Spontaneous spinal epidural hematoma in a toddler presenting with torticollis: case report and literature review

INTRODUCTION

Spontaneous spinal epidural hematoma (SSEH) is a rare entity, especially in toddlers and infants. The nonspecificity of its presenting symptoms in children may be a source of delayed diagnosis.

CASE DESCRIPTION

We report the case of a 20-month-old young boy without medical history who presented with irreducible torticollis, worsened a few days later by severe tetraplegia and respiratory distress. Spinal magnetic resonance imaging (MRI) showed a posterior epidural hematoma, extending from C3 to T1 and compressing the spinal cord. An urgent decompressive surgery via an extensive laminectomy and evacuation of the clot was performed. The patient demonstrated a partial neurological recovery on follow-up.

CONCLUSION

SSEH is a rare and serious condition that may compromise the functional and vital prognosis of the patient, hence the importance of prompt diagnosis and urgent treatment.

Ruptured intraventricular tuberculous brain abscess mimicking cystic neoplasm: a case report

Central nervous system (CNS) tuberculosis is a potentially life-threatening condition that may manifest in different forms and simulate other pathologies. It rarely involves the ventricles and the occurrence of primary intraventricular tuberculous brain abscess (TBA) has exceptionally been reported. As far as we know, ruptured intraventricular TBA has not been described before. An immunocompetent 56-years-old man was admitted for sub-acute intracranial hypertension with behaviour disorders. Cranial magnetic resonance imaging (MRI) showed a cystic lesion of the third ventricle containing fluid-fluid level with biventricular hydrocephalus and debris in the occipital horns. A ruptured cystic neoplasm was first considered. The patient underwent surgery via a right transcortical transventricular approach, combining both microscope and endoscope. The puncture of the lesion brought pus and the Ziehl-Neelson (ZN) staining demonstrated acid-fast bacilli. Intraventricular tuberculous abscess is an extremely rare condition that can take an unusual radiological appearance. This observation highlights the consideration of tuberculosis within the list of differential diagnosis of intraventricular cystic lesions in immunocompetent hosts.

Arachnoiditis Ossificans of the Lumbar Spine: A Rare Cause of Progressive Cauda Equina Syndrome

Arachnoiditis ossificans of the spine is a rare entity defined as an ossification of the leptomeninges resulting in neurologic decline. We describe the case of a 42-year-old woman, without any obvious predisposing factor, who presented with a progressive cauda equina syndrome. The imaging findings on magnetic resonance imaging were confusing by showing an atypical intraspinal lesion extending from L1 to S1. The computed tomography scan was more specific by showing suggestive images of a huge arachnoiditis ossificans of the lumbar spine. The patient underwent a large lumbar laminectomy with an incomplete resection of the ossified arachnoid. The histologic study confirmed the bony nature of the lesion. This illustrative case highlights the importance of helical computed tomography scan with multiplanar reconstruction for the diagnosis of arachnoiditis ossificans.

Unusual association of COVID-19, pulmonary tuberculosis and human immunodeficiency virus, having progressed favorably under treatment with chloroquine and rifampin

Infection with the new coronavirus has been declared an international health emergency. Its curative treatment is unknown and is the subject of several clinical trials. In addition, the concomitant association of COVID-19 with tuberculosis and the human immunodeficiency virus, hitherto never described, is potentially fatal. We report the illustrative case of a 32-year-old patient who presented this trifecta of infections and who did well under treatment with chloroquine and anti-mycobacterial drugs. This patient arrived at the ER with respiratory discomfort that had been evolving over a month with symptoms of flu and deterioration of her general condition. A chest CT scan revealed an aspect of lung miliary tuberculosis with isolation of Koch’s bacilli in the sputum. A polymerization chain reaction (PCR) was positive for COVID-19 on a nasopharyngeal swab. HIV serology was positive. The course was marked by a spectacular clinical improvement and two negative COVID-19 PCR controls at the end of treatment (at days 9 and 10). Anti-tubercular drugs (especially, rifampin) are powerful enzyme inducers that can reduce the effectiveness of chloroquine in our patient. This therapeutic success may be linked to the effect of anti-tubercular drugs against SARS ncov-2, especially rifampin, inhibiting the formation of messenger RNAs of SARS ncov-2 or to the synergistic effect of chloroquine and rifampin. Researchers should explore the effect of these drugs on SARS ncov-2.

