The Dilemma of the Physician, Going Back to The Clinician, Back to Basics

Background: Technology has allowed the scientific side of medicine to evolve more rapidly causing the “modern” physicians to greatly rely on laboratory values and imaging studies thereby leading to the loss of clinician abilities and skills. Case: A 52-year-old female with multiple cardiovascular co-morbidities including ischemic heart disease, presented to the emergency department in the morning with diffuse body pain associated with malaise, numbness and paresthesias of the right upper and lower extremity. This was followed by an “out of body” sensation. She then experienced transient sharp left-sided chest discomfort described as moderate to severe in intensity with a duration of approximately 2 minutes slowly subsiding on its own. Subsequently, she reported difficulty lifting the right hand and leg as well as slurred speech. The strength in her limbs returned within the hour but numbness and paresthesias persisted and continued to bother her. At the time of presentation, she was hypertensive but no other abnormalities were found on the physical examination. An elevated troponin level was noted but acute coronary syndrome (ACS) was unsuspected in the 12-lead electrocardiogram (ECG). A noncontrast computed tomography (CT) of the head was unremarkable. A subsequent 12-lead ECG revealed new T wave inversions in the lateral leads. This provoked a repeat neurological exam in greater detail, and there was objective weakness of the distal muscle groups of the right upper and lower limbs. The NIH score was now 6 (prior was 0). Brain magnetic resonance imaging (MRI) the following day showed an acute infarct of the left internal capsule. Approximately 72 hours after the initial presentation, the patient remarkably improved and was planned for discharge by the 5th admission day. Conclusion: Clinical skills are crucial in the technological era; it could definitely prevent mistakes or time matter diagnosis. Hence, a reason why in times of dilemma, a return to the basics promoting these skills will always be helpful.

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A case of pseudotumor cerebri secondary to acute leukemia

Journal of Neurology & Stroke ◽

10.15406/jnsk.2020.10.00420 ◽

2020 ◽

Vol 10 (3) ◽

pp. 105-107

Author(s):

Turgay Demir ◽

Filiz Koc ◽

Seyda Erdoğan

Keyword(s):

Acute Leukemia ◽

Lymphoblastic Leukemia ◽

Brain Magnetic Resonance Imaging ◽

Pseudotumor Cerebri ◽

Lymphoid Cells ◽

Temporal Region ◽

Opening Pressure ◽

Neurological Exam ◽

Magnetic Resonance Imaging Mri ◽

The Right

Introduction: Idiopathic intracranial hypertension (IIH) is a rare clinical condition in which an increase in intracranial pressure is seen without a lesion in the head. The association of IIH with haematological malignencies is not well known. Case: We present 19-year-old male with frequent episodes of headache that lasted up to 24 hours, localized to the bilateral temporal region accompanied with nausea and vomiting for two months. On the neurological exam, the lateral gaze was slightly restricted. Ophthalmological exam revealed bilateral papilledema, which was more pronounced on the right. Bilateral concentric constriction, more pronounced on the right , was observed on the computerized visual field exam. Brain Magnetic Resonance Imaging (MRI) showed swelling in the optic nerve sheats, rather than on the right. In the analysis of cerebrospinal fluid (CSF), the opening pressure was 370 mmH2 Cytological examination of the CSF showed atypical lymphoid cells. The patient was diagnosed as precursor lymphoblastic leukemia/lymphoma. Conclusion: Acute leukemia–induced clinical IIH has not been reported in the literature up to now, and the present case study will contribute to the literature in this regard. This phenomenon will be noteworthy for clinicians who encounter high CSF opening pressure, abnormal CSF biochemistry, and substantial cytology in cases presenting with clinical IIH.

