Complete Neurological Recovery Research Articles

Pediatric Cardiac Myxoma: A Rare Cause of Stroke in a Six-Year-Old Child.

This is a case report of a six-year-old child who presented with signs and symptoms of a stroke, which led to the detection of a left atrial myxoma. The myxoma was successfully removed four days after the stroke (one day after hospital transfer) and the child had nearly complete neurologic recovery.

Endoscopic Transventricular Transaqueductal Excision of Fourth Ventricular Neurocysticercosis: 2-Dimensional Endoscopic Video: 2-Dimensional Operative Video.

Ventricular neurocysticercosis is a challenging disease that may cause obstructive hydrocephalus and require surgical intervention.1,2 Cysts of the lateral and third ventricle can be addressed by neuroendoscopy and removal of the cyst, when feasible. Surgical excision of cysts from the fourth ventricle can be achieved through endoscopic or microsurgical techniques, depending on the experience of the surgeon and characteristics of the cyst. Unresectable cysts causing hydrocephalus require cerebrospinal fluid diversion through a ventriculoperitoneal shunt.1-8 Medical therapy consisting of antiparasitic and anti-inflammatory agents should be limited to patients where surgery is a poor option or in cases, where there are residual cysts in the body. Medical therapy can cause an inflammatory response resulting in adherence of the cyst to the ventricular wall, which increases the surgical complication rate. Therefore, surgical cyst excision should always precede medical therapy.2 The endoscopic transventricular transaqueductal approach has been described in the literature as a safe route to resect nonadherent cysts when performed by an experienced neuroendoscopist.1-5 Although descriptions of the procedure exist in the literature, no video outlines its detailed operative steps and relevant anatomy. In this video, we present a case of a 42-year-old woman who presented with obstructive hydrocephalus caused by a third ventricular cestode that migrated into the fourth ventricle during her hospitalization. The patient underwent an endoscopic transventricular transaqueductal excision of a fourth ventricular cyst with complete neurological recovery and without requiring ventricular shunting. The patient consented to the procedure and to the publication of her video and images. Institutional Review Board review is not required for a single case report.

Double Level Non-Contiguous Traumatic Lumbar Disc Herniation Presenting With Cauda Equina Syndrome: A Case Report and Literature Review.

A 52-year-old man presented with cauda equina syndrome after a motorcycle accident. Magnetic resonance imaging revealed traumatic disc herniation, at L2-L3 and L5-S1 levels without bony injury. He was managed successfully by wide laminectomy and microdiscectomy at both levels with complete neurological recovery at 2-month follow-up. With a reported incidence of 0.4%, traumatic disc herniation in the lumbar region is an uncommon occurrence that may resemble a spinal epidural hematoma in acute trauma. Although MRI may not reliably differentiate spinal epidural hematoma from disc herniation, urgent surgical intervention may be required in profound neurological deficits.

Non-traumatic complete cervical spine dislocation with severe fixed kyphosis: successful multidisciplinary approach to a challenging case

BackgroundTo our knowledge, there is no previous report in the literature of non-traumatic neglected complete cervical spine dislocation characterized by anterior spondyloptosis of C4, extreme head drop, and irreducible cervicothoracic kyphosis.Case presentationWe report the case of a 33-year-old Caucasian man with a 17-year history of severe immune polymyositis and regular physiotherapy who presented with severe non-reducible kyphosis of the cervicothoracic junction and progressive tetraparesia for several weeks after a physiotherapy session. Radiographs, computed tomography, and magnetic resonance imaging revealed a complete dislocation at the C4–C5 level, with C4 spondyloptosis, kyphotic angulation, spinal cord compression, and severe myelopathy. Due to recent worsening of neurological symptoms, an invasive treatment strategy was indicated. The patient’s neurological status and spinal deformity greatly complicated the anesthetic and surgical management, which was planned after extensive multidisciplinary discussion and relied on close collaboration between the orthopedic surgeon and the anesthetist. Regarding anesthesia, difficult airway access was expected due to severe cervical angulation, limited mouth opening, and thyromental distance, with high risk of difficult ventilation and intubation. Patient management was further complicated by a theoretical risk of neurogenic shock, motor and sensory deterioration, instability due to position changes during surgery, and postoperative respiratory failure. Regarding surgery, a multistage approach was carefully planned. After a failed attempt at closed reduction, a three-stage surgical procedure was performed to reduce displacement and stabilize the spine, resulting in correct spinal realignment and fixation. Progressive complete neurological recovery was observed.ConclusionThis case illustrates the successful management of a critical situation based on a multidisciplinary collaboration involving radiologists, anesthesiologists, and spine surgeons.

