Acute Paraparesis Research Articles

Letter to the Editor: Commentary on Acute Paraparesis Caused by Spinal Epidural Fluid After Balloon Kyphoplasty for Traumatic Avascular Necrosis: A Case Report (Korean J Neurotrauma 2023;19:398-402).

Letter to the Editor: Commentary on Acute Paraparesis Caused by Spinal Epidural Fluid After Balloon Kyphoplasty for Traumatic Avascular Necrosis: A Case Report (Korean J Neurotrauma 2023;19:398-402).

Traumatic Brain Injury and Guillain-Barré Syndrome: Tale of an Illicit Affair—Case Report and Brief Review of Literature

AbstractGuillain-Barré syndrome (GBS) is a common entity in neurology clinics. A variety of etiologies have been implicated in the presentation of GBS. Although rarely reported, traumatic brain injury (TBI) has also been reported to cause GBS. In this article, we report a similar case of GBS that occurred following TBI and the patient presented with acute flaccid paraparesis with intact strength in upper limbs. Paraparesis progressed to quadriparesis simulating a case of spinal injury, without any correlating imaging findings. Nerve conduction study findings, cerebrospinal fluid studies, and clinical examination led to the diagnosis of post-TBI GBS. A review of similar cases reported in literature is also attached. High index of suspicion should be maintained for GBS in all cases of imaging-negative post-TBI limb weakness which may simulate acute spinal injury.

Hyperintensity in Bilateral Posterior Limbs of Internal Capsule Due to Hypernatremia

Abstract Purpose: Osmotic demyelination syndrome is usually caused by rapid correction of hyponatremia but sometimes develops from acute severe hypernatremia. Studies suggested that serum sodium increasing at the rate of <6~8 mmol/L in 24 hours has a low risk of osmotic demyelination syndrome, but sometimes exceptions present. Aside from the classical sites of involvement, such as pons and basal ganglia, internal capsules are rarely affected. We report a case with acute paraparesis caused by acute hypernatremia-induced extrapontine myelinolysis involving the posterior limbs of bilateral internal capsules. Case: A 54-year-old man was admitted for aseptic encephalitis and moved to the intensive care unit due to poor consciousness and respiratory failure. Although cerebrospinal fluid pleocytosis was improved later, acute hypernatremia due to partial diabetes insipidus developed. He presented acute paraplegia two days later with a negative result on the whole spine MRI. Although the increasing rate of serum sodium did not exceed the recommended safety range, the extrapontine myelinolysis involving posterior limbs of the bilateral internal capsule, as long as the corpus callosum, still developed. The patient regained partial walking ability after one year. Conclusion: This case report extends the spectrum of classical osmotic demyelination in clinical manifestations, image findings, and the causal range of electrolyte derangements.

COVID-19 Associated Longitudinal Extensive Transverse Myelitis with Cerebral Spinal Fluid SARS-CoV-2 Detection

There have been multiple reports of COVID-19 associated neurological symp-toms, including several cases of para-infectious myelitis.We report a case of an 84-year-old male patient presenting with acute paraparesis coinciding with active mild COVID-19 pneumonia. Spinal cord magnetic resonance imaging (MRI) showed longitudinally extensive transverse myelitis (LETM) affecting the entire cervical cord to the tenth thoracic level, and cerebral spinal fluid (CSF) was positive for SARS-CoV-2. The patient was evaluated for other causes of LETM, which were convincingly excluded. He was treated with steroid pulses and plasmapheresis, with significant imaging improvement. The patient has since made a good recovery, being now able to walk unassisted. Although several instances of COVID-19 associated myelitis have been reported, positive identification of the virus in CSF is rare. The identification of viral material may support the hypothesis of direct spinal cord infection in co-occurrence with a para-infectious inflammatory reaction.