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Bilateral Type II Persistent Proatlantal Intersegmental Arteries

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s031716710001605x ◽

2013 ◽

Vol 40 (6) ◽

pp. 873-874 ◽

Cited By ~ 3

Author(s):

David Pelz ◽

Ranjith K. Menon ◽

Rick H. Swartz ◽

Richard I. Aviv ◽

Sean P. Symons

Keyword(s):

Magnetic Resonance ◽

Posterior Inferior Cerebellar Artery ◽

Brain Magnetic Resonance Imaging ◽

Internal Capsule ◽

External Carotid ◽

Occipital Artery ◽

Type Ii ◽

Posterior Limb ◽

Magnetic Resonance Imaging Mri ◽

The Right

A 64-year-old man with treated hypertension presented with acute left arm and leg weakness. A brain magnetic resonance imaging (MRI) and neck magnetic resonance angiography (MRA) were performed. There was restricted diffusion in the right internal capsule posterior limb consistent with an acute lacunar infarct. The MRA demonstrated aplastic bilateral cervical vertebral arteries (V1 and V2 segments). bilaterally, a variant artery arose from the external carotid just above its origin, extended superiorly then medially, and forming the vertebral artery (V3 and V4 segments). bilaterally, the occipital artery arose from the variant artery at the juncture where it turned medially. The right variant artery terminated intracranially in the right posterior inferior cerebellar artery. The left variant artery continued intracranially to supply the basilar. The appearance was consistent with bilateral persistent proatlantal intersegmental arteries (PPIA) type II.

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Muscle strength and inflammatory response to the training load in rowers

PeerJ ◽

10.7717/peerj.10355 ◽

2020 ◽

Vol 8 ◽

pp. e10355

Author(s):

Tomasz Podgórski ◽

Alicja Nowak ◽

Katarzyna Domaszewska ◽

Jacek Mączyński ◽

Magdalena Jabłońska ◽

...

Keyword(s):

Muscle Metabolism ◽

Creatine Kinase Activity ◽

Lower Limbs ◽

Total Testosterone ◽

Blood Biochemical ◽

Global Force ◽

Significant Difference ◽

Muscle Groups ◽

Torque Values ◽

The Right

Background Regular exercise leads to changes in muscle metabolism. The consequence of this is the adaptation to higher training loads.The aim of this study was to evaluate biomechanical and biochemical parameters describing the functions of skeletal muscles in periods when changes in training forms were introduced. Methods Seventeen male sweep-oar rowers, members of the Polish national rowing team, participated. The study was carried out at the beginning and at the end of the preparatory period. In the first and second examination measurements of torques of selected muscle groups and blood biochemical analysis were performed. Results There was observed a statistically significant decrease in the relative global force of the right lower limb between both terms of examination. A statistically significant increase in maximum torque was found for torso flexors. In the case of muscles responsible for torso rotation, a statistically significant decrease in the torque values of right torso rotators was observed. A significant difference was found with respect to creatine kinase activity, total testosterone concentration, total testosterone to cortisol ratio and total phenolics concentration (p < 0.05). Conclusion The study shows that the rowers’ training should be more focused on building the strength of lower limbs to prevent the overload of lumbar spine and that the amount of force developed may be significantly affected by the antioxidant potential of rowers.

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Overlapping anti-N-methyl-D-aspartate receptor (NMDAR) Encephalitis With Neuromyelitis Optica Spectrum Disorders: A Case Report

10.21203/rs.3.rs-907816/v1 ◽

2021 ◽

Author(s):

Jialin Pan ◽

Begench Ovlyakulov ◽

Lili zhou

Keyword(s):

Neuromyelitis Optica ◽

Brain Magnetic Resonance Imaging ◽

Chinese Patient ◽

Cerebellar Hemisphere ◽

Double Positive ◽

Blurred Vision ◽

Aspartate Receptor ◽

Nmdar Encephalitis ◽

Magnetic Resonance Imaging Mri ◽

The Right

Abstract BackgroundAnti-N-methyl-D-aspartate receptor (NMDAR) encephalitis can coexist with neuromyelitis optica spectrum disorder (NMOSD). Patients with overlapping anti-NMDAR encephalitis with positive NMDAR antibodies and aquaporin 4 immunoglobulin G (AQP4-IgG)-seropositive NMOSD are rare but should not be ignored.Case presentationThis report describes a unique case of anti-NMDAR encephalitis coexisting with NMOSD is presented. A 27-year-old male presented with blurred vision, cognitive impairment, psychosis, dysphagia, gait instability and urinary incontinence. Brain magnetic resonance imaging (MRI) showed abnormal signals in the right cerebellar hemisphere, temporal lobe, and corpus callosum. NMDAR antibodies were positive in the CSF. AQP4-IgG antibodies were positive in the serum. The patient's condition was stable following intravenous gamma globulin, corticosteroids, immunosuppressants and symptomatic treatments. ConclusionsThis case provides further evidence for the occurrence of anti-NMDAR encephalitis overlapping NMOSD with AQP4-IgG-seropositive in a Chinese patient. However, the mechanisms underlying the occurrence of double positive antibodies remain elusive.

