Left Lower Extremity Weakness Research Articles

Clinical Reasoning: A young adult presents with focal weakness and hemorrhagic brain lesions

A 25-year-old man who emigrated from Mexico 5 years ago presented with headache, altered mental status, and left hemiparesis. Initial history obtained from collateral sources indicated the patient had complained of a headache of increasing severity for the past 2 months. Two weeks prior to presentation, he experienced malaise, decreased appetite, nausea and vomiting, visual changes, and gait difficulties resulting in 2 falls. The day of presentation, he developed acute onset left upper and lower extremity weakness prompting emergency evaluation. On arrival he was lethargic, disoriented, and did not follow commands. Following intubation in the emergency department, he was transferred to the neurologic intensive care unit (ICU). He was febrile and tachycardic on arrival to the ICU. Upon cessation of sedation, the patient was ill-appearing but awake and able to cooperate with the neurologic examination. He was oriented to hospital name and year and was able to follow one-step commands. His pupils were equal, round, and reactive to light and accommodation. Bedside funduscopic examination showed normal discs and vessels. His extraocular movements were full except for the inability to adduct his right eye. He blinked to threat bilaterally but had left-sided visual neglect with a right gaze preference. He had left lower facial weakness. On motor examination, he had left flaccid paralysis as well as mild decreased strength in his right upper and lower extremities (4+/5) that might have been attributable to incomplete cooperation. Sensation was intact to light touch on the right but only to noxious painful nail bed stimulation on the left. Reflexes were brisk on the right and diminished on the left. He had a left Babinski sign. Head CT revealed 2 foci of hemorrhage in the right frontal and parietal lobes with associated vasogenic edema (figure 1). Figure 1 CT findings Two foci of hemorrhage are …

Unusual magnetic resonance imaging appearance of multiple cystic lesions in glioblastoma multiforme

The differential diagnosis of multiple ring-enhancing intraaxial lesions includes neoplastic, infectious, inflammatory, demyelinating and vascular lesions. We report a case of a 41-year-old man who presented with a brief history of left lower extremity weakness and sensory loss. Magnetic resonance imaging demonstrated multiple ring-enhancing lesions in the right frontal and parietal lobes. Neuroradiology interpretation was felt to be unlikely for a neoplastic process. The patient underwent stereotactic brain biopsy, which was diagnostic for glioblastoma multiforme. This case demonstrates the importance of histological confirmation of intraaxial brain lesions whenever feasible. The course of his disease and treatment are discussed and the literature reviewed.

Air Myelopathy Following a Cervical Epidural Injection

Epidural injections are commonly utilized procedure in pain clinics; these procedures are not without complications. We present a rare air entrapment within the substance of the spinal cord causing symptoms of myelopathy. Report of a case. A 56-year-old woman with chronic cervical pain underwent an elective cervical epidural injection. A small amount of Lidocaine was injected at the left cervical 7 to test needle patency; she immediately complained of severe cervical pain radiated to the left upper and lower extremities. The procedure was immediately terminated and needle was removed. Post-operative neurological examination revealed mild left lower extremity weakness and left hemiataxia. An immediate MRI of the cervical spine showed an air bubble within the cervical spinal cord that has resolved on the following imaging. The clinical syndrome also completely resolved. Although rare, epidural cervical injection can be complicated by air myelopathy.

Congenital paraspinal Ewing sarcoma family of tumors with an epidural extension

Congenital Ewing sarcoma family of tumors (ESFT) is a rare disease, and only 12 patients have been reported. Among those patients, only two had paraspinal tumors with an epidural extension. A 3-week-old infant boy presented with a huge dorsal mass. Whole-spine MRI scans showed a paraspinal mass with an epidural extension from the T11 to L2 levels, causing severe spinal cord compression. An initial operation was performed to confirm the pathological diagnosis. Twenty days after the first operation, the patient showed left lower-extremity weakness. A second operation was performed with a laminectomy from the T11 to L2 levels, and the epidural mass was radically resected. Pathologically, the tumor was confirmed as an ESFT. The patient received adjuvant chemotherapy. His neurological deficit recovered after the second surgery, and there was no tumor recurrence during 17 months of follow-up.

