Neurological Society of India

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Neurology India

ISSN 0028-3886

The Official journal of the Neurological Society of India

Editorial Board (2003) Editor Atul Goel

Associate Editors

Neurology India is indexed with: Index Medicus/MEDLINE Neurosciences Citation Index Current Contents Excerpta Medica/EMBASE Research Alert Biological Abstracts Health & Wellness Research Center Health Reference Center Academic InfoTrac One File Expanded Academic ASAP ExtraMed IndMed Issues are published quarterly in the months of March, June, September and December.

Aadil Chagla Sangeeta Rawat

D. K. Sahu

Members Asha Kishore

Ashok Mahapatra

J. M. K. Murthy

K. Radhakrishna P. Satish Chandra

K. Sridhar Rajneesh Kachhara

Manas Panigrahi S. K. Shankar

Umakant Misra

Uday Muthane

Vedanta Rajshekhar

Editorial Assistant

Copy Editor

Statistical Advisor

Praveen Sharma

Akshar

Anil Arekar

Immediate Past Editor Sudesh Prabhakar

Past Editors B. Ramamurthi A. K. Bagchi

A. D. Desai S. Kalyanaraman

P. N. Tandon J. S. Chopra

Neurological Society of India (Executive Committee 2003)

President Vice President Honorary Secreatry Honorary Treasurer Editor, Neurology India

Editorial Office: Department of Neurosurgery Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400012, India. Email: [email protected] Published by: Medknow Publications 12, Manisha Plaza, MN Road, Kurla (W), Mumbai - 400070, India Email: [email protected] Websites: www.neurologyindia.com https://journalonweb.com/neuroindia www.bioline.org.br/ni

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Managing Editor

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Dattatraya Muzumdar

: : : : :

Dr. J. S. Chopra Dr. S. R. Dharker Dr. V. K. Khosla Dr. V. S. Mehta Dr. Atul Goel

Past Presidents Dr. M. C. Maheshwari Dr. M. J. Chandy Executive Members Dr. B. S. Sharma (Neurosurgery) Dr. S. Nair (Neurosurgery) Dr. S. Kumaravelu (Neurology) Dr. V. Puri (Neurology) Dr. A. K. Gupta (Allied)

Neurology India January-March 2003 Vol 51 Issue 1

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Neurology India January-Mar ch, 2003

Free full text at www.neurologyindia.com and www.bioline.org.br/ni

CONTENTS

Vol. 51 Issue 1

Original Articles Increased cortical excitability with longer duration of Parkinson’s disease as evaluated by transcranial magnetic stimulation M. Bhatia, S. Johri, M. Behari

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Prognosis in children with head injury an analysis of 340 patients H. S. Suresh, S. S. Praharaj, B. Indira Devi, D. Shukla, V. R. Sastry Kolluri

Hemodynamic response to skull pins application in children: Effect of lignocaine infiltration of scalp P. Bithal, H. H. Dash, N. Vishnoi, A. Chaturvedi

Incidence of intracranial aneurysms in north-west Indian population K. Kapoor, V. K. Kak

A comparative study of classical vs. desmoplastic medulloblastomas P. Pramanik, M. C. Sharma, P. Mukhopadhyay, V. P. Singh, C. Sarkar

Ho: Yag laser assisted lumbar disc decompression: A minimally invasive procedure under local anesthesia S. Agarwal, A. S. Bhagwat

Endoscopic third ventriculostomy in obstructed hydrocephalus D. Singh, V. Gupta, A. Goyal, H. Singh, S. Sinha, A. K. Singh, S. Kumar

Bilateral subthalamic nucleus stimulation for Parkinson’s disease P. K. Doshi, N. A. Chhaya, M. H. Bhatt

Morbidity predictors in ischemic stroke J. N. Panicker, M. Thomas, K. Pavithran, D. Nair, P. S. Sarma

Detection of heat stable mycobacterial antigen in cerebrospinal fluid by Dot-Immunobinding assay A. Mathai, V. V. Radhakrishnan, C. Sarada, S. M.George

Clinical, radiological and neurophysiological spectrum of JEV encephalitis and other nonspecific encephalitis during post-mansoon period in India U. K. Misra, J. Kalita, D. Goel, A. Mathur

Free radical toxicity and antioxidants in Parkinson’s disease K. Sudha, A. V. Rao, S. Rao, A. Rao

Case Reports Interhemispheric subdural hematoma: An uncommon sequel of trauma A. Shankar, M. Joseph, J. Mathew, Chandy

Massive falx cerebri empyema A. K. Yende, S. Mohanty

Secondary holocord syringomyelia with spinal hemangioblastoma: A report of two cases S. B. Pai, K. N. Krishna

Tuberculous osteitis of clivus B. Indira Devi, A. K. Tyagi, D. I. Bhat, V. Santosh Neurology India January-March 2003 Vol 51 Issue 1

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C O N T E N T S (Contd.)

