Parietal Lobe Lesions Research Articles

Delay in Diagnosis of Brain Tumors: A Dilemma For Neurosurgical Community Due To Spirituality and Quackery In A Developing Country

Objectives: Primary and metastatic brain tumors are a significant cause of mortality and morbidity. The complex pathway to a cancer diagnosis is not human error and the achievements of better outcomes solely depend on the early diagnosis and management of symptomatic tumors. The estimated time between the first presentation to any health care professional and diagnosis is approximately 3 times longer in the UK as compared to other developed countries.
 Material and Methods: It was a descriptive study and included 52 patients who were admitted to the Neurosurgery department at Jinnah hospital Lahore. The required data were collected either directly from the patients or from the hospital record of discharged patients. Our study compares the time interval difference of presentation of a patient to a local care provider (Quacks, Hakeem, and spiritual healers) and Neurosurgeon as well as delay in surgical intervention even after diagnosis and radiological investigations.
 Results: 54% of patients presented with supratentorial lesions and out of these, parietal lobe lesions were more common (39%) while 29% of lesions were infratentorial. Around 50% of patients presented to a Local Care Provider within 20 days. However, only 42% of patients presented to a neurosurgeon after 6-9 months of the onset of symptoms.
 Conclusion: Public awareness is the key to timely diagnosis, proper management, and better outcomes. The availability of specialists in peripheral hospitals can bring a change in this regard.

Tumefactive demyelination-A Rare Presentation of Multiple Sclerosis

Background: Multiple Sclerosis is an inflammatory demyelinating disease having varied manifestations in terms of clinical featuresand radiological features. Rarely it may present as a large demyelinating lesionwith accompanying edema and mass effect, thereby simulating an intracranial tumor, known as Tumefactive Demyelination. Symptoms are usually related to the pressure of a focal mass lesion. When it manifests in a patient without pre-existing MS, it poses a diagnostic challengeas it may mimic a neoplasm, infarct or abscess. Thus, it is essential to recognize this rare clinical entity for proper patient management. Case Presentation: We report here a case of 40 years old female who presented with right sided hemiparesis. The initial brain imaging (CT) suggested left parietal lobe lesion suggestive of glioma. But MRI of the brain showed a cortical based lesion in left parietal lobe in parasaggital location which appeared hyperintense on both T2WI and FLAIR sequences. Further evaluation by MR spectroscopy suggested the lesion to be tumefactive demyelination. She was administered IV Methylprednisolone (1gm daily for 5 days) and responded well to treatment. The characteristic magnetic resonance findings of the patient, its acute onset, and its clinical improvement after corticosteroid therapy finally set the diagnosis of Tumefactive Demyelination. Conclusion: Tumefactive demyelinating lesions pose a unique diagnostic challenge in defining differential diagnosis and management and should always be considered in young patients presenting with tumour like lesions on imaging. Bangladesh Journal of Medical Science Vol. 21 No. 04 October’22 Page : 931-934

A Tetrad Cognitive Presentation of Gerstmann Syndrome: A Rare Manifestation of Stroke

Gerstmann Syndrome is a rare neurological presentation due to a lesion in the left dominant parietal lobe, manifesting as a tetrad of agraphia, acalculia, finger agnosia and right-left disorientation. We present a case of a 52-year-old man, right hand dominant, who presented to the Emergency Department with acute confusion for one day. He was disorientated to time, place and person. Focused neurological examination revealed atypical signs of acute stroke, comprising agraphia, acalculia, finger agnosia and right-left disorientation. Stroke protocol was activated and he underwent computed tomography brain perfusion, which confirmed a large penumbra area at the left middle cerebral artery territory. Computed tomography angiogram of the carotid arteries showed a long segment thrombosis in the left internal carotid artery. Emergency thrombectomy was abandoned due to impenetrable hard thrombus. He was treated with dual antiplatelet therapy and discharged after three days with partial improvement in terms of following commands, simple calculations and reduced finger agnosia. He was scheduled for outpatient follow up. This case highlights Gerstmann syndrome as an atypical manifestation of acute stroke.