[Uveitic glaucoma in Behçet's disease: When everything gets complicated]

INTRODUCTION

Behçet's disease is a systemic disease of unknown etiology. Its ocular manifestations are multiple and polymorphic, with uveitis at the top of the list. Classically, uveitis in Behçet's disease does not cause elevation of intraocular pressure. However, this may be found in 10 to 20% of cases, secondary to trabeculitis, trabecular obstruction by inflammatory cells, anterior or posterior synechiae, or induced by prolonged use of corticosteroids. Its occurrence is a major complication, the management of which is especially delicate when glaucoma occurs. The purpose of this study was to study the factors predictive of glaucoma in Behçet's disease.

MATERIALS AND METHODS

This is a retrospective study of all the charts of patients consecutively hospitalized for Behçet's disease over a period of 8years in the ophthalmology A department of the specialty hospital of Rabat university medical center.

RESULTS

Fifty patients were treated for Behçet's disease during the study period. There were 41 men (82%), and 9 women (18%). Glaucoma was diagnosed in 11 patients (22%). The mean age of this subgroup was 31years, with a gender ratio of 6 women/5 men. The glaucoma was associated with anterior synechiae in 4 cases, primary open-angle glaucoma in 5 cases, neovascular glaucoma in 1 case and seclusio pupillae in 1 case. Therapeutically, all patients were on glaucoma eye drops, and five underwent filtering surgery. Statistically, on univariate analysis, ocular hypertension was observed particularly in patients with low initial visual acuity (less than 1/10) (P=0.001), with severe posterior segment involvement, especially retinal vasculitis (29% vs. 6%, P=0.04), macular edema (40% vs. 4%, P=0.001), and optic disc edema (50% vs. 15%, P=0.02). A high number of recurrences was also associated with glaucoma (1.0 vs. 3.0, P<0.0001). On multivariate analysis, low baseline visual acuity, presence of retinal vasculitis, and high number of recurrences were independent risk factors for ocular hypertension in our patients followed for Behçet's disease.

CONCLUSION

Glaucoma can complicate the management of Behçet's disease. This glaucoma will be more difficult to manage in this delicate pathological context. It requires special vigilance in patients with severe posterior segment inflammation, to institute effective management to avoid its potentially blinding complications.

Awake Craniotomy with Functional Mapping for Glioma Resection in a Limited-Resource-Setting: Preliminary Experience from a Lower-Middle Income Country

BACKGROUND

Awake craniotomy with brain mapping aims to maximize resection of gliomas located within eloquent regions while minimizing the risk of postoperative deficits. This technique is common practice in the developed world but has yet to be implemented in most low- and middle-income countries (LMICs). We assessed the feasibility, safety, and efficiency of functional-based glioma resection using minimal facilities in a limited-resource institution.

METHODS

This is a retrospective review of patients harboring gliomas within eloquent regions who underwent awake craniotomy and tumor resection guided by cortico-subcortical mapping at a tertiary hospital of an LMIC. Patient characteristics, surgical results, and functional outcomes were studied.

RESULTS

Twenty consecutive patients with a mean age of 37 years were enrolled in the study. Seizure, present in 70% of patients, was the major presenting symptom. Eighteen patients had diffuse low-grade gliomas and 2 patients had high-grade gliomas. Intraoperative events were dominated by seizures, occurring in 5 patients (25%). The average extent of tumor removal was 89.5% and the rate of total and subtotal removal was 85%. New postoperative deficits were observed in 5 patients (25%), and permanent deficits were found in 1 patient (5%). The main hurdles encountered were the difficulties in investigating patients and human resource availability.

CONCLUSIONS

Awake craniotomy with brain mapping for functional-based resection of gliomas can be safely achieved in a limited-resource institution with good functional and oncologic results.