Vol. 51 Issue 1

Sudden bilateral foot drop: An unusual presentation of lumbar disc prolapse A. K. Mahapatra, P. K. Gupt a, S. J. Pawar, R. R. Sharma

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Paradoxical embolism through patent foramen ovale causing cerebellar infarction in a young boy Devidayal, B. R. Srinivas, A. Trehan, R. K. Marwaha

Fenestration of the posterior communicating artery M. Tripathi, V. Goel, M. V. Padma, S. Jain, M. C. Maheshwari, S. Gaikwad, V. Gupta, P. S. Chandra, V. S. Mehta

Lipoma in the region of the jugular foramen A. V. Prasanna, D. P. Muzumdar, A. Goel

Foramen magnum metastatic malignant melanoma S. B. Pai, K. N. Krishna

False aneurysm of cavernous carotid artery and carotid cavernous fistula: Complications following transsphenoidal surgery R. Kachhara, G. Menon, R. N. Bhattacharya, S. Nair, A. K. Gupta, S. Gadhinglajkar, R. C. Rathod

Giant vertebrobasilar junction aneurysms: Unusual cases A. Suri, V. S. Mehta

Gluteal abscess: A manifestation of pott’s spine R. Kumar, A. Chandra

Primary spinal extradural hydatid cyst N. K. Sharma, N. Chitkara, N. Bakshi, P. Gupt a

Orthostatic tremor: report of a case and review of the literature K. B. Bhattacharyya, S. Basu, A. D. Roy, S. Bhattacharya

Functional MR imaging of hand motor cortex in a case of persistent mirror movement P. N. Jayakumar, J. M. E. Kovoor, S. G. Srikanth, A. B. Taly, V. Kamat

Subependymomas in children: A report of five cases including two with osseous metaplasia M. K. Mallik, N. Babu, N. Kakkar, V. K. Khosla, A. K. Banerjee, R. K. Vasishta

Ocular myasthenia gravis co-incident with thyroid ophthalmopathy A. Yaman, H. Yaman

Three cases of recurrent epileptic seizures caused by Endosulfan S. Kutluhan, G. Akhan, F. Gultekin, E. Kurdoglu

Review Article Current Status of osmotherapy in intracerebral haemorrhage J. Kalita, P. Ranjan, U. K. Misra

Short Reports Cerebral salt wasting syndrome in a patient with a pituitary adenoma S. K. Singh, A. G. Unnikrishnan, V. S. Reddy, R. K. Sahay, S. K. Bhadada, J. K. Agrawal

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C O N T E N T S (Contd.)

Vol. 51 Issue 1

Recurrent intramedullary cervical ependymal cyst R. Chhabra, S. Bansal, B. D. Radotra, S. N. Mathuriya

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Carpal tunnel syndrome after 22 years of Colle’s fracture V. Goyal, M. Bhatia, M. Behari

Spontaneous subdural hematoma in a young adult with hemophilia D. Agrawal, A. K. Mahapatra

Occipital seizures presenting with bilateral visual loss S. Hadjikoutis, I. M. Sawhney

Phenylpropanolamine-induced intraventricular hemorrhage A. Prasad, K. K. Bhoi, K. Bala, K. S. Anand, H. K. Pal

Cauda-conus syndrome resulting from neurocysticercosis N. N. Singh, R. Verma, B. K. Pankaj, S. Misra

Stroke: A rare presentation of cardiac hydatidosis N. P. Singh, S. K. Arora, A. Gupta, S. Anuradha, G. Sridhara, S. K. Agarwal, P. Gulati

Intracranial aneurysmal bone cyst manifesting as a cerebellar mass S. Kumar, T. M. Retnam, T. Krishnamoorthy, S. Parameswaran, S. Nair, R. N. Bhattacharya, V. V. Radhakrishanan

Craniofacial surgery and optic canal decompression in adult fibrous dysplasia A. K. Mahapatra, P. K. Gupt a, R. R. Ravi

Letter to Editor Congenital toxoplasmosis infection Intracerebral schwannoma Unusual radiological picture in eclamptic encephalopathy Aseptic cerebral venous thrombosis associated with abdominal tuberculosis Oligodendroglioma causing calvarial erosion Congenital exostoses of the cervical vertebrae Brain abscess due to Streptococcus sanguis Carbamazepine induced immune thrombocytopenia Craniopharyngioma in an 82-year-old male Indian references in Neurology India Visual loss with papilloedema in Gullian-Barre- Syndrome