HGG-19. Co-occurrences of a high-grade glioma with cavernous malformations and pathogenic variants inPDCD10 andSMARCA4

INTRODUCTION: The co-occurrence of multiple disease processes can make for more challenging diagnoses. Here we report an unusual case of a patient found to have an IDH1-mutant high-grade glioma along with multiple cerebral cavernous malformations and pathogenic germline variants in PDCD10 and SMARCA4. CASE DESCRIPTION: A 17-year-old female presented with left arm paresthesia and weakness along with persistent headaches within the frontal and occipital regions that progressed in intensity to include nausea and emesis. A fast sequence magnetic resonance imaging (MRI) of her head was obtained that revealed the presence of multiple bilateral cystic lesions suspicious for cavernomas, with the most notable lesion in the right parietal lobe. Ophthalmology consultation revealed grade III papilledema bilaterally. A full brain MRI with and without contrast was obtained and demonstrated a right anterior parietal lobe lesion with associated mass effect, as well as multiple bilateral supratentorial and left cerebellar cavernous malformations. The patient underwent tumor debulking of her dominant lesion. Pathology revealed an IDH1-mutant diffuse astrocytoma, WHO grade III. Tumor genetic testing was done and identified a SMARCA4 and two TP53 variants. Germline genetic testing was then pursued which revealed a PDCD10 pathogenic variant consistent with familial cerebral cavernous malformation syndrome and a likely pathogenic variant in SMARCA4. Treatment of her high-grade-glioma included radiation therapy followed by maintenance oral temozolomide. DISCUSSION: This case illustrates the unusual co-occurrences of a high-grade glioma with familial cavernous malformation syndrome and germline pathogenic variants in PDCD10 and SMARCA4. Our patient continues to do well clinically, but because of her risk of developing small cell carcinoma of the ovary she has elected to undergo a prophylactic bilateral salpingo-oophorectomy. Recognition of abnormal genetic results is critical in the setting of multiple disease processes and can play a crucial role in the on-going care for a patient.

Cognitive, academic, executive and psychological functioning in children with spastic motor type cerebral palsy: Influence of extent, location, and laterality of brain lesions.

To investigate, in spastic motor-type cerebral palsy, the association between 1) the location and extent of brain lesions and numerous psychological outcomes; 2) the laterality of brain lesions and performance of verbal-related cognitive functions. The semi-quantitative scale for MRI (sqMRI) was scored for 101 children with cerebral palsy. Non-verbal and verbal proxy intelligence quotients (IQ), word reading, spelling, numerical operations skills, executive functioning, and psychological adjustment were assessed. Relationships between global and regional sqMRI scores and clinical scores were examined. The best multivariable linear regression model for each outcome was identified using the Bayesian Information Criteria. Regional sqMRI scores, gross motor functioning, manual ability, and epilepsy status were considered for inclusion as covariables. Where sqMRI scores made statistically significant contributions to models of verbal-related functioning, data were reanalysed including these sqMRI scores' laterality index. Verbal-related outcomes were compared between participants with left-sided versus bilateral brain lesions. Medial dorsal thalamus and parietal lobe lesions significantly accounted for poorer verbal proxy-IQ. Left-hemisphere lateralization of temporal lobe lesions was associated with poorer verbal proxy-IQ. Participants with bilateral lesions performed significantly better than those with unilateral left-sided lesions in verbal cognitive functions. Controlling for epilepsy diagnosis, participants with ventral posterior lateral thalamus lesions presented with better Behaviour Rating Inventory of Executive Function scores, although within the normal range. sqMRI scores were not significantly associated with some psychological outcomes or these only bordered on significance after accounting for relevant control variables. The laterality of early-life lesions influences the development of verbal-related cognitive functions.

A patient with granulomatous amoebic encephalitis caused by Balamuthia mandrillaris survived with two excisions and medication