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Paroxysmal kinesigenic dyskinesia–like phenotype in multiple sclerosis

Multiple Sclerosis Journal ◽

10.1177/1352458517702535 ◽

2017 ◽

Vol 23 (13) ◽

pp. 1795-1797 ◽

Cited By ~ 4

Author(s):

Roxana Pop ◽

Stefan Kipfer

Keyword(s):

Multiple Sclerosis ◽

Gene Mutations ◽

Brain Magnetic Resonance Imaging ◽

Acute Onset ◽

Intravenous Steroid ◽

Paroxysmal Kinesigenic Dyskinesia ◽

Hyperkinetic Movement Disorder ◽

Magnetic Resonance Imaging Mri ◽

The Right ◽

Rapid Regression

In April 2015, a 20-year-old woman with multiple sclerosis (MS) presented with acute onset of repetitive abnormal postures and choreatic movements of the right arm, precipitated by voluntary movements (online video 1 and 2). Brain magnetic resonance imaging (MRI) showed a new active MS lesion involving the basal ganglia on the left side (Figure 1(a)). Intravenous steroid treatment resulted in rapid regression of this paroxysmal kinesigenic dyskinesia (PKD)-like hyperkinetic movement disorder. The patient became asymptomatic within 3 months. PKD is characterized by recurrent uni- or bilateral choreoathetosis and usually represents an autosomal dominant inherited disorder caused by PRRT2 gene mutations. As in the present case, a PKD-like phenotype may be associated with MS relapses in presumably genetic negative cases.

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A Conjunctival Vascular Malformation as a Rare Presenting Sign of Wyburn–Mason Syndrome

Journal of Pediatric Neurology ◽

10.1055/s-0037-1607996 ◽

2017 ◽

Vol 16 (04) ◽

pp. 239-242

Author(s):

Gunnar Buyse ◽

Lieven Lagae ◽

Philippe Demaerel ◽

Frank Kesteloot ◽

Ingele Casteels ◽

...

Keyword(s):

Vascular Malformation ◽

Arteriovenous Malformations ◽

Brain Magnetic Resonance Imaging ◽

Rare Condition ◽

Vascular Lesion ◽

Facial Skin ◽

Sudden Appearance ◽

Magnetic Resonance Imaging Mri ◽

The Right ◽

The Brain

AbstractWyburn–Mason syndrome is a rare condition that is characterized by ipsilateral arteriovenous malformations affecting the eye, brain, and facial skin. A conjunctival vascular dilation can be a rare ocular presenting sign. We report a 6-year-old boy who attended the hospital because of the sudden appearance of a conjunctival vascular lesion in his right eye. Inspection of his facial skin showed a subtle discoloration along the right trigeminal nerve and a vascular structure of the conjunctiva. Fundoscopy showed dilated and tortuous retinal vessels. Brain magnetic resonance imaging (MRI) revealed a large arteriovenous malformation involving the thalamus and perimesencephalic area. Ophthalmologic and neuroradiologic findings were consistent with the diagnosis of Wyburn–Mason syndrome. The sudden emergence of a vascular malformation in the conjunctiva should alert the clinician to perform an ophthalmoscopy, and in our patient, this finding was the clue to diagnosis of Wyburn–Mason syndrome. Because of the association between retinal and intracranial arteriovenous malformations, an MRI of the brain is strongly recommended in all patients with ocular arteriovenous malformations.