Acute Lumbar Spinal Subdural Hematoma Inducing Paraplegia After Lumbar Spinal Manipulation: Case Report and Literature Review

BACKGROUND

Traumatic spinal subdural hematoma is an extremely rare occurrence that requires urgent investigation and most often prompt intervention. To our knowledge, this is the first reported case related to a spinal manipulative therapy.

CASE DESCRIPTION

This report describes a case of traumatic lumbar subdural hematoma after a spinal manipulative therapy without any predisposing factor. A 23-year-old man was admitted to the emergency department for partial cauda equina syndrome after a spinal manipulation performed by a physiotherapist. Magnetic resonance imaging showed an acute spinal subdural hematoma at L2-L3 level with cauda equina compression. The patient underwent an emergency L2 laminectomy with evacuation of the hematoma. He recovered completely his neurologic functions after 1 week.

CONCLUSION

Practitioners of spinal manipulations should be aware of spinal subdural hematoma as a possible complication. A rapid diagnosis with magnetic resonance imaging is mandatory, and emergency surgical decompression is usually the optimal treatment for spinal subdural hematomas with severe neurologic deficit.

Nasofrontal surgical reconstruction by external table flap of frontal bone following removal of a dermoid cyst revealed by a fistula: A case report and review of the literature

Nasofrontal fistulas correspond to the persistence of an abnormal communication of embryological origin between the deep layer of the skin and the central nervous system (CNS). They can rarely be associated with a dermoid cyst and be revealed by a locoregional infection, and especially neuromeningeal infections can be serious. The treatment is mainly surgical by performing a total excision of the cyst and the repair of defects. The authors report the case of an 18-month-old infant operated for a dermoid cyst revealed by a nasofrontal fistula. They insist on the characteristics of this pathology in order to establish a diagnosis and an early treatment to avoid the complications that can be heavy in certain cases. They describe the steps of nasofrontal reconstruction by a small flap taken from the outer table of the frontal bone with better esthetic results.

Penetrating head trauma: 03 rare cases and literature review

Penetrating head trauma (PHT) include all open head injuries with foreign object in the brain. Although less common than closed head trauma, penetrating head trauma carry a worse prognosis. We received three unusual cases of penetrating head injuries whose prognosis was different according to clinical presentation and initial management of the patient. Treatment of penetrating head trauma aims at controlling bleeding, controlling intracranial pressure and preventing infections. Despite the efforts made by national authorities as well as the adequate management in hospitals, penetrating head injuries are still frequent with significant mortality and morbidity.

[Prognostic factors in uveitis]

PURPOSE

To evaluate prognostic factors of vision loss among patients with uveitis.

MATERIAL AND METHODS

This descriptive and retrospective study included all patients diagnosed with uveitis who were seen at the teaching hospital of Rabat, Morocco, over a 5-year period. Information regarding demographic data, uveitis type, bilaterality of the disease, etiology and complications were gathered from patients' records. Statistical analysis was performed using SPSS software.

RESULTS

One hundred and thirty-nine eyes of 89 patients were included. There were 60.7 % men and 39.3 % women. The mean age (years) was 31.1±16.8. Median follow-up was 11 months. Median visual acuity (logMAR) on admission was 1.7 [0.7-2] and 1 [0.4-1.7] on the last visit (P<0.001). Fifty-nine percent of eyes had final visual acuity (VA) equal to or less than 1/10. Panuveitis (85.4 %) and posterior uveitis (72.7 %) were responsible for final VA equal to or less than 1/10 (P<0.001). Cataract, posterior synechiae, vitreous opacities, epimacular membrane (ERM) and cystoid macular edema (CME) were the most frequent complications. Using multivariate logistic regression, the prognostic factors associated with severe vision loss were the type of uveitis (posterior and panuveitis), CME, ERM, macular scarring and optic atrophy (P<0.05).

CONCLUSION

Although this study included a limited number of subjects, the results showed that final VA was equal or less than 1/10 in 59 % of eyes diagnosed with uveitis and was associated with risk factors including posterior segment involvement (panuveitis and posterior uveitis), CME and ERM.