BackgroundGranulomatous amoebic encephalitis (GAE) is a rare central nervous system infection caused by the Balamuthia mandrillaris or Acanthamoeba species. Diagnosis is challenging because of the non-specific clinical presentation, cerebrospinal fluid analysis, and radiological features. There is no effective treatment for GAE to date.Case presentationA 54-year-old male was admitted to hospital after experiencing acute onset of numbness and weakness on his left limb. Due to the initial consideration of intracranial tumor, surgical removal of the right parietal lesion was performed. However, the patient had a headache accompanied by diplopia, difficulty walking and a new lesion was found in the left occipital-parietal lobe two weeks after the first operation. High-throughput next-generation sequencing (NGS) detected the presence of high copy reads of the B. mandrillaris genome sequence in the patient’s blood, cerebral spinal fluid (CSF), and brain tissue. Pathological investigation of the brain tissue showed granulomatous changes and amoebic trophozoite scattered around blood vessels under high magnification. The patient was re-operated due to developing progressive confusion caused by subfalcine herniation of the left cerebral hemisphere. The lesions of the right parietal lobe were obviously decreasing in size after the first surgery, and the lesions of the left occipital lobe and the sunfalcine herniation didn’t ameliorate two months after the second surgery. The patient was transferred to local hospital for continuous treatment with sulfamethoxazole and azithromycin. After five months of the second surgery, the patient showed good recovery with mild headache.ConclusionsThis is the first report of a patient with B. mandrillaris encephalitis initially confirmed by NGS and have experienced two excisions, responding favorably to the combination of surgeries and medications. Early surgical resection of intracranial lesions combined with drug treatment may offer the chance of a cure.

INNV-11. COMPLETE RESPONSE TO SELPERCATINIB IN A PATIENT WITH RECURRENT GLIOBLASTOMA AND RET AMPLIFICATION

Abstract BACKGROUND Glioblastoma (GBM) is a malignant central nervous system tumor that remains largely incurable. Limited treatment options currently exist after disease progression on the standard of care first-line therapy. However, repurposing the use of approved therapies in patients with potentially targetable genomic alterations continues to be an emerging area of interest. Here, we present the first reported case of a patient with isocitrate dehydrogenase wild-type GBM with an underlying RET amplification who demonstrated a near-complete response (CR) while receiving therapy with the targeted RET inhibitor, selpercatinib. CLINICAL PRESENTATION A 48-year-old male with no significant past medical history presented with sudden onset of dizziness and confusion. Magnetic resonance imaging (MRI) revealed two rim enhancing lesions in the right parietal lobe and the patient underwent surgical resection with subsequent pathology revealing a GBM. Genomic analysis identified a RET amplification. After standard adjuvant therapy, the patient was treated with selpercatinib 160 mg twice daily as a continuous regimen with near CR on MRI after six weeks of treatment. The patient was continued on therapy for a total of eight months before having disease progression requiring discontinuation of selpercatinib and was then transitioned to the next line of therapy for disease stabilization. To better characterize the response, further whole-exome sequencing and analysis were performed on the original specimen. CONCLUSION Although selpercatinib is approved in RET-fusion positive lung and thyroid cancer, we present a remarkable case of a recurrent, RET-amplified GBM having a CR to selpercatinib. The case highlights the excellent blood-brain barrier penetration of selpercatinib, as well as its potential role in RET-amplified GBM. Larger biomarker-enriched studies are needed to confirm the results of this case report. However, given the rare incidence of RET alterations in GBM, findings from this report can help guide and support optimal treatment strategies for patients with RET-altered GBM.

Impact of Time Interval Between Diagnostic and Planning MRI on Tumor Volume and Anatomic Displacement for Brain Metastases Undergoing Stereotactic Radiosurgery