Giant cerebellar cavernous malformation in children: A case report and literature review.

Giant cerebellar cavernomas in children are rare and must be differentiated from hemorrhagic cerebellar tumors. The diagnosis and treatment of giant cerebellar cavernomas is challenging, but complete surgical resection can lead to favorable outcomes and complete neurological recovery in most cases. We present a case of eight months old baby who was diagnosed with a giant cavernoma resulting in secondary obstructive hydrocephalus with neuropsychiatric presentations. The patient underwent a paramedian craniotomy surgery with a suboccipital approach and complete surgical resection of the cavernoma was done. Over nine months of observation, the child showed improvement in their ability to walk and fully recovered from a neurological perspective. We also conducted a literature review to identify eleven cases of giant cerebellar cavernomas in children, including our case. The data were analyzed to determine the clinical features, treatment, and outcomes of giant cerebellar cavernomas in children.

Nerve Sheath Tumours In and Around Spine—A Series of 50 Cases

Abstract Background: Nerve sheath tumours in and around the spine, especially in the junctional zones, are a challenging endeavour for the surgeon, because of the difficulty in approaching these structures as well as their close proximity to the major vessels and nerves. Most of these tumours are benign in nature. They are usually very slow growing, and hence the tumour may be detected very late in its clinical course unless it compresses or encircles any of the major neurovascular structures early in its course. The surgical results after the excision of these tumours are excellent. Most of the patients get completely cured by prompt treatment. Here we present a series of 50 nerve sheath tumours in and around the spine operated over a period of 21 years. Materials and Methods: A retrospective study was done for 50 patients who underwent an operation for nerve sheath tumours in and around the spine, over a period of 21 years. Patient’s clinical and radiological data were extracted from the Medical Record Department (MRD) of our hospital and analysed. Results: Out of the 50 cases of nerve sheath tumours, 40 patients (80%) were of schwannoma and 10 patients (20%) were of neurofibroma. Overall, 10 patients had dumbbell tumours (neurofibroma+schwannoma). The mean age group was between 4th and 6th decade. Patients were followed up for a minimum of 1 year and a maximum of 20 years period. All of these tumours were benign except one patient who had a malignant neurofibroma of the C-8 nerve root. 15 out of 50 patients presented with paraparesis, 5 with paraplegia and another 5 with quadriparesis. All these patients had complete neurological recovery after surgical removal of the tumours. Conclusion: This case series brings out the nuances in the management of nerve sheath tumours in and around the spine and their results.

Isolated fourth ventricle craniopharyngioma: Representative case illustration and review of literature

Background: Sella and suprasellar areas are frequently affected by craniopharyngiomas. In this article, eight occurrences have been documented. One is new, and the remaining seven are from previously published articles. Their prevalence in the posterior fossa without expansion from the suprasellar area is unusual. Case Description: We present a case of a primary 4th ventricular craniopharyngioma of the posterior fossa in a 16-year-old male with no association with Gardner’s syndrome. He presented with sudden deterioration of consciousness level and was diagnosed as having a homogeneously contrast enhancing lesion occupying the 4th ventricle with obstructive hydrocephalus. The patient underwent emergency placement of external ventricular drain followed by complete removal of the tumor on the next day by midline suboccipital craniotomy with telovelar approach. Histopathological features were consistent with the adamantinomatous variety of craniopharyngioma. He had complete neurological recovery and no evidence of tumor recurrence in 1-year follow-up. Conclusion: The craniopharyngioma in our case was distinct because it was a solid tumor with no cystic component, exhibited homogeneous contrast enhancement in neuroimaging, developed in the fourth ventricle, and reached the level of foramen magnum, features that had rarely been documented previously. We also reviewed the literature on reported cases of 4th ventricular craniopharyngioma to strengthen knowledge in this area and highlight the embryological basis of ectopic craniopharyngioma.

