Variety in magnetic resonance imaging of enlarged perivascular space: Case reports

Introduction: Expansion of perivascular spaces leads to tissue damage in the surrounding parenchyma. Enlarged perivascular spaces (EPS) have been long regarded as benign and normal variants, and have been subject to little investigation. We report three cases of EPS in unusual locations with their typical findings and clinical symptoms as consideration to differentiate them from other brain lesions.

Case presentation: The first case was a 64-year-old woman presenting with vertigo, vomiting, and shoulder stiffness.  The second case was a 25-year-old woman who worked as an agricultural trainee who complained of intermittent headaches 3 years before admission.  The third case was a 42-year-old woman with dizziness and recurring headache. The MRI finding in T1 flair was a hypointense, which was surrounded by a hyperintensity wall. T2WI revealed a hyperintensity in the superior temporal lobe, with no pathological finding to prove an ischemic or infarction process in Diffuse Weighted Imaged (DWI) and Apparent Diffusion Coefficient (ADC) images.

Conclusion: These 3 locations in our case reports should be one of consideration for diagnosing an EPS with its typical feature. A routine MRI study is needed to follow up progressivity of EPS.

Keywords: enlarged perivascular space, magnetic resonance imaging, Virchow-Robin space

Correlation of vestibular schwannoma tumor with facial nerve weakness, hypoesthesia of face, and disequilibrium

Introduction: Vestibular schwannoma is the most common lesion in the cerebellopontine angle. Some of the most common symptoms arise as the tumor grows bigger such as disequilibrium, hypoesthesia of the face, and facial nerve paresis. Based on the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the Consensus Meeting on Systems for Reporting Results in Acoustic Neuroma, there is still no clarity of a single method used to measure the tumor itself.

Methods: This was a retrospective study to analyze the correlation between the size (anteroposterior and mediolateral) of the vestibular schwannoma with disequilibrium, hypoesthesia of the face, and facial nerve paresis among the patients in the Neurosurgery Department of Hasan Sadikin Hospital Bandung from January 2014 to December 2019. The data was analyzed using Spearman and Binary Logistic Regression.

Results: A total of 58 patients were included in this study with median age was 43 years, ranging from 21 – 72 years. The most common symptoms were disequilibrium (48.27%), followed by facial nerve paresis (39.65%) and hypoesthesia of face (20.68%). The mean anteroposterior size was 3.8 ± 1.17 cm and the mean mediolateral size was 3.0 ± 1.01 cm. There were significant correlation between disequilibrium with anteroposterior size (r = 0.385; p = 0.003) and mediolateral size (r = 0.409; p = 0.001). There were also significant correlation between facial nerve paresis with anteroposterior size (r = 0.458; p = 0.000) and mediolateral size (r = 0.321, p = 0.014).

Conclusion: There were significant correlations between the anteroposterior and mediolateral size of the tumor with the occurrence of disequilibrium and facial nerve paresis in patients with vestibular schwannoma.

Keywords: diameter, disequilibrium, facial nerve paresis, hypoesthesia of the face, vestibular schwannoma

Risk factors of mortality due to traumatic brain injury in Marsidi Judono general hospital, Belitung, Indonesia

Introduction: Traumatic brain injury (TBI) is a global problem and the biggest cause of mortality and disability of all trauma cases. This study aimed to determine the characteristics and relationship between risk factors for TBI and its impact on mortality and also to provide epidemiological data related to TBI in Belitung regency.

Methods: A retrospective study was conducted using secondary data from the medical records of participants who met the inclusion and exclusion criteria at dr. H. Marsidi Judono General Hospital Belitung from January to December 2019. Data were analyzed as univariate, bivariate, and multivariate using binary logistic regression.

Results: Two hundred and seventy patients were included in this study. Men were more likely to have a TBI than women in all categories (65.9%). The adolescent age group (33.7%) followed by adults (31.5%) were the largest contributors to TBI. Road traffic accident cases (86.7%) dominated the incidence of TBI. The use of headgear was still lacking (36.7%) while cases of road traffic accidents were high. The use of ambulances was lacking (10.4%) compared to other vehicles. A total of 119 patients (44%) were hospitalized in either the general ward or ICU with an average length of hospitalization was 3 days. Of all TBI cases, the mortality rate was 11.9%. People with older age have a higher mortality rate compared to other age categories (OR 1.052; 95% CI: 1.001 – 1.106).