Stereotactic radiosurgery (SRS) is increasingly used in brain metastasis patients. However, the impact of the timing on tumor volume change and tumor anatomical displacement between the diagnostic and treatment planning imaging is not well studied.Consecutive patients diagnosed with brain metastases and treated with SRS between July, 2017 and June, 2020 were evaluated. Only patients who underwent an institutionally standardized diagnostic MRI (MRI-1) and a treatment planning MRI (MRI-2) with identical imaging parameters were included. The impact of histology, inter-scan interval, lesion location, volume and size were evaluated on final lesion size, volume and anatomic displacement. Correlations were assessed using Kendall's rank correlation. The Kruskal Wallis rank sum test was used for all other comparisons.We included 101 eligible patients (531 lesions) with median inter-scan interval of 8 days (range: 1-42); 50% were NSCLC and 25% breast cancer. The three most common locations of lesions were the frontal (181 lesions, 34%), temporal (96, 18%), cerebellar (91, 17%) lobes. Median MRI-1 diameter and volume were 0.50 cm (Range: 0.23-0.89 cm) and 0.06 cm3 (Range: 0.01-4.62 cm3), respectively. Median percentage change in lesion diameter and volume were +9.5% (Range: -8.4% to +61.2%) and +20% (Range: -20% to +200%), respectively. Overall, there was a statistically significant change in percent tumor volume change between MRI-1 to MRI-2 (P = 0.01). Directional displacements exceeded 1 mm in 18 (3%) lesions in right to left (RL), 28 (5%) superior to inferior (SI), and 25 (4.7%) anterior to posterior (AP) directions. Overall, 355 (67%) lesions had any displacement in at least 1 direction between MRI-1 and MRI-2 and 205 (38%) in all 3 directions. Median lesion centroid displacement was 0.48 mm (0.10-3.09 mm) and was larger than 1 mm in 66 (12%) lesions. Differences were also observed across tumor histologies (P = 0.01); melanoma brain metastases had the largest magnitude changes. Tumor displacement also differed across various histologies with largest displacement in renal cell carcinoma metastases (P < 0.001). Magnitude of displacement was also significantly associated with tumor location (P = 0.03) with the largest displacement in parietal lobe lesions. Across all lesions, there was a difference in tumor size change in patients treated on corticosteroids (P = 0.01).Volumetric and positional changes can occur during the planning process for SRS and are histology and location specific. Additional analyses are key to understanding the impact of each of these variables, corticosteroids, and systemic therapy to better understand and model tumor dynamics.T. Kutuk: None. R.P. Tolakanahalli: None. A. Williams: None. M.C. Tom: Research Grant; Blue Earth Diagnostics. J.D. Vadhan: None. H. Appel: None. M.D. Hall: Research Grant; Florida Department of Health; Proton Collaborative Group (PCG) Executive Council. D. Wieczorek: None. S.D. Davis: None. M.W. McDermott: Consultant; Stryker, Diende. V. Siomin: None. M.D. Chuong: Research Grant; ViewRay, AstraZeneca. Honoraria; ViewRay, Sirtex, Accuray. Speaker's Bureau; ViewRay, Sirtex, Accuray. Advisory Board; ViewRay, Advanced Accelerator Applications. Travel Expenses; ViewRay, AstraZeneca, Accuray; Particle Therapy Cooperative Group. Manages the operations and activities within the proton center; Miami Cancer. M.P. Mehta: None. A. Gutierrez: Honoraria; ViewRay, Elekta. R. Kotecha: None.

O01 Post-transplant lymphoproliferative disorder (PTLD) in a patient with rheumatoid arthritis

O01 Post-transplant lymphoproliferative disorder (PTLD) in a patient with rheumatoid arthritis

Presurgical Planning with Open-Source Horos Software for Superficial Brain Arteriovenous Malformations

Surgical planning for treating brain arteriovenous malformations (bAVMs) is challenging because it entails visualizing 3-dimensional (3D) relationships between the nidus, its feeding and en passage arteries, and draining veins. Surgical experience in developing the capacity to mentally visualize pathological bAVM angioarchitecture could be complemented by this software, and thus potentially lower the steep learning curve for understanding complex bAVM angioarchitecture. We evaluated the clinical application of freely available online 3D reconstruction software in facilitating visualization of AVM angioarchitecture for presurgical planning. Preoperative Digital Imaging and Communications in Medicine magnetic resonance imaging/magnetic resonance angiography images of 56 superficial bAVMs from 2013 to 2018 were processed using open-source software Horos. 3D rendered images were compared with the surgical view to evaluate software accuracy and determine its value as a preoperative tool. 3D reconstructed images were compared with intraoperative recordings. A useful image identifying both the main feeding artery and draining vein was achieved in 35 of 56 cases (62.5%). Reconstructions of small AVMs (nidus ≤2 cm) and those located within the temporal or cerebellar cortex were less useful due to soft tissue artifacts. Frontal and parietal lobe lesions had significantly higher rates of identifying feeding arteries and draining veins (P < 0.05). Presurgical planning for resection of superficial bAVMs using Horos software allows for a comprehensive 3D analysis of the bAVM angioarchitecture. This technique is most useful for frontal and parietal lobe lesions, and aids the surgeon in formulating an optimal surgical strategy. The 3D reconstruction of the brain surface offers a surgical map not influenced by brain shift.