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Forthcoming Events

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Instructions for Contributors

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Neuroimage Dyke-Davidoff-Masson syndrome D. S. Shetty, B. N. Lakhkar, J. R. John

Tolosa- Hunt syndrome: MRI before and after treatment R. Koul, R. Jain


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Case Report

Paradoxical embolism through patent foramen ovale causing cerebellar infarction in a young boy Devidayal, B. R. Srinivas, A. Trehan, R. K. Marwaha Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

A previously healthy young boy who suffered an acute stroke involving superior cerebellar artery circulation is presented here. Echocardiography revealed a patent foramen ovale through which paradoxical embolism had probably occurred. Low dose aspirin was started and surgical closure was planned to prevent further recurrences. Key Words: Cerebellar infarction, Patent foramen ovale, Paradoxical embolism.

Cerebellar infarction occurs very rarely in children. Embolism from a cardiac source is implicated in about one-third of all patients younger than 40 years.1 With the advent of newer methods of echocardiography, paradoxical embolism through a patent foramen ovale (PFO) is increasingly recognized in association with embolic strokes 2-4 especially involving the superior cerebellar artery circulation.1 The communication describes a young child who suffered an embolic stroke. He had a PFO which probably allowed the embolus to reach the systemic circulation.

Case Report A 9-year-old boy was admitted with a history of weakness of left side of the body and unsteadiness of gait. A month prior to admission, after vigorous outdoor activity, he experienced sudden severe headache and giddiness followed by several bouts of vomiting which relieved his headache. The vomiting and headache continued intermittently. After 2 days, he was observed to be veering on either side whilst walking and had difficulty holding objects in his left hand. The unsteady gait and the weakness in the left hand started improving after 4-5 days. There was no seizure, unconsciousness, memory loss, dysarthria or bowel and bladder disturbance. He had hypertension for which amlodipine had been started by the primary care physician. His development had been normal. There was no family history of cerebrovascular accidents but his paternal grandparents and his father were hypertensive. Physical examination revealed a well-nourished child. The peripheral pulses were well palpable. The blood pressure ranged between 120-130/60-70 mm Hg in all four limbs. There was mild decrease in

muscle tone and grade IV/V power in left upper and lower limbs. There were cerebellar signs such as dysdiodokokinesia, positive finger-nose and knee-heel tests and mild gait ataxia. Cranial nerves and optic fundus examination were normal. Examination of the other systems was unremarkable. Complete blood count, serum electrolytes, renal and liver function tests, cholestrol and lipid profile were within normal limits. HBsAg and VDRL tests were negative. Screening tests for coagulation were normal. The urine examination showed no sediment and no proteinuria. Tests done to exclude a collagen-related disease or a vasculitis syndrome, namely lupus anticoagulant, rheumatoid factor, anticardiolipin antibodies, antineutrophilic cytoplasmic antibodies, LE cell and antinuclear factor were all negative. An ultrasonogram of kidneys and suprarenal structures, doppler studies of renal vessels, micturating cystourethrogram and dimercaptosuccinic acid renal scan showed no abnormality. Magnetic resonance imaging of the brain, done in the initial days of illness, had shown an area of abnormal hyperintensity on T2weighted and fast FLAIR (fluid attenuated inversion recovery) images involving the left cerebellar hemisphere which was hypointense on T1-weighted images. The rest of the brain parenchyma including the brainstem was normal. These findings were consistent with a fresh infarction involving the left cerebellar hemisphere in the vascular territory of the superior cerebellar artery (SCA). Magnetic resonance angiography done after 4 weeks, showed no abnormality of vessels. An echocardiogram, using colour doppler flow, revealed a small PFO with a left to right shunt. Thus, paradoxical embolism from a subclinical venous thrombosis was presumed to have occurred causing cerebellar infarct in the area supplied by SCA. Non-surgical transcatheter closure of PFO was initially planned but cost constraints compelled the parents to opt for a surgical closure at a subsequent date. He was started on low dose acetyl salicylate. At a 6 months follow-up he had no apparent neurological deficit.

Discussion Cerebellar infarctions are known to occur in approximately 1.5% of elderly patients with stroke.5 The incidence in the pediatric population is unknown. In one study, only 4.4% of 45 infants and children with cerebrovascular disorders, were found to have cerebellar infarction.6 The presumed causes

Dr. R. K. Marwaha Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India.