Persistent Increase of Cardiac Troponin I in Plasma without Evidence of Cardiac Injury

A 69-year-old man with diabetes mellitus type II, hypertension, dyslipidemia, and prior ischemic strokes presented to the emergency department with complaints of balance difficulties and inability to stand unassisted of 2 weeks’ duration. The patient’s home medication regimen included atenolol, lisinopril, amlodipine, metformin, and glipizide. He is a retired chef and a former smoker (20 pack-years). He has 2 brothers, both of whom had myocardial infarctions in their 50s. The patient’s physical examination was remarkable for frequent premature contractions, left lower extremity weakness, and impaired coordination. His electrocardiogram revealed sinus rhythm with frequent premature ventricular contractions and diffuse nonspecific T-wave abnormalities. Results of a comprehensive metabolic chemistry panel were within the reference intervals except for increases in glucose (158 mg/dL; reference interval, 74–99 mg/dL) and creatinine (1.5 mg/dL; reference interval, 0.7–1.3 mg/dL). The hemoglobin A1c value was 7.4% (reference interval, <6.0%). Cardiac troponin I (cTnI)1 concentrations were increased at 0.27, 0.22, and 0.25 μg/L (Abbott Architect assay; 99th percentile, <0.03 μg/L) over a span of approximately 8 h. The patient was admitted to the cardiology service on the basis of these abnormal results. A transthoracic echocardiogram revealed a preserved left ventricular systolic function with evidence of impaired diastolic filling. A cardiac catheterization evaluation revealed an ulcerated plaque in the left anterior descending artery with >70% stenosis, which was treated with a bare-metal stent. The presenting symptom of balance difficulty failed to resolve after the coronary intervention, and the patient remained unable to stand unassisted. A neurologic evaluation included magnetic resonance imaging, which found no evidence of an acute stroke. He was discharged with a diagnosis of orthostatic hypotension. Three months later, the patient presented to the emergency department with several days of balance difficulty. The initial cTnI value was increased at 0.10 μg/L, prompting admission to the cardiology …

Stroke in Sickle Cell Anemia After Excellent Response to Hydroxyurea.

