Non-functional pituitary carcinoma

We present as case to review and present the clinical features, diagnosis and treatment of non-functional pituitary carcinoma (NFPC). We operated on a case of NFPC. After surgery, gamma knife therapy, temozolomide chemotherapy and whole craniospinal irradiation, the patient still had poor tumor control and died 7 months after operation. FPC is very rare. It needs to be diagnosed with a combination of clinical suspicion, imaging and dynamic monitoring. It is necessary to find more effective methods to control the progress of tumor while routine treatment fails.

Dramatic improvement of segmental Zoster Paresis by late-onset antiviral therapy

Focal paresis secondary to Herpes zoster (HZ) is a rare neurological complication and should be kept in mind in the differential diagnosis of acute weakness with corresponding dermatomal rashes. In this case report, we illustrate an 84-year-old male patient, who presented with focal upper extremity weakness following HZ on right C4-8 dermatome. After clinical and electrophysiological evaluations, segmental zoster paresis was diagnosed. Although antiviral medication(oral brivudine) had been administered previously, oral valacyclovir and low dosage methylprednisolone were initiated. In the following 2 months interval, a progressive and dramatic recovery in extremity weakness and neuropathic pain were achieved. The clinical course of this patient may give substantial perspectives regarding the clinical evaluation of similar cases.

Dealing with COVID-19 in Medical Practice: Yet an Uncertain Situation

COVID-19 pandemic is still uncertain and is going to last longer. The world has learnt a lot to fight against it. However, the world has to learn to live and deal with it in the days ahead. Medical practice has to be innovated and modified to protect medical professionals as well as patients.

MR Imaging Spectrum of Neuro Rhino Sino Orbital Fungal Infections in patients treated for COVID

Objectives: To analyse the spectrum of imaging findings of fungal infection as seen in MRI images of priorly treated for COVID. Materials and methods: The different patterns of findings of Neuro Rhino Sino Orbital Fungal Infections as seen in MRI images in 100 patients who received standard treatment for COVID in recent past and presented with suggestive signs and symptoms. Results: No positive MRI findings to suggest any neural tissue, orbital or Sino nasal involvement was seen in 35 % of cases. Only sino nasal involvement noted in 23 % cases. Sino-nasal as well as orbital involvement seen in 21 % cases. Neuro Sino Naso Orbital lesions were seen in 11% cases. Non fungal orbito-facial soft tissue inflammation was seen in 10 % cases. Conclusion: In patients who have received standard treatment for Covid and who later developed signs and symptoms of neural, orbital or Sino nasal involvement; positive imaging findings were noted in 65% cases. Fungal infections were seen more in middle aged population [40-60 years of age]. About 75 % of affected patients were known diabetics. Neural involvement was least common. This study proposes a new staging system [Stage 0, X, I, II, III, IV] for describing the affected region by fungal infection.

Prognostication of Traumatic Brain Injury using International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury score in Nepalese Cohort

Introduction: Traumatic brain injury disease of major importance globally. Prognostic models are useful for making decisions in the clinical practice. The aim of this study was to assess the accuracy of International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) score in predicting outcome in moderate to severe TBI at 3 months. Materials and Methods: All patients admitted to National Trauma Center, National Academy of Medical Sciences with moderate to severe traumatic brain injury from February 2020 to February 2021 were included in the study. IMPACT scores (core/extended core/ lab) were recorded separately at admission. Outcome was measured with Glasgow Outcome Scale (GOS) at the time of discharge and at six months. Correlation between observed and predicted outcomes was evaluated by Pearson’s correlation coefficient (r). Sensitivity and specificity were plotted in the receiver-operating characteristic (ROC) curve, and the area under the curve (AUC) was calculated to determine the discrimination ability of this prognostic model. Results: A total of 112 patients were enrolled in the study. Eighty (71.4 %) patients had moderate and 32 (28.57 %) had severe TBI. The median age was 33 years with male preponderance (M: F=4:1). Thirty three (29.5 %) patients died within 6 months of TBI, and 38 (33.9 %) patients had an unfavorable outcome. Pearson correlation coefficient showed good correlation between observed and predicted outcomes. Hosmer-Lemeshow test showed good model fit for IMPACT core, IMPACT extended and IMPACT lab in diagnosing mortality and unfavorable outcome in six months (p>0.05). The ROC curve indicated that all 3 models could accurately discriminate between favorable and unfavorable outcomes, as well as between survival and mortality (unfavorable outcome AUC= 0.905, 0.940, 0.955; mortality AUC= 0.875, 0.914, 0.917 respectively) in our patient population. Conclusion: The IMPACT score is a good prognostic model to predict 6-month outcomes in moderate to severe TBI at admission in Nepalese patient population. Among the three IMPACT models, IMPACT lab has the greatest discriminating ability.