Conclusion: The mortality rate due to TBI reaches 11.9% in this region, with age as a statistically significant predictor of mortality due to TBI. Older patients tend to have a higher likelihood of death due to TBI. The data obtained can be used by general practitioners, disease preventative planners, and policymakers to reduce mortality due to TBI in Belitung regency.

Keywords: Belitung, risk factors of mortality, road traffic injury, traumatic brain injury

Profile of the brain arteriovenous malformation at National Brain Center hospital in 2015 – 2016: Epidemiological study

Introduction: Brain arteriovenous malformation (AVM) is a congenital vascular lesion in which arterial blood flows directly into draining veins without capillary networking. The estimated incidence rate is approximately 1 case for 100,000 people a year. Clinical presentations are headache, seizure, neurological deficit, and others that are caused by space-occupying lesions. The treatment of brain AVM consists of microsurgery resection, embolization, stereotactic radiosurgery to conservative treatment.

Methods: The design of the study was a descriptive non-analytical study. Data were taken from patients' medical records, radiological records, and catheter lab data records at National Brain Center Hospital in 2015 – 2016.

Results: There were 32 patients with AVM. The characteristics of brain AVM in our study were mostly men (62.5%), productive age ranging from 20 – 29 years (31.25%), manifested as seizure (43.75%), presence with Glasgow Coma Scale (GCS) score 15 (87.5%), and rupture of brain AVM nidus (59.38%).

Conclusion: Brain AVM predominantly occurred at a young age and the management varied on the Spetzler-Martin grading. In addition, the likelihood of rupture was influenced by the characteristics of the lesion, such as size, age, location of the nidus, and history of rupture of brain AVM nidus.

Keywords: brain arteriovenous malformation, epidemiology, profile

Non-powder lateral penetrating craniocerebral gunshot wound in a 10-year-old girl: A case report

Introduction: Non-powder lateral penetrating craniocerebral gunshot wounds (PCGW) is one of the lethal types of penetrating head injury. The mortality rate is higher in adults than in pediatric populations and influenced by the clinical and radiologic findings as to the important predictors for prognostication in patients with PGCW.

Case presentation: A 10-year-old girl presented with a gunshot wound to the head 1 day prior. She was accidentally shot by her brother with an air gun from approximately 2 feet from the gun barrel. She develops a loss of consciousness for 30 minutes and weakness over the left arm. On physical examination, the Glasgow Coma Scale (GCS) was E3V5M6, weakness on the left arm, and an entrance wound over the right temple without an exit wound. The skull X-ray showed the pellet fragment and the computed tomography (CT) scan showed the bullet track starting from the right frontotemporal towards the left parietooccipital region, damaging both hemispheres with associated intraventricular hemorrhage (IVH). She was undergone a craniotomy procedure to remove the bullet fragment, debridement of the necrotic tissue, and evacuate the blood clot over the bullet track. The patient was discharged after postoperative day 7 with good recovery of neurological function and good GCS and Glasgow Outcome Scale (GOS) score. After 6 months of follow-up, neither a new deficit nor other signs and symptoms were developed.

Conclusion: Non-powder PCGW can cause significant damage to the intracranial compartment, despite its low velocity. The mortality rate in pediatrics is lower than in the adult population. The management mandated an urgent surgical procedure to remove any blood clot and debridement of any foreign bodies encountered. Such complications in the short- or long term can be developed in any patient and should be treated expectantly.

Keywords: guns, neurosurgery, non-powder firearms, pediatric, traumatic brain injury

Silicone hypersensitivity necessitating removal of ventriculoperitoneal shunt in schizencephaly patient complicated with hydrocephalus: A case report

Introduction: Allergic reaction to shunt material is rarely encountered. We report a case of hypersensitivity to silicone-based shunt material that did not subside with corticosteroid which required shunt removal.

Case presentation: A 5 years old child with spastic quadriplegic cerebral palsy was brought to our ER due to loss of consciousness. Physical examination revealed anisocoria of the pupils (2 mm / 7 mm) and Glasgow Coma Scale score of E2VxM3. Head computed tomography (CT) scan showed a fluid collection in the frontotemporal region and the appearance of schizencephaly.

Conclusion: Allergic reaction to silicone in ventriculoperitoneal shunt material is extremely rare. Polyurethane-based tubes are usually used as a substitution for silicone tubes. However, these tubes were not available and were not covered by insurance in Indonesia. Ventriculostomy is another option for selected cases.

Keywords: schizencephaly, silicone hypersensitivity, ventriculoperitoneal shunt