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Neuromyelitis Optica in a Nepalese Man

Case Reports in Neurological Medicine ◽

10.1155/2017/8596781 ◽

2017 ◽

Vol 2017 ◽

pp. 1-4

Author(s):

Yogesh Subedi ◽

Utsav Joshi ◽

Sanjeeb Sudarshan Bhandari ◽

Ashbina Pokharel ◽

Ashbita Pokharel

Keyword(s):

Spinal Cord ◽

Neuromyelitis Optica ◽

Immunoglobulin G ◽

Cervical Spinal Cord ◽

Immunosuppressive Treatment ◽

Lower Limbs ◽

Inflammatory Disorder ◽

Hyperintense Signal ◽

Muscle Groups ◽

The Right

Background. Neuromyelitis optica is a severely disabling inflammatory disorder of the central nervous system of autoimmune etiology that mainly affects the optic nerves and spinal cord. Here, we present a case report detailing a patient with tingling and weakness of right upper and lower limbs who was neuromyelitis optica immunoglobulin G-positive. Case Presentation. A 46-year-old Nepalese man presented to the hospital with a history of tingling and weakness of right upper and lower limbs that developed over a period of two months. Clinical evaluation showed diminished power across all major muscle groups in the right upper and lower limbs. Magnetic resonance imaging of his cervical spine showed T1 iso- to hypointense signal and T2 hyperintense signal in central cervical spinal cord from first to sixth cervical level, probably suggestive of myelitis or demyelination. The patient was immediately started on intravenous methylprednisolone. The diagnosis of neuromyelitis optica was later confirmed with strongly positive neuromyelitis optica immunoglobulin G. Conclusion. In resource limited setting, in the absence of tests for neuromyelitis optica immunoglobulin G, treatment was started and the patient’s condition started to get better. Hence, early initiation of aggressive immunosuppressive treatment is essential in such cases.

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Surgical Resection of a Cavernous Malformation of the Anterior Perforated Substance: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy354 ◽

2018 ◽

Vol 17 (2) ◽

pp. E64-E64

Author(s):

Alejandro Enriquez-Marulanda ◽

Abdulrahman Y Alturki ◽

Luis C Ascanio ◽

Ajith J Thomas ◽

Christopher S Ogilvy

Keyword(s):

Optic Tract ◽

Brain Magnetic Resonance Imaging ◽

Mass Effect ◽

Brain Structures ◽

Acute Onset ◽

Elective Resection ◽

Cavernous Malformations ◽

Patient Consent ◽

Magnetic Resonance Imaging Mri ◽

The Right

Abstract Cavernous malformations (CMs) are intracranial vascular anomalies of the brain blood vessels which are usually asymptomatic but sometimes may cause headache, seizures, or focal neurologic symptoms.1 The latter may be attributed to either hemorrhage of the lesion or due to associated mass effect.2 Here, we describe the case of a 27-yr-old woman who had an acute onset of headache and occasional left sided peripheral visual disturbances. A brain computed tomography scan revealed intraparenchymal hemorrhage near the right hypothalamus and a brain magnetic resonance imaging (MRI) was consistent with an anterior perforated substance CM. Medical management was pursued but severe headache persisted for several weeks to the point of interfering with normal daily function. Given the evidence of past hemorrhage and the persistence of symptoms, a microsurgical resection was indicated. She was scheduled for an elective resection through a right frontotemporal craniotomy. The lesion was found in the right anterior perforated substance, just above the optic tract and was resected without complications. The patient was neurologically stable at discharge. At 4-mo follow-up, the patient had a significantly decreased intensity of headache and an adequate resection cavity on MRI. Otherwise, she was neurologically intact. Cavernous malformations of deep brain structures, such as the anterior perforated substance can be surgically treated but carry a challenging procedure with a risk of visual deficits. In the following video illustration, we narrate this operative case and highlight the nuances of this approach. Patient consent was obtained for the submission of the video to this journal.