Three cases of paroxysmal alien limb phenomena due to epileptic seizures and review of literatures

BackgroundThe alien hand phenomenon (AHP) is a rare disorder of involuntary limb movement together with a loss of sense of limb ownership. AHP occurs as a consequence of frontal, callosal, or posterior cerebral lesions. To characterize the phenomenon of AHP, three patients with paroxysmal AHP were described and proved to be focal seizures by using video-EEG monitoring.MethodClinical history of 3 epileptic patients with AHP was collected. EEG and MRI were performed in each patient. One patient completed EEG monitoring and postoperative pathological examination. We also review the recent literatures and summarize the characteristics, types and hypothetic mechanisms of epileptic AHP.ResultsCase 1 had AHP of the left arm followed by the left arm convulsion or AHP only. MRI imaging showed a lesion in the posterior parietal lobe. After complete resection of the lesion, he remained seizure free for 1.5 years. Cases 2 and 3 had AHP and convulsion. The three cases did not have auto-motor signs, so they were identified to be the posterior type of APH.ConclusionsThe mechanism underlying AHP remains poorly .understood. Currently, little is known for the epileptic paroxysmal AHP, a quite rare form of AHP. AHP can be represented before or immediately after convulsion, or be represented by the paroxysmal symptom only.

Extraventricular Neurocytoma in Parietal Lobe

AbstractExtraventricular neurocytoma (EVN) was classified as a World Health Organization (WHO) grade II tumor; however, EVN is not fully understood; it presents a variable histological feature that included oligodendroglioma-like, neuropil-like matrix, ganglion or gangloid cells, perivascular pseudorosettes, vessel hyalinization, calcifications, and myxoid degeneration. In some very rare cases, atypical histological features such as increased mitotic figures, focal necrosis, endothelial cell proliferation, and Ki-67 index of &gt;2% made this tumor more aggressive and more susceptible to recur. We present the case of a young patient who presents with a 2-year history of seizure without other symptoms. Magnetic resonance imaging reveals a parietal lobe and well-circumscribed lesion treated by gross total resection and adjuvant radiotherapy. Clear guidelines to treat this kind of lesions are not well established and there is not a consensus of correct treatment in these tumors.

Xylological Variant of Reverse Fregoli Syndrome, Delusions of Being a Tree

The delusion of being a living animate non-animal object has not heretofore been reported. A 21-year-old right-handed cisgender female, two months prior to presentation, noted stiffness and difficulty with ambulation. One-month prior to admission, she experienced recurrent depression with myriad vegetative and nonvegetative symptoms of depression. On admission her chief complaint was I am a tree, standing motionless and minimally responding to query. After treatment with quetiapine, mirtazapine and hydroxyzine for a one-week period, her perception of being a tree fully resolved. Abnormalities in Mental Status Examination: Anxious mood repeatedly stating, I am a tree. Standing still for long periods of time, refusing blood pressure to be obtained and expressing fear of constricting flow. Neuropsychiatric Testing: Beck Depression Inventory Type II: 33 (severe depression). The rapid response to risperidone is consistent with Cotard's syndrome, which has been noted to respond rapidly to neuroleptics (Sharma, 2014). However, in Cotard's syndrome, replacement by a living non-animal object has not hitherto been reported. Body infestation with animate objects, as in Ekbom syndrome, only includes animals not botanicals (Chaudhary, 2019). This could be viewed as Reverse Inanimate Capgras Syndrome: instead of an imposter replacing a close friend, who then is inserted into the sufferer; a tree has replaced the sufferer. Peradventure, this may fit into the construct of Intermetamorphosis, a misidentification syndrome associated with the belief that individuals have transformed into other persons (Jariwala, 2017). Botanical Intermetamorphosis, the belief by the sufferer that the other individual is transformed from a person into a plant has not been described. Reverse Intermetamorphosis is the projection of an external individual into the person suffering or a syndrome of altered physical and psychological identities of the self (Silva, 1990). However, in this situation, the objects are all human or animate animals not botanicals. In Fregoli syndrome, there is an altered physical identity of others. In Reverse Fregoli syndrome, the sufferer assumes the physical but not the psychological identity of the stranger (Silva, 1990). But in this instance, the stranger is human as opposed to a plant life form. In the current case there is only altered physical identity (into a tree) not psychological identity. The current case may also be interpreted as a Botanical Variant of Interparietal Syndrome. In this condition, parts of the body are perceived to be lifeless, due to lesions of the inferior parietal lobe including supramarginalis gyrus, angular gyrus and the basalis parietalis area (Angyal, 1935). Investigation for those whom have Intermetamorphosis, Fregoli syndrome, Capgras syndrome, Interparietal syndrome, and Cotard's syndrome for the presence of delusions involving plant life is warranted.

