modalities do not give a proper diagnosis. CASE REPORT: By Aug’13, a 60/M, presented to a local hospital with acute confusional state and left focal seizures. He has DM, HT & renal impairment. His CT showed left temporal resolving bleed with edema, on which varying diagnoses like AVM / Cavernoma etc., were made (fig-1). He was treated with anti epileptics and discharged. Later MRI brain was done which was reported as left temporal neoplasm. He was having right LL marching parasthesia without any focal neurological deficits. A detailed EEG with additional leads showed epileptic focus at left temporal region (fig-2). A repeat MRI with MRS with 1.5 Tesla machine, confirmed 5x2.5x2 cm left medial temporal low grade glioma (fig-3). He was admitted, anti- epileptic drugs and other doses were adjusted. The crawling sensation totally subsided. Blood Sugar and Blood Pressure brought under control. CONCLUSION: Initial presentation of low grade glioma may be seizures, altered sensorium or confusional state. For correct diagnosis of intra cranial lesions, high quality MRI scans cannot be compromised. Non contrast CT, lower Tesla MRI can be utilized for screening purpose only. INTRODUCTION: If a patient develop a stroke on a preexisting stroke, it will be possible to make a clinical diagnosis, only if the area and/or pathology of two strokes are different. Suppose a patient with right MCA infarct, develop again right MCA infarct, it will be difficult to make a correct diagnosis of site, size of the lesion. It will also be difficult to say whether the second stroke is organic. CASE REPORT: 50/F, a known case of DM/HT/DCM had left hemiplegia by Sep’12 (fig 1). She improved over a period of 2 wks, and she could gradually walk in a circumduction gait without support. She had Rt CCA intraluminal thrombus with severe LV dysfunction. Her CT showed moderate sized Rt MCA infarct. During Aug’13, she had worsening of left hemiparesis which could not be assessed correctly. A repeat CT showed almost the same findings as that of old infarct(fig2). 90% occlusion in Rt CCA was noted. MRI brain revealed two small foci of high parietal infarct (hyperintense in DWI) within the old infarct (fig 3). She received a course of Heparin, improved to some extent and discharged. CONCLUSION: Diffusion weighted images are more helpful in diagnosing acute infarct even if it occurs within the region of old infarct. 1. www. 191.9, 192.8, M9450/3 2. Neu ind mar-Apr, 2012.60(2), 243 Neurology. 1997 Apr;48(4):891-5. KNB 13: 9 -4
  • 5. 1.Common site of Neuro fibroma a.Extradural b.Intramedullary c.Extramedullary d.Intraventricular 2.Contrast enhancing paediatric neoplasm a.Choroid Plexus Papilloma b.Giant cell astrocytoma c.Medullo blastoma d.All the above 3.Blood product Methemoglobulin seen in MRI after one week of intracerbral haemorrhage is a.Hypermagnetic b.Paramagnetic c.Diamagnetic d.Conramagnetic 4.Pengiun sign in MRI is seen in a.Parkinson’s disease b..Multiple system atrophy c. Progressive Supranuclear Palsy d.Olivo Ponto Cerebellar Atrophy 5.Cortical ribbon sign in MRI is seen in a. CNS HIV b. CJD c. SCA d. Rabies 6.Frontal horn dilatation in CT scan is seen in Huntington’s Chorea a.True b.False 7.Correct the jumbled letters of VALDREN SHELTOR ZAP; degenerative disorder (NBIA) which is not often used now a days 8.Unilateral temporal T2 hyperintensity seen in a.Glioma b.HSE c.Infarct d.All of the above 9.Match diagnosis and the needed skull Xray 1 Pituitary lesion a.Down’s view 2.Basilar invagination b.Lateral view 3.CP angle lesion c.AP view 4.Eagle’s syndrome- d.Open mouth 10.To differentiate between post operative gliosis and recurrence of glioma the scan advised is a.MRI b.fMRI c.PET d.SPECT 11.Shouldering in Myelogram is a feature of a.Neurofibroma b.Disc Prolapse c.Pott’s spine d.Spinal AVM 12.Non contrast CT scan may miss a.Low grade glioma b.CVT c.Tuberculoma d.All of the above 13.In routine MRA, the contrast agent used is a.Iodine b.Gadolinium c.Non ionic contrast agent d.None of the above 14.MRI sequence for diagnosing acute infarct is a.FLAIR b.T1 & T2 c.DWI d. PWI 15. The location of tumor in intracranial NF is a.Pons b.IV Ventricle c.CP angle d.Pituitary 16.16 yrs old girl presented with Writer’s cramp, she has a ring in her eye. The likely diagnosis is a.Parkinsonism b.Wilson Disease c.Hypothyroidism d.Neurocysticercosis 17.60 yrs old male presented with large Rt MCA Stroke seen in CT. The immediate action is a.Thrombolysis b.Heparin c.Decompression d.Ecospirn 18. The findings noted in CECT of CVT is a. Eye of Tiger sign b. SDH c. Hyperdense MCA sign d. Empty delta sign Supplement to Kasturi Neuro Bulletin 13:9 - Mini Neuro Quiz Editor’s Decision is final.