Transfusion-Associated Reversible Cerebral Vasoconstriction Syndrome in Pediatrics: A Case Report and Review of Literature

Background Reversible cerebral vasoconstriction syndrome (RCVS) is a rare complication of packed red blood cell (pRBC) transfusion primarily reported in adults with severe chronic anemia due to menorrhagia. It is characterized by a triad of rapidly changing and reversible segmental cerebral artery narrowing and dilatation, thunderclap headache, and benign cerebrospinal fluid findings. 1,2 More than 50% of patients experience blurring of vision or cortical vision loss, and a subset of patients develop hemiparesis or aphasia. 1 There are emerging case reports of RCVS in pediatric patients, however the literature examining this transfusion complication in children is limited. The rarity and potential severity of RCVS warrants better understanding by pediatric hematology and transfusion providers. Results We describe a previously healthy 4 year-old male who presented with pallor and laboratory parameters consistent with severe iron deficiency anemia. Chest x-ray showed cardiomegaly, and echocardiogram demonstrated pericardial effusion, moderate left ventricular dilation, and moderate coronary artery dilatation. His history was notable for an extremely selective diet and at least 50 ounces of cow's milk daily. The patient was admitted, and over the course of 3 days, he received a total of 43 mL/kg of pRBCs (602 mL total) in 8 aliquots, and his hemoglobin (Hgb) increased from 1.4 g/dL to 11.4 g/dL (Fig. 1). He then re-presented 5 days after discharge with altered mental status and malignant hypertension. Brain MRI/MRA was consistent with RCVS, with luminal irregularities in multiple anterior and posterior circulation intracranial arteries creating a beaded appearance. He was treated supportively with aggressive blood pressure control and made a complete neurologic recovery 8 days after presentation. At hematology clinic follow-up 2 months post-discharge, he remained at his typical neurologic baseline. Conclusions The connection between blood transfusion and RCVS is postulated to be due to a rapid increase in hematocrit and blood viscosity, which alters cerebral autoregulation and leads to hypertensive encephalopathy despite systemic normotension. 3 The increased viscosity may also lead to vasospasm. 3 When a patient with severe chronic anemia receives a pRBC transfusion, there is increased cerebral blood flow and viscosity, resulting in decreased vasodilation, increased vascular resistance, and cerebral vessel constriction. However, these are hypothesized mechanisms with little supportive experimental data. Vasculopathies and vasoconstrictive medications 2 are also risk factors for RCVS. There are 4 previous reported cases of pediatric RCVS associated with pRBC transfusion. 2 patients were acutely ill with complications of sickle cell anemia. 7,9 Another case occurred in a patient with systemic lupus erythematosus 8, and the fourth occurred in the setting of severe iron deficiency anemia. 5 Several features of our patient's clinical course are similar to the reported cases of transfusion-related RCVS 5 and warrant highlighting: 1) severe chronic anemia with cardiac dysfunction and 2) the large volume of transfused pRBCs over a short period resulting in a significant increase in Hgb. However, our patient developed symptoms of RCVS sooner than other published cases and did not have seizure or stroke. Pediatric guidelines recommend pRBC transfusion for Hgb levels between 5-10 g/dL, depending on the clinical scenario. 4 There are few data to guide Hgb targets for pediatric patients presenting with severe anemia. Over-transfusion does not offer physiological benefit and poses risk of transfusion-related adverse events. A case report from Dou et al 6 proposed that a >5 g/dL Hgb increase was associated with a greater likelihood of developing RCVS. For this patient with cardiac dysfunction and social concerns including lack of primary care, the potential benefits of achieving a higher Hgb with pRBC transfusions were prioritized. RCVS should be considered in pediatric and adult patients recently transfused for chronic severe anemia presenting with headaches or other neurological symptoms. Prompt recognition of RCVS may prevent unnecessary treatment and potentially limit risk of neurologic compromise. The role of the volume and rapidity of the pRBC transfusions in the development of RCVS warrants further study. Fig 1. Timeline of initial presentation, detailing blood transfusions