Non-dysraphic Subpial Intramedullary Lipoma of Cervicothoracic Spine

Intramedullary spinal cord tumors are rare and comprise less than one percentage of all central nervous system (CNS) neoplasms. When encountered, most are found in the lumbosacral region with coinciding spinal dysraphism. Here, we discuss a case of isolated non-dysraphic intramedullary lipoma of cervicothoracic spine in an adolescent who was surgically managed with posterior decompression and subtotal resection via laminoplasty. A 21-year-old male adolescent, without a history of spinal dysraphism, presented with a progressive sensory ataxia. This manifestation was attributed to magnetic resonance documented intramedullary lipoma, extending from C7 to T2 spinal level. Patient underwent subtotal surgical resection of the lesion; and histopathology report was confirmed as spinal lipoma. Surgical management of this rare pathology has a wide variety of options depending on clinical presentation. In our case, a subtotal resection and laminoplasty was achieved with no further worsening of neurologic symptoms.

Rare Case of Wernicke Encephalopathy with Initial Negative Diffusion-Weighted Imaging

In this report, we present a rare patient with Wernicke encephalopathy (WE) in whom the initial magnetic resonance imaging (MRI) was normal. However, cranial MRI, performed two weeks later, showed lesions compatible with WE. Via the presentation of this patient, we discuss the need for future studies of larger cases including the temporal evaluation of the MRI characteristics of Wernicke encephalopathy.

Retinoblastoma Extending up to the Optic Chiasma and Presenting as a Suprasellar Mass

Retinoblastoma is the most common ocular malignancy of childhood. It is present in childhood with leukocoria and strabismus. Most patients are diagnosed under 3 years of age. Funduscopic examination can reveal an intraocular mass, but imaging is essential for complete evaluation of the lesion. Although ultrasound is a non-invasive and relatively inexpensive screening tool, cross-sectional imaging is required to assess the involvement of optic nerve and intracranial spread. We report a case of retinoblastoma in a 5 year old male child who presented with headache diminution of vision in both eyes. Contrast enhanced magnetic resonance imaging (MRI) revealed an enhancing soft tissue mass in the right eye with involvement of optic nerve and optic chiasma and contiguous with a large suprasellar mass causing hydrocephalus. Non-contrast computed tomography (CT) showed extensive calcifications in the mass lesion.

Pseudotumor Cerebri in the Setting of Differentiation Syndrome in a Patient with Acute Promyelocytic Leukemia Treated with All-trans Retinoic Acid During Induction Therapy

Introduction: Differentiation syndrome, a well-known complication of all-trans retinoic acid (ATRA) in patients with acute promyelocytic leukemia (APML), can very rarely have ophthalmic manifestations. Pseudotumor cerebri (PC) in the setting of differentiation syndrome (DS) in patients undergoing induction with all-trans retinoic acid has rarely been reported elsewhere. We herein report one such case. Case Presentation: A 28-year-old, non-obese female diagnosed as acute promyelocytic leukemia underwent induction with all- trans retinoic acid and Idarubicin. On day 4 of the treatment, she developed high grade fever (104 – 105 F), dry cough, hypotension, tachycardia, and tinnitus. Chest X ray showed floppy shadows in bilateral lungs. On physical examination, bilateral lower limb edema was noted. She also experienced sudden weight gain of 5 kilogram in 48 hours. After careful exclusion of systemic infection, she was suspected as having DS. She also noticed a reduction in vision in right eye. On eye examination, her best-corrected visual acuity (VA) was 6/60 in the right eye (RE) and 6/6 in the left eye (LE). Fundus evaluation revealed bilateral disc edema with peripapillary hemorrhages along with slight tortuosity of vessels and a yellowish lesion over the fovea in RE. Suspecting DS, she was treated with injection dexamethasone 10 mg twice daily and all- trans retinoic acid was temporarily discontinued. Immediately after its discontinuation, her headache lessened and vision improved gradually. After 2 weeks, her VA was 6/12 in RE and 6/6 in LE which improved to 6/6 in both eyes at 3 months. The patient was also receiving oral voriconazole for fungal prophylaxis and the potentiation effect of all- trans retinoic acid could thus be explained. Conclusion: Pseudotumor cerebri associated with all-trans retinoic acid treatment in acute promyelocytic leukemia, even though frequently reported in pediatric patients, is rare in adults. Ophthalmological evaluation is mandatory in all these patients under all-trans retinoic acid therapy.

Concept of 'Central' or 'Axial' Atlantoaxial Instability

The atlantoaxial joint is the most mobile joint of the spine and is most liable to develop instability. Atlantoaxial instability can be identified on observation of facetal alignment on lateral profile imaging, telltale clinical and radiological evidence and by direct observation of instability by manual manipulation of bones during surgery. Central or axial atlantoaxial instability is when there is no abnormal increase in atlantodental interval on dynamic imaging and there is no dural or neural compression by the odontoid process. Understanding and appropriately treating central or axial atlantoaxial instability can have clinical implications.