Acute reversible paraparesis secondary to cerebral aneurysm: An unusual presentation

Acute reversible paraparesis secondary to cerebral aneurysm: An unusual presentation

Recurrent Hypokalemic Paresis–A Possibility of Liddle-Gitelman Overlap

Hypokalemia can occur due to various causes that have diverse manifestations varying from mild asthenias to acute onset paraparesis to life-threatening cardiac arrhythmias. A proper algorithmic evaluation for hypokalemia can help us identify various correctable causes and can be life-saving. Here, we discuss a case of 35-year-old hypertensive female who had presented as a case of acute onset flaccid paraparesis. We have further discussed our approach in reaching her diagnosis and stressed upon importance of algorithmic approach in the evaluation of patients presenting with recurrent hypokalemia. It may help in unmasking a rarer cause.

Dorsal Dermal Sinus with Intramedullary Epidermoid Cyst in a Toddler: A Tiny Clue to Underlying Major Neurological Condition

Background: Skin dimples at specific sites of the body at birth are a clue to underlying congenital malformation and intimate the need for extensive evaluation. A midline dimple in the spinal region may be a sign of occult spinal dysraphism in a neonate. Methods: A toddler presented with clinical symptoms and signs of acute paraparesis. The child also had thoracic dermal sinus on clinical examination. The child was evaluated with hematological and radiological investigations to diagnose the cause of acute paraparesis. Results: Hematological investigations were normal. Magnetic resonance imaging of the spine showed an intramedullary epidermoid cyst at the D1 vertebral level to D4 vertebral level with dorsal dermal sinus at the D3 vertebral level. Conclusion: We are reporting this case to insist on clinical examination of all neonates for skin dimples and detailed evaluation of neonates with suspicious skin dimples to prevent future neurological disability. A clinically significant skin dimple implies impending neurological problems in a patient.

Acute Paraparesis Syndrome after a Ruptured Aneurysm of the Azygos Anterior Cerebral Artery (P12-5.016)

<h3>Objective:</h3> To describe a rare case of acute paraparesis syndrome (APS) after a ruptured aneurysm of the azygos anterior cerebral artery (ACA). <h3>Background:</h3> The incidence of APS within 24 hours after subarachnoid hemorrhage is very rare. Additionally, the pathophysiology of this syndrome remains poorly defined. Nonetheless, the literature suggests it could emerge from a bilateral ACA vasospasm, acute hydrocephalus, or global cerebral edema and can be associated with poor clinical status. The azygos ACA is a rare variant whose unique anatomy intensifies the hemodynamic stress on the arterial wall, making aneurysm formation closely associated with this anomaly. <h3>Design/Methods:</h3> A 72-year-old man with a past medical history of hypertension presented to the hospital with the complaint of acute paraparesis after a thunderclap headache and transitory loss of consciousness. The physical exam showed paraparesis with brisk patellar and Achilles reflexes and a neutral response to bilateral plantar stimulation. No abnormalities were noticed on the cranial nerves, coordination, and sensory examination. <h3>Results:</h3> Routine laboratory studies were normal. Brain computed tomography revealed an acute punctate hemorrhage of an aneurysm located in the frontal interhemispheric fissure. Magnetic Resonance Imaging (MRI) of the spine was unremarkable. Brain MRI showed unspecific white matter abnormalities, and an MR angiography showed a 4.3 mm saccular aneurysm in the right ACA A3 segment in the bifurcation of an azygos ACA. The patient underwent coiling of the aneurysm and was able to walk unassisted nine weeks after the procedure. <h3>Conclusions:</h3> Acute paraparesis syndrome is a rare manifestation of a ruptured anterior communicating artery or anterior cerebral artery aneurysm. Here, we present an atypical etiology of APS caused by a ruptured aneurysm of the azygos ACA. To the best of our knowledge, this is the first description of an APS after a ruptured aneurysm of the azygos ACA. <b>Disclosure:</b> Dr. Moreno-Zambrano has nothing to disclose. Dr. Jimenez Zambrano has nothing to disclose. Jose Francisco Ortega Tola, MD has nothing to disclose. Dr. Yepez has nothing to disclose. Wilson Cueva has nothing to disclose.