Acute hemorrhagic leukoencephalitis in a young female with excellent response to corticosteroids

Background: Acute hemorrhagic leukoencephalitis (AHLE) is a rare fulminant entity of acute disseminated leukoencephalitis (ADEM) that has a rapidly progressive polysymptomatology corresponding to areas of brain affected. It’s characterized by rapid cognitive decline, coma or even rapid death. It is postulated to be a post infective immune mediated monophasic demyelinating disease. Diagnosis is clinical supported by CSF and MRI findings. It is challenging to differentiate the disease from MDEM (multiphasic demyelinating encephalomyelitis) and multiple sclerosis during the initial presentation.Case presentation: Here we report a case of a 36-yearold Sri Lankan Sinhalese lady who presented with seizure following febrile illness followed by gross right sided hemiparesis later progressing to mutism and cognitive decline. Her CSF showed pleocytosis 12/cumm with 5% polymorphs, red cells, mildly high proteins with normal glucose and positive oligoclonal bands. MRI showed evidence of multiple focal supra and infratentorial signal abnormalities and gyral thickening with hemorrhages, largest lesions being in left frontal region with mass effect but no herniation. She was diagnosed with AHLE and treated with high dose IV methyl prednisolone later converting to oral prednisolone tapering regime. She was continued on intravenous cefotaxime and acyclovir as per meningoencephalitis. Improvement with steroids was dramatic with complete neurological recovery, minimal sequel and no recurrences at 6 months follow up.Conclusion: The case is a representation of a very rare entity of an infrequently reported disease which needs high degree of clinical suspicion with early imaging for aggressive and early immunosuppressive treatment that may hinder progression to commonly described sequel including coma, death or residual neurology. The predictions on future MDEM or MS on first presentation and overlap are areas that need further exploration.

Abstract 151: The PRINCESS 2 Trial: A Randomized Study to Assess the Impact of Ultrafast Hypothermia on Neurologic Function in Out-of-Hospital Cardiac Arrest With Initial Shockable Rhythm

Background: The impact of ultrafast hypothermia, i.e. delivered intra-arrest or immediately after return of spontaneous circulation (ROSC), on functional neurologic outcome after out-of-hospital cardiac arrest (OHCA) is unclear. In two prior trials, prehospital transnasal evaporative intra-arrest cooling was safe, feasible and reduced time to target temperature. Both studies showed trends towards improved neurologic recovery in patients with shockable rhythms. The aim of the PRINCESS2-study is to assess whether cooling, initiated either intra-arrest or immediately after ROSC, followed by in-hospital hypothermia, significantly increases survival with complete neurologic recovery as compared to standard normothermia care, in OHCA patients with shockable rhythms. Methods/Design: This investigator-initiated, randomized, controlled trial will randomize patients at the scene of cardiac arrest to either transnasal cooling within 20 minutes from Emergency Medical System arrival with subsequent hypothermia at 33°C for 24 hours after hospital admission (intervention), or to standard of care with no prehospital or in-hospital cooling (control). Fever (>37,7 o C) will be avoided for the first 72 hours in both groups. All patients will receive post resuscitation care and withdrawal of life support procedures according to current guidelines. Primary outcome is survival with complete neurologic recovery at 90 days, defined as modified Rankin scale (mRS) 0-1. Key secondary outcomes include survival to hospital discharge, survival at 90 days and mRS 0-3 at 90 days. In total, 970 patients are required to detect an absolute difference of 9 % (from 45 to 54 %) in survival with neurologic recovery (80 % power and 2-sided α=0,5). Recruitment starts in Q3 2023 and we expect maximum enrolment to be achieved during 2024 at 20-25 European and US sites. Discussion: This trial will assess the impact of ultrafast hypothermia applied on the scene of cardiac arrest on survival with complete neurologic recovery in patients with OHCA and shockable rhythm

Abstract 18058: Dorsal Root Ganglion Nerve Block Causing Reverse Takotsubo Cardiomyopathy