Abstract 4622 IntroductionStrokes occur in about 10% of children with sickle cell anemia (SS) less than 10 years old. These strokes are usually ischemic in nature. Stroke due to SS in adults is less common and is usually hemorrhagic in nature. We wish to report an unusual adult patient with SS and excellent response to HU who developed a stroke that was unrelated to SS. Case Report and ResultsA 35-year-old female with sickle cell anemia had mitral valve prolapse and migraine headaches presented 2 days after developing abrupt bilateral blurry vision, left facial numbness and weakness of her left leg. Her SS has been complicated by acute chest syndrome, bilateral hip avascular necrosis and frequent painful crises prior to hydroxyurea (HU) therapy. She was enrolled in the multicenter study of hydroxyurea (MSH) in SS and has been on 2500mg of HU per day for the past 13 years. She had an excellent response to HU with no recurrent acute chest syndrome and decreased need for blood transfusion. After starting HU, the frequency of crises requiring hospital admission decreased from 1 admission every 1 to 2 months to less than 1 admission per year except when hydroxyurea was discontinued for pregnancy. Her fetal hemoglobin increased from 6.1 % before HU to a maximum of 45%. Her MCV increased from 96 fl to a maximum of 132 fl and Hb from 8.0 g/dl to 9.8 g/dl Her exam was remarkable for left lower extremity weakness which was more pronounced proximally. All cranial nerves were intact and there was normal sensation bilaterally. CT scan of the brain showed three foci of hypodensity and MRI of the brain showed increased signal on T2, FLAIR and diffusion weighted images within the frontoparietal deep white matter consistent with infarction in the border zone of the middle cerebral artery (MCA)-anterior cerebral artery (ACA). MR angiography of the intracerebral and extracerebral vessels demonstrated focal narrowing of the right MCA at the trifurcation suggesting an embolic cause. Common causes of stroke were ruled out with routine studies. Her hemoglobin electrophoresis after admission but before blood exchange transfusion showed HbS of 55% and HbF of 45%. She underwent exchange transfusion 2 days after admission and was started on chronic blood exchange transfusions with the assumption that she had ischemic stroke due to SS. Initial transthoracic echocardiogram with contrast injection did not show an atrial shunt. Follow-up transesophageal echocardiogram after discharge showed a secundum atrial septal defect with a defect size of 1.4 cm. Right heart catheterization was performed and the pulmonary flow to systemic flow (Qp/Qs) was 1.7:1. An Amplatzer atrial septal defect (ASD) closure device was deployed with transesophageal echocardiographic guidance and a large thrombus was removed from the right atrium. At the patient's request exchange red cell transfusions were discontinued. The patient has continued treatment with hydroxyurea and aspirin. ConclusionsYoung patients with cryptogenic stroke have a much higher prevalence of atrial shunts and in particular patent foramen ovale than patients with other forms of stroke and therefore a cause-effect association is suggested. Young adults with stroke should be evaluated for common and reversible causes of stroke including paroxysmal emboli. Transesophageal echocardiography is the gold standard for diagnosing atrial shunts. Strokes in patients younger than age 55 are related to paroxysmal emboli and have a risk of recurrence of approximately 30% within one year. High risk features for stroke recurrence with an atrial shunt include hypercoagulable states, large opening and presence of an atrial septal aneurysm. Optimal management of patients with a stroke and an atrial shunt is unknown. Options include surgical closure, percutaneous device closure, anticoagulation and antiplatelet therapy. Patients with sickle cell disease and stroke should receive long term blood transfusions to reduce HbS below 30% if the stroke is felt to be related to sickle cell disease vasculopathy. The patient described with SS had a stroke and had an atrial septal defect that was repaired. The MRI/MRA findings are consistent with paroxysmal emboli. The patient is receiving treatment with hydroxyurea and aspirin having discontinued red cell exchange transfusions and at two years of follow-up has not had a recurrent stroke. Disclosures:No relevant conflicts of interest to declare.

The Recovery of Running Ability in an Adolescent Male After Traumatic Brain Injury: A Case Study

The purpose of this case study was to document outcomes after a rehabilitation program in an adolescent male after traumatic brain injury. Three years after sustaining an injury in a skiing accident, a 17-year-old boy participated in a rehabilitation program with the goal of acquiring the ability to run one mile with his peers. On initial evaluation, the individual had significant left lower extremity weakness, impaired standing balance, limited endurance, and running limitations. He was able to run 10 m wearing a plastic ankle-foot orthosis on the left side but required supervision for safety. The intervention included strength training once weekly for 17 weeks, body weight-supported, treadmill-based locomotor training once weekly for 15 weeks followed by a combination of overground locomotor training and strengthening exercise once weekly for six weeks. After the intervention, muscle strength of the lower extremities increased and the individual was able to run one mile independently. The quality of his running improved, with better mechanics to absorb forces at impact during the absorption phase and increased lower extremity extension during the propulsion phase. A rehabilitation program consisting of strengthening and locomotor training improved running speed, quality, and endurance in an adolescent male after traumatic brain injury. He was able to progress to a less restrictive carbon fiber brace as a result of gains in lower extremity strength. This change in ability allowed him to participate in physical education by running on a track and playing softball with his peers.