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Devidayal, et al: Paradoxical embolism and cerebellar infarction

include migraine, fibromuscular dysplasia, vertebral dissection with or without trauma, atlanto-axial subluxation, vigorous exercise and dehydration, embolism from the heart and unknown origin.1,7-9 As was seen in the present case, infarcts in the SCA territory are usually cardioembolic in origin.10 At least 42% of cerebellar infarctions occurring in the S CA circulation were attributable to cardiac source of embolism primarily from PFO and rheumatic heart disease.1 Patent foramen ovale is now increasingly recognized as an important source of paradoxical embolism in patients less than 55 years of age with cryptogenic strokes.2-4 The risk increases if PFO is associated with atrial septal aneurysm.3 It has also been suggested that PFO may be responsible for stroke more often than is usually suspected.2 Although PFO could be detected easily by conventional echocardiography in this child, the detection may be difficult at times. Transesophageal and contrast echocardiography can detect this abnormality in the majority of those in whom routine echocardiography is negative. 2-4 Even then, repeated trials are necessary if the first one is negative.10 The evidence of PFO in cryptogenic stroke should prompt a search for a subclinical venous thrombosis as the embolic source.2-4 In our patient, a diligent search for conditions associated with thrombosis, proved futile. It was, therefore, presumed that hard physical activity and dehydration were the predisposing factors to latent thrombosis. Closure of PFO is necessary to prevent further recurrences and avoid life-long anticoagulation.11 Although non-surgical closure by transcatheter technique seems ideal,12 the cost of the double umbrella device precludes the use of this option in a country with limited resources. Surgical closure can also be achieved with minimal morbidity.11,13 The medical treatment depends on the perceived cause of infarction. As aspirin may provide sufficient prophylaxis after initial ischemia,3 this was started in our patient. The long-term prognosis is favorable and the majority of patients survive their illness, although recurrences and rare deaths have been reported.1,14,15 Recurrences after surgery need

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further evaluation to identify causes other than paradoxical embolism.11 The propositus serves to highlight the need for extensive investigation of young children presenting with stroke. The identification of an underlying cause could lead to prompt institution of remedial measures to avoid further morbidity.

References 1. 2. 3.

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5. 6.

7. 8.

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14. 15.

Barinagarrementeria F, Amaya LE, Cantu C. Causes and mechanisms of cerebellar infarction in young patients. Stroke 1997;28:2400-4. Lechat P, Mas JL, Lascault G, Loron P, Theard M, Klimczac M, et al. Prevalence of foramen ovale in patients with stroke. N Engl J Med 1988;318:1148-52. Hanna JP, Sun JP, Furlan AJ, Stewart WJ, Sila CA, Tan M. Patent foramen ovale and brain infarct. Echocardiographic predictors, recurrence, and prevention. Stroke 1994;25:782-6. Klotzsch C, Janssen G, Berlit P. Transesophageal echocardiography and contrast-TCD in the detection of a patent foramen ovale:e xperience with 111 patients. Neurology 1994;44:1063-6. Macdonell RAL, Kalnins RM, Donnan GA. Cerebellar infarction:natural history, prognosis and pathology. Stroke 1987;18:849-55. Keiden I, Shahar E, Barzilay Z, Passwell J, Brand N. Predictor of outcome of stroke in infants and children based on clinical data and radiological correlates. Acta Pediatr 1994;83:762-5. Caplan LR. Migraine and vertebrobasilar ischemia. Neurology 1991;41:55-61. Deiz-Tejedar E, Munoz C, Frank A. Cerebellar infarction in children and young adults related to fibromuscular dysplasia and dissection of vertebrobasilar artery. Stroke 1993;23:763-6. Rosman NP, Wu JK, Caplan LR. Cerebellar infarction in the young. Stroke 1992;23:763-6. Terasaki T, Hino H, Hashimoto Y, Hara Y, Uchino M. A case of parado xical brain embolism in a 17-year old boy. Rinsho Shinkeigaku 1998;38:339-41. Dearani JA, Ugurlu BS, Danielson GK, Daly RC, McGregor CG, Mullany CJ, et al. Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events. Circulation 1999;100:171-5. Bridges ND, Hellenbrand W, Latson L, Filiano J, Newburger JW, Lock JE. Transcatheter closure of foramen ovale after presumed parado xical embolism. Circulation 1992;86:1902-8. Ruchat P, Bogousslavsky J Hurni M, FischerAP, Jeanrenaud X, von Segesser LK. Systematic surgical closure of patent foramen ovale in selected patients with cerebrovascular events due to paradoxical embolism. Early results of a preliminary study. Eur J Cardiothorac Surg 1997;11:824-7. Fowler M. Two cases of basilar artery occlusion in childhood. Arch Dis Child 1962;37:78-81. Heckmann JG, Handschu R, Huk W. Acute lethal stroke affecting all brain supplying arteries due to paradoxical embolism through a pataent foramen ovale. Cerebrovasc Dis 2000;10:164-7.

Accepted on 01.05.2001.