A 65-years-old female presents to the emergency room after C2 dorsal root ganglion nerve block for cervicogenic headaches, where intraoperatively she became hypotensive and unresponsive with sinus tachycardia to the 140s. She required brief intubation and intravenous vasopressors for resuscitation and was quickly extubated with complete neurologic recovery within hours of presentation. Her vital signs were within normal limits. She had no clinical signs of heart failure on exam. Laboratory values were within normal limits except for elevated hs- troponin which peaked at 1136ng/L. Her EKG showed nonspecific ST changes and T-wave inversion in the high lateral leads. She underwent transthoracic echocardiogram and was found to have basal to mid inferior wall and inferoseptum akinesis with reduced left ventricular ejection fraction of 35-40%. She was initially asymptomatic, but six hours after presentation developed radiating left arm pain then crushing chest and throat pain, with an uptrend in her troponins to 6539, without dynamic EKG changes. She was urgently taken to the cath lab and was found to have clean coronaries, and ventriculography was performed with findings consistent with reverse takotsubo. She was started on low dose beta blockers and ARBs with complete resolution of symptoms. Reverse takotsubo is a rare variant of takotsubo cardiomyopathy, where basal and midventricular segments of the left ventricle are akinetic, with the majority of patients recovering systolic function within months. This condition is frequently triggered by an intense trigger. To our knowledge, this is the first described case of a high-cervical nerve block precipitating takotsubo.

Never say never: successful extracorporeal cardiopulmonary resuscitation (ECPR) following a prolonged out-of-hospital cardiac arrest due to spontaneous coronary artery dissection

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may be a life-saving rescue therapy for patients with severe cardiac disease of any origin and circulatory failure. Data in the literature have demonstrated that the use of advanced mechanical circulation has resulted in improvements in both survival and quality of life; despite this, cardiogenic shock and refractory cardiac arrest remain conditions with high mortality. Opportune identification of patients who can benefit from it may improve outcomes. However, the shortage of guidelines on indications often results in a high mortality rate and poor outcome. Due to ethical issues, randomised controlled studies with VA-ECMO have not been conducted so no recommended evidence-based guidelines exist for VA-ECMO patient-selection criteria. Therefore, the indications depend only on expert opinion after reviewing the literature. Case description: We report the case of a young female patient who presented with an out-of-hospital cardiac arrest (OHCA) due to spontaneous coronary dissection. She was treated with extracorporeal cardiopulmonary resuscitation (ECPR) with excellent results in terms of short and long-term survival, and neurological outcome. This was despite the presence of several clinical and laboratory negative prognostic factors on the basis of the current literature, and the lack of general consensus among the relevant medical personnel. Conclusion: We were able to explain the favourable outcome only on the basis of clinical data. We can conclude that the availability of advanced resources in the area (timeliness of the rescues, quality of the resuscitation, an advanced haemodynamic management centre nearby) has contributed to determining the complete clinical and neurological recovery of the patient.

Vasculitis and Ischemic Stroke in Lyme Neuroborreliosis-Interventional Management Approach and Literature Review.

In rare cases, Lyme neuroborreliosis (LNB) can induce cerebral vasculitis leading to severe stenosis of the cerebral vasculature and consecutive ischemia. Therapy is based on anti-biotic treatment of the tick-borne disease, whereas interventional therapeutic options have not been assessed yet. We report on a patient with LNB and concomitant stenoses and progressive and fatal vasculitis of the cerebral vessels despite all therapeutic efforts by the departments of neurology and interventional neuroradiology. In this context, we also conducted a literature review on endovascular treatment of LNB-associated cerebral ischemia. A 52-year-old female presented with transient neglect and psychomotor slowdown (initial NIHSS = 0). MRI and serology led to the diagnosis of basal meningitis due to LNB with vasculitis of cerebral arteries. Despite immediate treatment with antibiotics and steroids, neurologic deterioration (NIHSS 8) led to an emergency angiography on day 2 after admission. Hemodynamically relevant stenoses of the MCA were treated via spasmolysis and PTA, leading to almost complete neurological recovery. Despite intensified medical treatment, the vasculitis progressed and could only be transiently ameliorated via repetitive spasmolysis. On day 19, she again presented with significant neurologic deterioration (NIHSS 9), and PTA and stenting of the nearly occluded MCA were performed with a patent vessel, initially without hemorrhagic complications. Despite all therapeutic efforts and preserved stent perfusion, vasculitis worsened and the concurrent occurrence of subdural hemorrhage led to the death of the patient. Neuroradiological interventions, i.e., spasmolysis, PTA, and, if necessary, stenting, can and should be considered in cases of LNB-induced vasculitis and stroke that are refractory to best medical treatment alone. Neuroradiological interventions can be considered in patients with vascular complications of Lyme neuroborreliosis as an additional extension of the primary drug therapy.