  • 6. 19. The prognosis of the Pontine bleed is a.Poor b.Good 20. The likely diagnosis of enumerous ring enhancing lesions by MRI is a.Sarcoidosis b.Secondaries c.AV Malformation d.Neurocystecercosis 21. Hypohalamo- hypophyseal fibres are formed by the axons of a. Supraoptic b. Paraventricular c. Both d. None 22. Midbrain structure which projects to the corpus striatum is a. Pyramidal tract b.Medial Longitudinal Fasciculus c.Medial Geniculate Body d.Substantia Nigra 23. A lesion of subthalamus results in a.Chorea b. Athetosis c.Hemiballismus d.Dystonia 24. Which lobe is directly above the tentorium? a. Parietal lobe b. Temporal lobe c. Cerebellum d. Occipital lobe 25. Which part of brainstem region is in the tentorial region a. Pons b. Medulla c. Hypothalamus d. Midbrain 26. Myelin sheaths are formed by a. Oligodendrocytes b.Schwann cells c.Both d.None 27. Role of arachnoid granulation is to a. Produce CSF b. Stain CSF c. Transfer CSF to venous system d. Transfer CSF to lymphatic. 28. Floor of IV ventricle is associated with a. Medulla b. Pons and Medulla c. Pons, Medulla and Cerebellum d. Midbrain, Pons & Medulla 29. Ligaments attach between the exit and entrance of ventral and dorsal roots following each spinal nerve a.Pial b.Dura c.Collagen d.Flavii 30. Spinal C8 root, exits between the vertebrae a. C6-C7 b. C7-C8 c. C7-T1 d. T1-T2 31. Cauda equina is formed by the dorsal and ventral roots of _____ segments of spinal cord a.Lumbar b.Sacral c.Lumbosacral d.Coccygeal 32. Safest point to sample CSF is between a. C7-T1 b. L1-L2 c. D12 – L1 d. L3-L4 33. In syringomyelia (expansion of central canal) there will damage to the a. Spinothalamic tract b.Spino reticular tract c. Corticospinal tract d. All of the above 34. The vessel lateral to the chiasm is a. Anterior cerebral artery b. Middle cerebral artery c. Posterior communicating artery d. Internal cerebral artery 35. Central retinal artery is the branch of a.Internal Carotid b.External Carotid c.Ophthalmic d.Choroidal 36. Area of the medulla containing the spinal nucleus of trigeminal nerve is supplied by a. Anterior inferior cerebellar artery b. Posterior inferior cerebellar artery c. Superior cerebellar artery d. Vertebral artery 37. Which limb of internal capsule contain cortical approach a. Anterior limb b. Posterior limb c. Both d. Neither
  • 7. 38. Ganglionic ICH occur due to rupture of a. Lenticulostriate A b. Posterior Communicating A c. Anterior Cerbral A d. Internal cerebral Vein 39. The reception of the saccula and semicircular canals are examples of a. Chemoreception b. Nociception c. Mechanoception d.Osmoreception 40. Incidence of post stroke seizure is > 30% a. True b. False 41. Olivo cerebellar axons terminate in the cerebellum by a. Mossy fibers b. Climbing fibers c. Basket cell axons d. None 42. Tumours originating from Schwann cells of VIII Cr.N compress which cranial nerve? a. IX & X b. VII c. V d. VI 43. Tendon, joints, muscle spindle and skin are innervated by axons whose cell bodies are in a.Pyramidal tract b.Muscle Spindle c.Spinal AHC d.Neurons 44. Most devastating effects are produced by sudden occlusion of origin of a. MCA b. ACA c. VA d. PCA 45. Which vessels supply the speech area commonly? a. Right MCA b. Left MCA c. Left PCA d. Rt &Lt PCA 46.In uncal herniation, which portion of brainstem is compressed a.Midbrain b.Upper Pons c.Lower Pons d.Medulla 47. In right frontal lobe infarct, eye balls will look towards a. Right Side b.Left Side c.Upwards d.Downwards 48. in cerebellar herniation , which portion of brainstem is compressed a.Midbrain b.Upper Pons c. Medulla d. None 49.IV fluid to be avoided in increased intracranial pressure a. Normal Saline b. 3% saline