Tuberculous meningitis: neuroimaging features, clinical staging and outcome

Forty-two patients diagnosed with tuberculous meningitis in Kuala Lumpur Hospital based on clinical criteria, cerebrospinal fluid analysis and response to antituberculous treatment over a seven year period were included in this study. Relevant information was obtained from pa-tients’ medical case notes and neuroimaging findings were evaluated. The clinical presentation of pa-tients was staged according to Medical Research Council for tuberculous meningitis. Fisher’s Exact Test was used to determine the correlation between the neuroimaging features, clinical staging and outcome of patients. 52.4% of patients had stage 2 disease, 28.6% stage 3 and the remainder stage1 disease. 95.2% of patients had various neuroimaging abnormalities and only 4.8% had normalneuroimaging findings. The commonest neuroimaging findings were hydrocephalus and meningealenhancement. 47.6% of patients survived without any complication. 23.8% developed morbidity ei-ther with minor or major neurological deficit and 28.6% had died at the end of the study period.Among patients with negative neuroimaging findings, one died and another one survived withoutany complication. Among patients with abnormal neuroimaging findings, 25% developed morbidity,27.5% died and 47.5% survived without complication. The only neuroimaging feature significantlycorrelated with clinical outcome was the presence of hydrocephalus. Therefore, hydrocephalus isimportant in the prognosis of the disease and should be considered an indicator of poor clinical out-come. There was no significant correlation between clinical staging and clinical outcome, nor wasthere a significant correlation between clinical staging and individual neuroimaging feature

Reversible splenial lesion syndrome in neuroleptic malignant syndrome.

Background: Reversible focal lesions in the splenium of the corpus callosum (SCC) or reversible splenial lesion syndrome are rare and little is known about their pathophysiology. Case summary: The authors describe a case of a 65-year-old female who presented with fever, abnormal behaviour and mild hypernatremia. She was on neuropsychiatric treatment for bipolar disorder but denied any history of seizure. After an extensive workout to exclude infection, a clinical diagnosis of neuroleptic malignant syndrome (NMS) was made. Initial magnetic resonance imaging (MRI) of the brain showed a lesion in the SCC characterized by high-signal intensity on T2-weighted and FLAIR sequences with reduced signal intensity on T1-weighted sequence. Diffuse weighted imaging (DWI) showed restricted diffusion. There was no enhancement following Gadolinium administration. The follow-up MRI 8 weeks later showed complete resolution of the SCC lesion. Conclusion: While the pathophysiology of reversible SCC lesions is still unclear, this case highlights the need to consider NMS in the differential diagnosis of reversible splenial lesion of the corpus callosum

The Spetzler-Martin grading system and management of patients with intracranial Arteriovenous malformation in a tertiary referral hospital

Introduction: An arteriovenous malformation (AVM) is an abnormal collection of blood vessels in which arterial blood flows directly into the draining vein without the normal interposed capillaries. The Spetzler-Martin grading system has been widely accepted worldwide to estimate the pretreatment risks and predict the outcome of patients with intracranial AVM. In Malaysia, we still do not have the baseline data of this grading system. Methods: A total of 33 patients from a tertiary referral hospital diagnosed with intracranial AVM based on neuroimaging findings over a 4-year period were studied. Medical records were traced and neuroimaging findings were analysed. The AVMs were graded according to the Spetzler-Martin grading system and Fisher’s exact test was used to assess statistical difference between the grades of the AVM and management plan for the patients. Results: Four patients were graded as Grade 1, 9 patients as Grade II, 10 patients as Grade III, 6 patients as Grade IV and 4 patients as Grade V. Ten patients were treated conservatively; six patients underwent surgery and embolisation respectively. Four patients underwent radiosurgery and a combination of embolisation while surgery and radiosurgery were given to 5 patients and 2 patients respectively. Statistically significant difference (p=0.016) was found between the Spetzler-Martin grading system and the management of intracranial AVMs. Conclusion: The management decision was not made based on the grading of the AVMs. It is recommended that all AVM patients be routinely graded according to this system prior to treatment. Keywords: Intracranial arteriovenous malformation

An unusual cause of blepharospasm

We describe a rare case of multiple dilated Virchow-Robin spaces in the brainstem in a patient presenting initially with blepharospasm with subsequent spread to involve the face and neck. On magnetic resonance imaging (MRI), these lesions demonstrated an isointense signal to cerebrospinal fluid on all sequences with no mass effect or enhancement. Although rare, this condition should be considered part of the differential diagnosis when evaluating cystic abnormalities in the brainstem. This is the first reported case of blepharospasm with subsequent orofacial and neck dystonia caused by dilated Virchow-Robin spaces. The imaging findings and differential diagnoses are discussed

Central nervous system intravascular lymphoma in a Malaysian.

Intravascular lymphoma (IVL) is a rare subtype of extranodal diffuse large cell lymphoma, characterized by intravascular proliferation of B or T lymphocytes within small blood vessels; which may lead to occlusive symptoms, its neurological involvement has been said to be uncommon among Asians. 1 We describe a Malaysian with central nervous system IVL, to demonstrate that IVL is an important differential diagnosis in diffuse brain pathology also among Asians