Hypomyelination caused by a novel homozygous pathogenic variant in FOLR1: complete clinical and radiological recovery with oral folinic acid therapy and review of the literature

BackgroundNeurodegeneration due to cerebral folate transport deficiency is a rare autosomal recessive disorder caused by biallelic pathogenic variants in FOLR1. Onset typically occurs in late infancy and is characterized by psychomotor regression, epilepsy, and a hypomyelinating leukodystrophy on magnetic resonance imaging. If left untreated, progressive neurodegeneration occurs. However, early treatment with folinic acid has been shown to stabilize or reverse neurological features. Approximately thirty patients have been described worldwide. Here, we report the first two cases with genetically proven cerebral folate transport deficiency from South-Eastern Europe, describe the effect of oral folinic acid therapy on clinical and neuroradiological features and review the literature.ResultsTwo siblings presented in childhood with clinical and radiological findings consistent with a hypomyelinating leukodystrophy. Exome sequencing revealed a novel homozygous pathogenic variant in FOLR1 (c.465_466delinsTG; p.W156G), confirming the diagnosis of neurodegeneration due to cerebral folate transport deficiency. Folinic acid treatment was promptly initiated in both patients. The younger sibling was treated early in disease course at 2 years of age, and demonstrated complete recovery in clinical and MRI features. The older sibling, who was 8 years of age at the time of diagnosis and treatment, demonstrated partial but substantial improvements.ConclusionWe present the first account in the literature that early treatment initiation with oral folinic acid alone can result in complete neurological recovery of both clinical and radiological abnormalities in neurodegeneration due to cerebral folate deficiency. Moreover, through the report of these patients along with review of the literature, we provide information about the natural history of the disease with comparison of treatment effects at different stages of disease progression. This report also reinforces the importance of universal access to genetic testing to ensure prompt diagnoses for treatable disorders.

Posterior interosseous nerve paralysis secondary to an extraneural ganglion cyst from a radial neck pseudarthrosis: illustrative case.

Many benign and malignant tissue or bony lesions have been reported as causes of extrinsic or intrinsic posterior interosseous nerve (PIN) neuropathy at the proximal forearm/elbow region. The authors describe an unusual cause of external compression of the PIN due to a ganglion cyst arising from a radial neck pseudarthrosis (a false joint). Decompression of the PIN with the release of the arcade of Frohse was performed with resection of the radial head and the ganglion cyst. By 6 months postoperatively, the patient had a complete neurological recovery. This case illustrates a previously unreported cause of extraneural compression of the PIN from a pseudarthrosis. The mechanism for compression in this case from the radial head pseudarthrosis is likely attributable to the sandwich effect, in which the PIN is sandwiched between the arcade of Frohse at the supinator from above and the cyst below.