A Case of Takayasu Arteritis Presenting with Sensorineural Hearing Loss as First Manifestation

We report the case of a 26-year-old male patient diagnosed with Takayasu arteritis after 4 years of first manifestation. He developed sensorineural hearing loss in left ear, followed 2 years later by acute onset paraparesis and hypertension, and followed another 2 years later by short duration of upper backache, chest pain, palpitations, and breathlessness. On examination, he had hypertension without any significant blood pressure (BP) difference within arms with all peripheral pulses palpable. Diagnosis confirmed with computerized tomography aortography showing multifocal wall thickenings in entire aorta. In our case, the first presentation was otological followed 2 years later by hypertension. Our report points toward fact that hypertension, though the most common, may not be the first manifestation and characteristic examination finding of BP difference, and pulselessness may not be seen in all cases. High risk of suspicion and early use of specific investigation in cases of multisystem involvement in young hypertension are crucial for timely diagnosis.

Ischemic myelomalacia and closed spinal dysraphism in multiple finishing swine.

Ischemic myelomalacia secondary to fibrocartilaginous emboli (FCE) is an idiopathic disease in humans and animals. On the other hand, congenital spinal cord malformations result from neural tube defects in fetal development (ie, spinal dysraphism), with structural anomalies referred to collectively as myelodysplasia. Spinal dysraphisms are frequently accompanied by skin and vertebral abnormalities because of the embryogenic relationship. In this observational case study, we report the pathologic findings of 13, 18- to 24-weeks-old pigs from a large conventional operation that presented with acute paraparesis. Ischemic myelomalacia secondary to FCE was observed in 5 of 13 examined pigs. Congenital spinal cord malformations located between the caudal thoracic and sacral spinal cord were identified in 7 pigs, with structural abnormalities that ranged from diplomyelia/split cord malformation to segmental spinal dysgenesis (myelodysplasia) to caudal agenesis. Concurrent myelomalacia and congenital spinal cord malformations in the same or different sites were noted in 2 pigs. No spinal lesion was observed in 3 pigs. Although gross vertebral abnormalities were not observed herein, intervertebral instability due to minor defects in the articular facets, as well as other unidentified factors, is suspected to contribute high incidence of FCE. It is likely that these congenital malformations were previously underdiagnosed or are possibly new conditions associated with continuous inbreeding and genetic improvement in the modern swine industry.

A Rare Scenario of Acute Traumatic Thoracic Disc Herniation and Review of the Literature

Background and Importance: Sequestrated thoracic disc herniation after a traumatic event without an apparent spinal fracture or dislocation is an extremely rare scenario. Case Presentation: Evaluation of an elderly female with acute paraparesis secondary to a fall down to the ground revealed a right-sided extruded disc at the level of T10-T11. At 6-month follow-up, she made a dramatic recovery following an appropriate surgical intervention. Conclusion: With occurrence of acute paraparesis following a traumatic event, MRI of the vertebral column is necessary, even in the absence of tomographic evidence of fracture-dislocation.

Thyrotoxic periodic paralysis. A case report

In 19-26% of patients hospitalized with suspected stroke, the cause of neurological symptoms are not cerebrovascular diseases. In this case of newly diagnosed thyrotoxic periodic paralysis we presented the clinical, laboratory and instrumental features of the disease. The search for the cause of periodic paralysis allowed to identify an endocrinological disease - diffuse toxic goiter, prescribe antithyroid therapy. The data of prospective patient observation are presented. We discussed a differential diagnostic range of diseases with acute low paraparesis, including rupture of an aneurysm of the anterior communicating artery, bilateral infarction in territory of anterior cerebral arteries, thrombosis of upper sagittal sinus, acute spinal strokes and Guillain - Barre syndrome. The need to include thyrotoxic periodic paralysis in patients with acute lower paraparesis in the differential diagnostic series is substantiated.