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Complete Microsurgical Resection of Large Retrochiasmatic Hypothalamic Craniopharyngioma by Transpetrosal Approach: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz250 ◽

2019 ◽

Author(s):

Qazi Zeeshan ◽

Juan P Carrasco Hernandez ◽

Nina T Yoh ◽

Laligam N Sekhar

Keyword(s):

Frozen Section ◽

Brain Magnetic Resonance Imaging ◽

Optic Chiasm ◽

Pituitary Stalk ◽

Excessive Sleepiness ◽

Microsurgical Resection ◽

Magnetic Resonance Imaging Mri ◽

Prefixed Chiasm ◽

The Right ◽

Retrochiasmatic Region

Abstract This two-dimensional video shows the technical nuances of complete microsurgical resection of a hypothalamic craniopharyngioma located in the retrochiasmatic region by the transpetrosal approach. This 49-yr-old man presented with progressive fatigue, excessive sleepiness, and difficulty in vision in both eyes. He was found to have right CN 3 paralysis and bitemporal hemianopsia on neurological examination. Further workup revealed panhypopituitarism. Brain magnetic resonance imaging (MRI) demonstrated a large solid retrochiasmatic hypothalamic lesion with homogeneous contrast enhancement, measuring 2.1 × 2.6 × 2.4 cm. Optic chiasm was prefixed, and the tumor was just posterior to the pituitary stalk area. The preoperative differential diagnosis included hypothalamic astrocytoma, craniopharyngioma, germinoma, and histiocytosis. Because of the prefixed chiasm, a presigmoid, transpetrosal approach was performed. Our initial plan was a large biopsy, but based on frozen section histology, we decided to excise the tumor completely. The tumor had a pseudocapsule, which was firm and yellowish. It was debulked, dissected from the surrounding hypothalamus, and removed completely. The pituitary stalk was found at the anterior and inferior ends of the tumor and was preserved. Postoperatively, the patient developed diabetes insipidus and requires desmopressin replacement, which was gradually tapered. For panhypopituitarism, he is receiving thyroxine, hydrocortisone, and testosterone. Postoperatively, patient had an improvement in vision in his left eye and ptosis was improving in the right eye with mRs 1- at 10-wk follow-up. An informed consent was obtained from the patient prior to the surgery, which included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

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Distinct pattern of microsusceptibility changes on brain magnetic resonance imaging (MRI) in critically ill patients on mechanical ventilation/oxygenation

Neuroradiology ◽

10.1007/s00234-021-02663-5 ◽

2021 ◽

Cited By ~ 1

Author(s):

Majda M. Thurnher ◽

Jasmina Boban ◽

Martin Röggla ◽

Thomas Staudinger

Keyword(s):

Mechanical Ventilation ◽

Critically Ill ◽

Critically Ill Patients ◽

Brain Mri ◽

Brain Magnetic Resonance Imaging ◽

Internal Capsule ◽

Neurological Complications ◽

Subcortical White Matter ◽

Distinct Pattern ◽

Magnetic Resonance Imaging Mri

AbstractPurposeOver the years, interesting SWI abnormalities in patients from intensive care units (ICU) were observed, not attributable to a specific cause and with uncertain clinical significance. Recently, multiple SWI-hypointense foci were mentioned related to neurological complications of SARS-COV-2 infection. The purpose of the study was to describe the patterns of susceptibility brain changes in critically-ill patients who underwent mechanical ventilation and/or extracorporeal membrane oxygenation (ECMO).MethodsAn institutional board-approved, retrospective study was conducted on 250 ICU patients in whom brain MRI was performed between January 2011 and May 2020. Out of 48 patients who underwent mechanical ventilation/ECMO, in fifteen patients (median age 47.7 years), the presence of SWI abnormalities was observed and described.ResultsMicrosusceptibilities were located in white-gray matter interface, in subcortical white matter (U-fibers), and surrounding subcortical nuclei in 13/14 (92,8%) patients. In 8/14 (57,1%) patients, SWI foci were seen infratentorially. The corpus callosum was affected in ten (71,4%), internal capsule in five (35,7%), and midbrain/pons in six (42,8%) patients.ConclusionWe showed distinct patterns of diffuse brain SWI susceptibilities in critically-ill patients who underwent mechanical ventilation/ECMO. The etiology of these foci remains uncertain, but the association with mechanical ventilation, prolonged respiratory failure, and hypoxemia seems probable explanations.

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