P.139 Cerebral toxoplasmosis in an HIV-negative patient

Background: Toxoplasma gondii is a protozoan parasite with the ability to infect any nucleated cell in humans. Most immunocompetent infected individuals are asymptomatic. Latent toxoplasma can become reactivated in immunocompromised individuals though this is exceptionally rare in HIV-negative individuals. Methods: We present the case of a 47-year-old male with chronic immunosuppression secondary to marginal zone lymphoma and steroid therapy. Results: The patient presented to hospital with a 1-week history of word-finding difficulties, intermittent right facial numbness and leg weakness, and tonic-clonic seizures. CT head showed a left temporal heterogenous mass measuring 2.8 × 2.8 × 3.5 cm. Biopsy of the lesion showed Multiple tachyzoites and rare bradyzoites with strong positivity for the toxoplasma specific immunostain. The patient was treated with trimethoprim/sulfamethoxazole which resulted in complete neurologic recovery. Conclusions: Our literature review included 32 cases of cerebral toxoplasmosis in HIV-negative patients with an overall mortality rate of 48%. Cerebral toxoplasmosis has a predilection for immunosuppressed patients with an underlying hematologic malignancy (74%, n= 23). Successful treatment requires early recognition of the disease and prompt treatment with sulfamethoxazole and trimethoprim, pyrimethamine, or sulfadiazine. Patients who recover from acute toxoplasmosis should remain on lifelong suppressive antibiotic therapy to prevent relapse.

A Rare Case of Meningoencephalo-Myelitis with a Tubercular Origin

Tuberculosis (TB) can affect any bodily system including the central nervous system (CNS). CNS involvement in Tb is fairly uncommon with poor prognosis due to its high mortality and morbidity. Though meningoencephalitis is a frequent presentation of TB, myelitis along with it is rare. Due to the lack of detailed information about meningoencephalo-myelitis, the risk factors and prognosis of these patients are not fully understood. We report such a rare instance of tuberculosis involving the brain, meninges and spinal cord. The patient was a 13-year-old female with the complaints of fever, both lower limb weakness and urinary retention. The diagnosis was made based on the patient’s medical history and physical examination which showed meningeal syndrome, spinal cord and cranial nerve involvement. The diagnosis was confirmed by the analysis of cerebrospinal fluid, magnetic resonance imaging of the brain and spinal cord, and biochemical evidence of tuberculous infection. The patient had a marked clinical improvement and complete neurologic recovery after anti-tubercular treatment and high doses of systemic corticosteroids. The purpose of presenting the case is to share the bizarre presentation of CNS tuberculosis, a diagnostic and therapeutic emergency. Early diagnosis and immediate management may help with the unfavorable prognosis and our report hopes to shed light on it. J Medicine 2023; Vol. 34, No. 2(1) Supplement: 225

Outcome of Single Stage Anterior and Posterior Surgery for Tuberculous Paraplegia.

Morbidity and mortality from tuberculosis, a significant infectious illness, are expected to rise worldwide. The projected number of new cases rose from 7.5 million in 1990 to 11.9 million in 2005, a 58.6% increase in 2011. The widespread belief that TB is no longer a public health concern is unfounded; on the contrary, the link between HIV/AIDS and antibiotic resistance has further exacerbated the crisis that already existed. Similar to the nations in sub-Saharan Africa, India is now considered a Group IV country, with an annual risk of infection between 1% and 2.5%. 2. Although 60% of TB cases occur in people who are HIV-positive, only 3-5% of cases in HIV-negative individuals are skeletal. The most frequent type of articuloskeletal tuberculosis is spinal tuberculosis. 1. The goal of this study is to evaluate the neurological outcome of anterior debridement, fusion, posterior instrumentation, and early rehabilitation in individuals with spinal cord injuries. 2. The goal of this study is to determine the prevalence of pressure ulcers, hypostatic pneumonia, and urinary tract infections urinary tract infections (UTIs) among these individuals. 3. The goal of this study is to determine the frequency of graft-related problems. 4. See how well these individuals are able to keep their corrected deformities from returning. Patients who had simultaneous anterior (anterior debridement and bone grafting) and posterior (posterior instrumentation and fusion) procedures were followed prospectively. Thirty patients' films were examined. In addition, cord edema was suggested in 13 of the patients based on the presence of strong signal intensities there. Myelomalacia signs were seen in one patient, but he or she went on to make a complete neurological recovery. The average duration of operation was 355 minutes, and this included the time needed to position the patient for the two separate procedures. There was an 89.5% rate of neurological recovery with an average corrected loss of 6.98 degrees (0.20 degrees to 35.90 degrees), and the complication rate was acceptable in the group analyzed.

