Mirror Movements and Myelomeningocele: Report of A Single Case and Review of Literature

How to Cite This Article: IIbtihel Rébai I, Benrhouma H, Kraoua I, Drissi C, Ben Hammouda M, Gouider-khouja N. Mirror Movements and Myelomeningocele: Report of A Single Case and Review of Literature. Iran J Child Neurol. 2013 Summer;7(3):58-61. ObjectiveMirror movements (MM) have been described in several pathological conditions. Their association with neural tube defects is rare, and only 5 cases have been reported in literature to date. We report on a case of MM associated with cervical myelomeningocele, and we discuss the diffusion tensor imaging findings and the underlying mechanism. References1. Cohen LG, Meer J, Tarkka I, Bierner S, Leiderman DB,Dubinsky RM, et al. Congenital Mirror Movements. Abnormal organization of motor pathways in two patients. Brain 1991;114(Pt 1B):381-403.2. Rasmussen P. Persistent mirror movements: a clinicalstudy of 17 children, adolescents and young adults. DevMed Child Neurol 1993;35(8):699-707.3. Forget R, Boghen D, Attig E, Lamarre Y. Electromyographicstudies of congenital mirror movements. Neurology 1986;36(10):1316-22.4. Erdincler P. Cervical cord tethering and congenital mirrormovements: is it an association rather than a coincidence?Br J Neurosurg 2002;16(5):519–22.5. Odabasi Z, Gökçil Z, Kütükçü Y, Vural O, Yardim M.Mirror movements associated with cervical meningocele:case report. Minim Invas Neurosurg 1998;41(2):99–100.6. Erol FS, Topsakal C, Ozveren MF, Akdemir I, CobanogluB. Meningocele with cervical dermoid sinus tract presenting with congenital mirror movement and recurrent meningitis. Yonsei Med J 2004;45(3):568–72.7. Andrabi Y, Nejat F, El Khashab, Ashrafi MR. Mirror movement associated with neural tube defects. Neuropsychiatr Dis Treat 2008;4(6):1273–76.8. Avery LW, Rentfro CC. The Klippel–Feil syndrome. A pathological report. Arch Neurol Psychiat 1936;36:1068- 76.9. Gunderson CH, Solitaire GB. Mirror movements in patients with Klippel–Feil syndrome. Arch Neurol 1968;18(6):675–9.10. Tuch DS, Reese TG, Wiegell MR, Makris N, Belliveau JW, Wedeen VJ. High angular resolution diffusion imaging reveals intravoxel white matter fiber heterogeneity. Magn Reson Med 2002;48(4):577-82.11. Mamata H, Mamata Y, Westin CF, Shenton ME, Kikinis R, Jolesz FA, et al. High-resolution line scan diffusion tensor MR imaging of white matter fiber tract anatomy. AJNR Am J Neuroradiol 2002;23(1):67-75.12. Galléa C, Popa T, Billot S, Méneret A, Depienne C, RozeE. Congenital mirror movements: a clue to understandingbimanual motor control. J Neurol 2011;258(11):1911-9.

Bone wax causing a middle trunk plexopathy following vertebral artery injury: a neuroradiological pitfall

Abstract Background Bone wax is a hemostatic agent widely used in surgery. Since it is neither absorbed nor metabolized, its use remains risky and a potential cause of complications. Even though its MRI radiological characteristics are distinguishable, it is generally misinterpreted as postoperative hematoma or trapped air. We report the first case in literature of brachial plexopathy due to the compressive mass effect of bone wax and the main clues that led us to establish this diagnosis prior to its surgical resection. Case presentation A 20-year-old male, victim of stabbing presented with an open wound of the right latero-cervical region with a vascular injury of the V2 segment of the right vertebral artery on CT angiography. He was first admitted for bleeding from the neck uncontrollable with external pressure. The patient underwent an emergency surgical vertebral artery ligation. Forty-eight hours later, he reported a feeling of paresthesia of right arm with right-sided weakness. Neurologic examination revealed a motor deficit of the right triceps and wrist extensor muscles and absence of the triceps reflex. A postoperative compression of the C7 cervical root or the middle trunk of brachial plexus was initially suspected. A cervical MRI demonstrated a T1- and T2-weighted images well-defined right mass located laterally to the spinal cord in the epidural space at the level of C6–C7 vertebrae with a signal-intensity void on both sequences. T2*-weighted images showed no signal attenuation. It did not enhance after contrast administration. An epidural hematoma was less probable since acute hematoma is typically hypointense on T2*-weighted images. Computed tomography helped rule out residual postoperative air trapped in the epidural space based on the density study of the mass compared to air. Finally, a residual surgical foreign material used for packing during the procedure was suspected. The massive use of bone wax was ultimately confirmed by the surgeon and surgically removed with complete immediate postoperative recovery. Conclusions This case highlights the importance of a nuanced critical approach of neurosurgeons and neuroradiologists when interpreting postoperative neuroimaging scans of the spine. It is crucial to always consider foreign body-related complications and to review the per-operative procedure in details