c. 5% dextrose d. 5% dextrose in normal saline 50.Which of the following is not associated with cytotoxic brain edema a. Brain Tumor b.Ischemic Stroke c.Hepatic encephalopathy d.Hypoxic encephalopathy 51.Which of the following is the first line investigation in a patient with suspected subarachnoid hemorrhage a. Lumbar puncture b. CT brain c. MRI brain d.EEG 52. Hemorrhage in which portion of brain warrant urgent surgical evacuation a. Pons b. Basal ganglia c. Cerebellum d. Frontal lobe 53.Which of the following is most commonly the cause of spinal epidural abscess a.Lumbar puncture b.Osteomyelitis c. Penetrating trauma d. Hematogenous spread 54. Which of the following drug is used in the management of Guillaine Barre syndrome a. Interferon alpha b. IV immunoglobulin c. IV methyl prednisolone d. Oral prednisolone 55. With regards to headache which is not a red flag a. Fever b. Rapidity of onset c. Age >75years d. Duration > 4 days
  • 8. 56.Which of the following is the only thrombolytic agent approved for the management of acute ischemic stroke a. streptokinase b. alteplase c. tenecteplase d. urokinsae 57.All of the following imaging features favours tuberculous meningitis except a. Basal exudates b. Abscess c. Vasculitis d. Tuberculoma 58. Loading dose of phenytoin for management of status epilepticus is a. 5mg/kg b. 10mg/ kg c. 15mg/kg d. 30mg/kg 59. Which portion of brain is preferentially involved in Herpes Simplex Encephalitis a. Frontal lobe b. Parietal lobe c. Temporal lobe d. Occipital lobe 60.Which of the following is not the feature of Neuroleptic Malignant Syndrome a. fever b. altered sensorium c. movement disorder d. hemiparesis 61.Empirical antibiotic therapy for bacterial meningitis is a. Ceftriaxone + Vancomycin b. Ampicillin + Gentamycin c. Ampicillin d. Ampicillin + Vancomycin 62. BP reduction in acute ischemic stroke is not warranted in a. Carotid Dissection b. Associated MI c. BP > 140/100 d.Thrombolysis plan 63. In which of the following situation, Heparin is indicated in ischemic stroke a. All Ischemic Strokes b. Cardio Embolic Stroke c. Carotid Artery Stroke d. Lateral Medullary Stroke 64. All the following is associated with increased CSF lymphocyte count except a. Acute Pyogenic Meningitis b. Partly Treated Pyognic Mengts c. Tuberculous Meningitis d. Fungal Meningitis 65. Drug preferred to treat psychosis in parkinson’s disease a. Haloperidol b. Chlorpromazine c. Quetiapine d. Trifluperazine 66. Starting AED therapy is indicated in all of the following conditions, except a. Abnormal neurological examination b. Focal Seiz with todds paralysis c. Single provoked Seizures d. Abnormal EEG 67. Therapeutic concentration of serum Phenytoin is a.10-20 ug/ml b.20-30 ug/ml c.30-40 ug/ml d.40-50 ug/ml 68.Checking Sr. AED is indicated for a. Drug Toxicity b. Compliance c. Sr. level Assessment d. All 69. First AED introduced was a.Phenobarbitone b.Bromide c.Phenytoin d.Primidone 70.All AEDs act at sodium channel except a.Phenytion b.Carbamazepine c.Oxcarbamazepine d.Gabapentin 71. All are side effects of topiramate except a.Sedation b.Glaucoma c.Renal stone d.Weight gain 72. % of patient who do not respond to treatment with single AED a.33 b.25 c.66 d.75 73. Drug of choice for absence seizure a.Valproate b.Carbamazepine c.Phenytoin d.Oxcarbazepine 74.All are seizure inducing AED, except a.Phenytoin b.Valproic acid c.Phenobarbitone d.Primidone 75. Oxcarbazepine is better than CBZ in the following a. Rash is less common b. Hyponatremia is less common c. Better pt tolerability d. All of the above I thank our neuro team (Dr.Thirumurthy, Dr.Balakrishnan, &Dr.Gnanshanmugam) in preparing and permitting the Q&A to present to you