Catatonia associated with seizures due to parietal cavernoma.

Catatonia associated with seizures due to parietal cavernoma.

SURG-05. AN AWAKE SURGERY FOR A CHILD SUFFERING FROM EPILEPSY DUE TO DYSEMBRYPLASTIC NEUROEPITHELIAL TUMOR LOCATED IN THE LEFT PARIETAL LOBE

BACKGROUNDAn awake surgery is a useful measure to remove tumors located close to eloquent areas of the brain to reduce surgical complications and maximize the resection. However, it has some disadvantages compared to surgeries under general anesthesia. Generally speaking, applying it to a child under 15 years-old (y/o) is hesitating because of anxiety, poor tolerance, failure to cooperate in tasks and so forth. Here, we present a case of a 13y/o girl who underwent an awake surgery due to dysembryplastic neuroepithelial tumor (DNT) located in the left parietal lobe. CASE PRESENTATION: She consulted our hospital for epileptic seizures. MRI showed a multilocular mass lesion in the left parietal lobe. The tumor was located in or close to eloquent areas. The epilepsy was refractory even with multiple antiepileptic drugs (AEDs). A Wada examination revealed that her speech area is on the left hemisphere. The operations were performed in two stages. Prior to the operations, we had several thought-out simulations in the operating room and ICU with her, her parents, and our staff including nurses and lab technicians. The first operation was to perform tumor biopsy and place intracranial electrodes. The histological diagnosis was DNT. Video electroencephalogram showed that the epileptogenic lesion was around the tumor. The second operation resulted in total tumor resection and reduction of paroxysmal epileptic spikes without major complications. She is seizure free for more than three years with two AEDs.CONCLUSIONCareful preparations may enable an awake surgery even for a child under 15y/o.

Association between stroke lesions and videofluoroscopic findings in acute stroke patients.

We aimed to assess stroke lesions, which play a key role in determining swallowing dysfunction, and findings of videofluoroscopy (VF), which provides the most accurate instrumental assessment for evaluating swallowing function, in patients with acute stroke. We enrolled 342 patients with first-time acute stroke (age 70.4 ± 12.6years, 142 female). Patients with dementia and altered mental status due to severe stroke were excluded. All patients underwent cranial magnetic resonance imaging to identify the location of stroke lesion, VF, and tongue pressure measurement. Aspiration was detected in 45 (13.2%) patients. Multivariate analysis identified parietal lobe lesion and the National Institutes of Health Stroke Scale (NIHSS) score as independent significant factors for aspiration (odds ratio 6.33, 95% confidence interval [CI] 2.25-17.84, p < 0.001; odds ratio 1.12, 95% CI 1.03-1.20, p = 0.004, respectively). Swallowing reflex delay was detected in 58 (17.0%) patients. Multivariate analysis identified habitual drinking, basal ganglia lesion, and the NIHSS score as independent significant factors for swallowing reflex delay (odds ratio 0.51, 95% CI 0.26-0.99, p = 0.047; odds ratio 1.91, 95% CI 1.09-3.67, p = 0.041; odds ratio 1.12, 95% CI 1.05-1.20, p < 0.001, respectively). Additionally, oral cavity and pharyngeal residues were independently associated with tongue pressure. Parietal lobe lesions are associated with aspiration and basal ganglia lesions with swallowing reflex delay.

Solitary cerebral metastasis from undiagnosed prostate cancer. Potential role of multiparametric MRI prostate in pre-treatment diagnostic protocols

A 73-year-old man presented with a three-week history of weakness and loss of co-ordination of the left-hand side and weakness of left-hand grip. MRI brain revealed an enhancing lesion in the right parietal lobe, adjacent to the central sulcus, with surrounding oedema and a small satellite lesion in motor cortex. Body CT and FDGPET CT revealed no obvious primary neoplasm. The patient underwent craniotomy with resection of the lesion, subsequent histopathology confirmed a metastatic carcinoma of likely prostate cancer primary origin. The patient was on 5-ARI (Finasteride) for lower urinary tract symptoms that decrease serum PSA levels to half and had benign feeling prostate on digital rectal examination (DRE). Subsequent MRI prostate confirmed presence of a lesion with very high probability of prostate cancer. The patient’s serum Prostate Specific Antigen (PSA) level was 6.8 (13.6 corrected for Finastride) which is relatively low in the context of metastatic disease. Given the recent NICE guidelines of using pre-biopsy multiparametric MRI (mpMRI) for diagnosis of prostate cancer, we suggest that in patients with cerebral metastases of unknown primary, with negative body CT, FDG PET-CT, low PSA and negative DRE, mpMRI prostate should be included in diagnostic protocol in the selected group of men, to enable early diagnosis and performing more suitable and targeted treatment. Keywords: Brain metastasis; prostate cancer; multiparametric MRI; metastasis of unknown origin