[Prevalence of exfoliation syndrome and cardiovascular diseases in patients scheduled for cataract surgery]

PURPOSE

To study the prevalence of exfoliation syndrome (XFS) and its association with cardiovascular disease in patients scheduled for cataract surgery.

MATERIAL AND METHODS

This is a retrospective, single center, descriptive study of 260 patients admitted to a tertiary teaching hospital in Rabat, Morocco, between January 2015 and March 2016 and scheduled for cataract surgery. All patients had a preoperative cardiovascular exam, an electrocardiogram and, if needed, echocardiography. Statistical analysis was performed using SPSS software. Results with a P-value<0.05 were considered statistically significant.

RESULTS

This study included 246 patients: 146 women (59.3 %) and 100 men (40.7 %). The mean age (years) was 67.6±10.1. The percentage of XFS increased with age (P=0.02). Sixty-two percent of patients with cardiovascular disease also had exfoliation syndrome (P<0.001). Patients with XFS had hypertension in 46.5 % of cases. 14 subjects (19.7 %) had ischemic heart disease and XFS. Using multivariate logistic regression and after adjusting for age, diabetes mellitus, hypertension, ischemic heart disease and arrhythmias, smoking was the only factor associated with exfoliation syndrome (P=0.01, odds ratio=5.2, confidence interval 95 %=1.35-20.15).

CONCLUSION

Exfoliation syndrome is a common condition in the aging cataract population. Ischemic heart disease and hypertension are frequently associated with XFS. Smoking could be another factor associated with this syndrome.

Foramen magnum meningioma's management: the experience of the department of neurosurgery in Marrakesh

Our study is a retrospective analysis of the clinical data, surgical outcomes, histological finding and prognosis of foramen magnum meningiomas through a serie of 8 cases operated at the department of neurosurgery at Mohammed VI medical university hospital, Marrakesh. From January 2002 to December 2015. There were 3 male and 5 female patients (mean age, 46.75 years). Cervico-occipital pain (100%) and motor deficit (100%) were the most common presenting symptoms. MRI was the most appropriate diagnostic tool in visualizing tumors of this region. All operations were performed by the posterior approach and gross total resection was achieved in 7 cases. Surgical mortality was 20%. 3 other patients had complications like CSF leak (25%), meningitis (12,5%) and transient worsening of neurological deficit (12.5%) but made neurological recovery later. Foramen magnum meningiomas have long been regarded as difficult lesions both in terms of diagnosis and management. However, with the availability of MR imaging, newer surgical techniques and skull base exposures, the excision of these lesions is becoming easier and safer.

Epilepsy: unusual presentation of cerebral hydatid disease in Children

Cerebral hydatid disease is very rare, representing only 2% of all cerebral space occupying lesions even in the countries where the disease is endemic. Intracranial hydatid cysts are more common in children and occur more frequently in the supratentorial space. The aim of this paper is to describe the characteristic features of computed tomography (CT) and magnetic resonance imaging (MRI), and to determine the clinical presentation and surgical outcome of cerebral hydatid disease. A 7-year-old girl was admitted to the emergency department because of an epileptic attack. On radiological examination a round, cystic lesion appeared in the parietal lobe and caused shift of the midline structures. The cyst was successfully removed using the dowling technique. The postoperative period was uneventful and seizures were not seen during follow up. Hydatid cyst of the brain presents clinically as intracranial space occupying lesion and is more common in children, it is well demonstrated by CT and MR examinations, and Surgery is the treatment option with affordable morbidity and low mortality.

[Hemangiopericytoma of the cerebellopontine angle: case report and review of literature]

Les hémangiopéricytomes primitifs du système nerveux central sont rares et représentent moins de 1% des tumeurs intracraniennes. La localisation au niveau de l'angle ponto-cerebelleux est très rare, pouvant simuler un neurinome de l'acoustique ou un méningiome. Le diagnostic de certitude est basé sur l’étude histologique et immunohistochimique. Notre but est d'illustrer avec une revue de la littérature les aspects clinico-radiologiques, anatomopathologiques et la prise en charge thérapeutique de ce type de lésion.