Acute paraparesis during surfing: the perils of riding the wave

A 47-year-old man presented to the emergency department with atraumatic acute onset lumbar back pain while attending a surfing lesson at an artificial wave lake. It occurred when transitioning from a prone position, with a hyperextended back, to standing on the surfboard, a manoeuvre known as ‘

Tenofovir-induced distal renal tubular acidosis: A rare cause of recurrent hypokalaemic paralysis

Tenofovir disoproxil fumarate was the first nucleotide analogue reverse transcriptase inhibitor to be approved for treatment of human immunodeficiency virus infection. It is a relatively safe drug but can present with nephrotoxicity. We report a case of 36-year-old male who presented with acute onset flaccid paraparesis. He was a diagnosed case of acquired immunodeficiency syndrome for 9 years ago and was on tenofovir-based antiretroviral therapy for last 6 months. As the patient had normal anion gap metabolic acidosis, hypokalaemia and urine pH > 5.5, distal renal tubular acidosis (RTA) was suspected. He improved dramatically within 24 h of hospitalisation after potassium correction to regain normal power. Tenofovir-induced distal RTA presenting as hypokalaemic paralysis is a very rare complication of tenofovir; hence, we are reporting this case. In addition, we suggest regular follow-up of patients taking tenofovir with urine analysis and serum potassium to detect this complication earlier as it is reversible.

Acute paraparesis syndrome after ruptured anterior communicating artery aneurysm.

Here, we describe a series of 7 patients who presented with acute paraparesis due to anterior communicating artery aneurysm rupture. This study aimed to assess the clinical and radiological factors associated with acute paraparesis syndrome caused by subarachnoid hemorrhage (SAH).Between June 2005 and December 2012, our institution consecutively treated 210 patients with anterior communicating aneurysm rupture within 24 hours after ictus. We divided the patients into 2 groups based on the presence (n = 7) and absence (n = 203) of acute paraparesis after anterior communicating aneurysm rupture.Diffusion-weighted magnetic resonance imaging revealed high intensity in the medial aspects of the bilateral frontal lobes in 3 patients. The mean third ventricular distance at the time of admission was 9.2 mm (range, 8–12.5 mm), and the mean bicaudate distance was 33.9 mm (range, 24–39 mm). There was a significant difference in the bicaudate distance (P = .001) and third ventricle distance (P = .001) between the 2 groups. Acute hydrocephalus and global cerebral edema (GCE) were confirmed radiologically in all patients in the acute paraparesis group. The presence of acute hydrocephalus (P = .001) and GCE (P = .003) were significantly different between the groups.Acute paraparesis syndrome after SAH is transient and gradually improves if the patient does not develop severe vasospasm. The present study demonstrates that acute paraparesis after SAH is associated with acute hydrocephalus and GCE.

Spinal Aneurysmal Bone Cyst Causing Spinal Cord Compression

A previously well female teenager presented with acute paraparesis. She reported a 2-month history of atraumatic back pain. Four days before admission, she progressed from walking independently to inability to mobilize. She had fecal incontinence and micturition difficulty. On examination, she had T8 sensory level with pinprick (including perineum) with reduced power (mostly 2-3/5, worse on the right) and lower limb hyperreflexia.

Long‐term outcome of a dog with surgically resected thoracic intramedullary haemangioblastoma and concurrent lumbosacral disease

AbstractA 5‐year‐old male, neutered, English Bulldog presented for acute progressive paraparesis. Neurological examination revealed a weak withdrawal reflex in the left pelvic limb and lumbosacral pain, suggestive of a L4–S3 myelopathy. Magnetic resonance imaging revealed an incidental intramedullary mass at the T9 vertebra and L7–S1 intervertebral disc protrusion with bilateral foraminal stenosis. The dog was treated with epidural methylprednisolone. Repeat neurological examination postepidural revealed normal withdrawal reflexes and resolution of lumbosacral spinal pain. However, progressive paraparesis, thoracolumbar pain and epaxial muscle atrophy were evident. A T3–L3 myelopathy was suspected secondary to the intramedullary mass. The mass was surgically resected, and histology revealed haemangioblastoma. Neurological status improved initially, but deteriorated later due to the lumbosacral disease. The dog improved following repeat methylprednisolone epidural injection, but remained paraparetic. This case report is consistent with previous literature and provides additional information on the treatment and prognosis of spinal cord haemangioblastoma with concurrent lumbosacral disease.