Gerstmann syndrome as a disconnection syndrome, evidence from DTI tractography: A case report

Gerstmann's syndrome is a syndrome caused by lesions of the dominant parietal lobe. It has historically been a subject of dispute as it is often accompanied by other neuropsychological deficits such as aphasia. Novel neuropsychological tests and neuroimaging techniques have lately changed the perspective allowing to decode a conjunction of symptoms like Gerstmann's. In our case, we present Diffusion Tensor Imaging Tractography findings of a patient who acutely exhibited Gerstmann's tetrad. Using advanced structural neuroimaging we tested a hypothesis that up until recently could only be challenged post mortem. Our study offers much needed patient neuroimaging data helping to establish Gerstmann's as a disconnection syndrome. More reports of Gerstmann's syndrome patients including high resolution tractography and fMRI data are needed.

Implicit-statistical learning in aphasia and its relation to lesion location

BackgroundImplicit-statistical learning (ISL) research investigates whether domain-general mechanisms are recruited in the linguistic processes that require manipulation of patterned regularities (e.g. syntax). Aphasia is a language disorder caused by focal brain damage in the left fronto-temporal-parietal network. Research shows that people with aphasia (PWA) with frontal lobe lesions manifest convergent deficits in syntax and ISL mechanisms. So far, ISL mechanisms in PWA with temporal or parietal lobe lesions have not been systematically investigated. AimsWe investigated two complementary hypotheses: 1) the anatomical hypothesis, that PWA with frontal lesions display more severely impaired ISL abilities than PWA with posterior lesions and 2) the behavioural hypothesis, that the magnitude of impairment in ISL mechanisms correlates to syntactic deficits in aphasia. MethodsWe tested 13 PWA, 5 with frontal lesions and 8 with posterior lesions, and 11 non-brain-damaged controls on a visual statistical learning (VSL) task. In addition, all PWA completed several linguistic tasks. Reaction times, obtained in the VSL task, were analyzed using linear mixed-effects model. Correlational statistics were used to assess the relationship between VSL task performance and linguistic measures. Results and DiscussionWe did not find support for the anatomical hypothesis as patients with spared frontal regions also manifested impaired ISL mechanisms. This is attributed to a) ISL mechanisms being vulnerable to other cognitive dysfunctions and/or b) ISL mechanisms anatomically extending to the posterior brain regions. Notably, ISL mechanisms were impaired, but not absent in aphasia. With regards to the behavioural hypothesis, we provide empirical evidence of correlation between ISL mechanisms and syntactic, but not lexical impairment in aphasia. We discuss both the theoretical contributions to the debate of domain-independence of ISL mechanisms and clinical implications for implicit language therapy.

A rare case of fatal cerebral phaeohyphomycosis caused by Cladophialophora bantiana in an immunocompetent individual in India.

Background and Purpose: Herein, we describe a rare case of fatal cerebral phaeohyphomycosis by Cladophialophora bantiana in an immunocompetent individual without any underlying risk factors.Case report: A 55-year-old female presented with a short history of fever for 1 month, as well as headache, sudden onset of right-sided upper and lower limb weakness, and loss of speech for 10 days. Contrast-enhanced magnetic resonance imaging scan revealed large, peripherally enhancing, well-defined, cystic, space- occupying, axial lesion in the left parietal lobe with a mass effect. The patient was subjected to craniotomy, and the drained pus revealed pigmented septate hyphae in potassium hydroxide mount examination, which was identified as Cladophialophora bantiana. The patient was started on amphotericin B and voriconazole. However, she developed acute respiratory infection leading to multi-organ failure and death on day 27 post-operation.Conclusion: In the absence of comparative trials owing to the rarity of the disease, the radical resection of lesion, drainage of pus, and prolonged targeted antifungal therapy with close postoperative radiological surveillance are the therapeutic measures of choice for patients with brain abscess caused by phaeoid fungi.