Onyx© Embolization of Dural Arteriovenous Fistulae at the Cranio-Cervical Junction (P8-5.024)

<h3>Objective:</h3> To report two cases of CRC fistula treated successfully with endovascular embolization with Onyx©. <h3>Background:</h3> Dural arteriovenous fistula (dAVF) are rare vascular malformations; a rare subset of this group are dAVFs located at the cranio-cervical junction. Subarachnoid hemorrhage (SAH) is one of the possible neurological complications of cranio-cervical (CRC) fistula rupture. Treatment options include radiosurgery, endovascular embolization and/or open surgery. The use of liquid embolic agent is a reasonable option for endovascular treatment. <h3>Design/Methods:</h3> A single institution retrospective case report identified two case of cranio-cervical junction (CRC) fistulae that were treated successfully with Onyx© embolization. <h3>Results:</h3> Two patients were identified to have cranio-cervical junction DAVF in which one patient presented with SAH, and the 2^nd patient presented with bulbar symptoms due to rapidly worsening edema in the brainstem. Both fistulas were supplied from the vertebral artery; one at the level of Dural ring of the vertebral artery and the other at the jugular foramen level which was also supplied by ascending pharyngeal artery. Onyx© embolization was the treatment of choice in both cases. The Onyx© embolization resulted in 80% reduction of the fistula nidus in the first case, and complete occlusion of the fistula in the second and the third case. The 6 months follow-up revealed complete occlusion of both fistulas with complete neurological recovery <h3>Conclusions:</h3> This case series suggests that the treatment of CRC fistulae with Onyx© embolization is efficacious with good clinical outcomes. <b>Disclosure:</b> Dr. Gharaibeh has nothing to disclose. Dr. Al-Chalabi has nothing to disclose. Dr. Oliver has nothing to disclose. Dr. Jumaa has nothing to disclose.

Rapid Development of High-Grade Dural Arteriovenous Fistula During Pregnancy: A Case Report (P14-5.010)

<h3>Objective:</h3> We present a case of minimally symptomatic, radiographically occult dural arteriovenous fistula (dAVF) evolving into intracerebral hemorrhage shortly after pregnancy. <h3>Background:</h3> dAVFs are generally acquired arteriovenous shunts thought to be caused by pathological neo-arterialization within an occluded vein. While a relatively common entity, rapid dAVF development has rarely been described in the setting of pregnancy. <h3>Design/Methods:</h3> Case report. <h3>Results:</h3> A 30-year-old nulliparous woman was referred to our outpatient clinic following subacute onset of left-predominant pulsatile tinnitus and mild bifrontal headache. Brain magnetic resonance imaging (MRI) revealed diffuse evidence of intracranial hypertension, which was supported by elevated opening pressure on lumbar puncture (LP). MR angiography and venography were within normal limits. She was diagnosed with idiopathic intracranial hypertension and started on acetazolamide with improvement in symptoms. At 6-month follow-up, she was seven weeks pregnant and reported mild worsening of tinnitus After discontinuation of acetazolamide. She remained clinically stable until three weeks after an uneventful spontaneous vaginal delivery when she presented with thunderclap headache, confusion, and aphasia. Head computed tomography (CT) was significant for a 4 mL acute frontotemporal intracerebral hemorrhage. CT angiography demonstrated a large vascular malformation of the left sphenoid wing. Cerebral angiogram confirmed a dAVF fed by the left inferolateral trunk, middle meningeal arteries, and arteries of the foramina spinosum, ovale, and rotundum, and draining into enlarged cortical veins. The fistula was successfully obliterated transarterially with a liquid embolic system. Three months following embolization, she has made complete neurological recovery with resolution of tinnitus. <h3>Conclusions:</h3> Radiographically occult dAVF can emerge and become symptomatic during pregnancy and the post-partum period. Potential mechanisms include systemic changes in hormone levels, shifting hemodynamics, and local phenomena of thrombosis, hypoxia, and secondary angiogenesis. Neurologists should consider this entity when evaluating women with new headache or focal symptoms in the peripartum setting. <b>Disclosure:</b> Dr. Sheibani has nothing to disclose. Dr. Voetsch has nothing to disclose. Prof. Orru has nothing to disclose. Dr. Lerner has received publishing royalties from a publication relating to health care. Dr. Culbertson has nothing to disclose.