Pulmonary arterial thromboses and gall bladder wall oedema in a cat with bronchioloalveolar carcinoma

AbstractAn 11‐year‐old male neutered British Shorthair cat presented with acute collapse, dyspnoea and paraparesis. Left atrial enlargement and left‐sided congestive heart failure were excluded by point‐of‐care ultrasonography, and gall bladder wall oedema was detected. Comparative venous blood gas analyses confirmed ischaemia of the hindlimbs, and echocardiography was consistent with pulmonary hypertension. The patient was euthanased and a postmortem examination revealed pulmonary artery thromboses associated with bronchioloalveolar carcinoma.

Acute spinal cord ischemic stroke; A rare but potentially devastating stroke emergency in young healthy adults

Introduction: Acute spinal cord infarction represents 1% of all strokes. The neurological presentation of spinal cord infarction is defined by vascular territory i.e. anterior or posterior spinal arteries. A broad spectrum of diseases can cause spinal cord infarction, most common cause is surgical repair or diseases of the thoracoabdominal aorta. MRI of the spine shows hyperintensities on T2WI, restricted diffusion on DWI and vertebral body infarction adjacent to a cord signal abnormality. Poor prognostic factors for recovery are severe impairment at presentation, female sex, advanced age, and lack of improvement in the first 24 hours. We describe clinical presentation, radiological findings and 3-month outcome of four patients who presented with ischemic spinal cord infarction. Methods: We retrospectively analysed our prospectively collected data and found four cases of spinal cord infarction for the period of May 2020 to April 2021. Total of 1,326 stroke patients (1125 i.e. 85% ischemic and 201 i.e. 15% haemorrhagic) were admitted in Hamad General Hospital. At our centre, spinal cord infarction accounts 0.30% of total stroke and 0.35% of ischemic strokes. We describe four young patients, presented with abrupt onset of focal neurologic deficit. Their MRI of the spine revealed hyperintensity signals in T2WI, restricted diffusion on DWI of spinal cord. Two patients had vertebral artery occlusion or dissection. One patient was discharged home and three patients underwent multidisciplinary rehabilitation program. Discussion: Spinal cord infarction may present with acute paraparesis or quadriparesis with devastating consequences. Blood flow to the spinal cord is influenced by perfusion pressure. The most common cause of spinal cord infarction in this case series was vertebral artery dissection or occlusion. Our case series suggests early recognition of spinal cord stroke, appropriate investigations and early treatment with further rehabilitation could improve patient outcome. Conclusion: Spinal cord infarction, a rare but devastating condition, represents 1% of all strokes but 0.3% of total strokes at our centre. Early recognition of spinal cord ischemia especially when presenting with abrupt onset focal neurological deficit, focus on underlying pathology with appropriate imaging and further investigations, secondary stroke prevention and rehabilitation are vital factors to improve neurological recovery. Future randomized trails are needed to establish the efficacy and safety of drug therapy including rt-PA in spinal cord infarction. Abbreviations: ASA: Anterior spinal artery; PSA: Posterior spinal artery; MRI: Magnetic resonance imaging; MRA: Magnetic resonance arteriogram; DWI: Diffusion weighted imaging; ICP: Intra-cranial pressure.

Spinal cord compression with acute para-paresis due to thoracic aneurysmal bone cyst (ABC): a case report and review of the literature

Aneurysmal bone cysts (ABCs) are benign, highly vascular osseous lesions characterized by cystic, blood-filled spaces surrounded by thin perimeters of expanded bone. Children and young adults are most often affected by spinal ABCs; more than 75% of patients are younger than 20 years old at the time of presentation. Although ABCs have been documented in all areas of the axial and appendicular skeleton, ABCs of the spine present unique challenges due to the risk of vertebral destabilization, pathological fracture, and vertebral body (VB) collapse with neurological compromise. We describe here a case of a 12-year-old child who presented with cervical pain and gait disturbances starting a few weeks prior to his admission with acute paraparesis at the time of admission. Subsequently he was found to have a Thoracic ABC involving T1-T3.This was accompanied by T2 vertebral body collapse and spinal cord compression. He was investigated and treated promptly by resection of the aneurysmal bone cyst with posterior Cervical-thoracic instrumentation. There was full post-operative neurological resolution.