Extensive and Largely Reversible Ischemic Cerebral Infarctions in a Prepubertal Child with Hypertension and Cushing Disease

A 10-yr-old boy with Cushing’s disease (CD) suffered an acute ischemic infarction after transsphenoidal surgery. The patient presented with weight gain, poor growth, hypertension, and other classic symptoms of CD. The hypertension was difficult to control despite therapy with multiple agents; blood pressure averaged at 150/90 mm Hg with brief elevations as high as 220/120 mm Hg. Laboratory evaluation revealed classic biochemical features of CD (1); magnetic resonance imaging (MRI) of the brain revealed a microadenoma that was removed via transsphenoidal surgery. Two days postoperatively, the patient developed left lower extremity weakness and was lethargic. Postoperative MRI of the brain showed abnormalities typical for acute ischemic infarction using fluid-attenuated inversion recovery (FLAIR) as well as diffusion-weighted imaging; these abnormalities were not present on preoperative MRI (Figs. 1​1 and 2​2).). He was found to be a carrier of the prothrombin 20210 G-to-A polymorphism but the rest of the workup (including factor V leiden, lupus anticoagulant, protein C, and protein S) was entirely normal. Anticoagulation therapy with heparin was started, followed by aspirin. The patient received physical therapy and was able to ambulate on discharge. By his 8-month visit, the patient had no residual motor deficits. Follow-up MRI revealed minimal scarring 2 yr after the event (Fig. 3​3),), and the patient has fully recovered. Figure 1 Preoperative MRI of the brain: A, T2-weighted; B, FLAIR; C, diffusion-weighted. There are no brain abnormalities present. Figure 2 Brain images obtained 2 d after surgery using identical techniques as in Fig. 1​1.. A, T2-weighted images show no definite brain lesions. However, FLAIR (B) as well as diffusion-weighted (C) images reveal abnormal areas of increased signal intensity ... Figure 3 Brain MRI obtained 2 yr after surgery. A and B, T2-weighted (A) and FLAIR (B) images show small glial scars in two of the ischemic infarctions previously identified in the right cerebral hemisphere; the third infarction had completely resolved. C, Diffusion ... Hypertension is a common feature in children with CD, and conventional antihypertensives may only be partially effective (2,3). CD is also a hypercoaguable state associated with increased incidence of thromboembolic complications, especially after surgery (4). Hypertension is a known major risk factor in cerebral infarctions and may be overlooked in the pediatric population. Annual incidence rates for pediatric arterial ischemic stroke (AIS) have ranged from 0.6–7.9 per 100,000 children per year. AIS is more common in males than females and blacks compared with whites; reported outcomes for AIS in children reveal that on average up to 30% of children were neurologically normal at follow-up (5). This is the first report of an ischemic stroke in a child with CD. Hypertension and hypercortisolemia were risk factors for the acute ischemic event in our patient. Early recognition and treatment of hypertension in patients with CD is important to avoid possible cerebrovascular complications; the prognosis appears to be good, if recognized and treated early.

Painless Acute Aortic Dissection Presenting as Left Lower Extremity Weakness and Numbness

Acute aortic dissection usually presents with a sudden, painful, tearing sensation in the chest or back. However, acute aortic dissection may also present atypically without pain and with solely neurological symptoms. We describe a case of painless acute aortic dissection which presented as acute left lower extremity weakness and numbness. These neurological symptoms are due to vascular occlusion causing peripheral ischaemic neuropathy. It is imperative to consider acute aortic dissection in the differential diagnosis of acute neurological syndromes.

Persistent primitive hypoglossal artery with retrograde flow from the vertebrobasilar system: a case report

The persistent primitive hypoglossal artery (PPHA) is one of the pairs of arterial connections that exist in the human embryo between the developing anterior and posterior circulation. Normally the PPHA arises from the cervical internal carotid artery (ICA) and passes through the hypoglossal canal to join the caudal basilar artery (BA). In most cases the vertebral arteries (VA) are either hypoplastic or aplastic and the posterior communicating arteries (PComA) are absent; thus, the main supply to the posterior circulation comes from the internal carotid via the PPHA in an antegrade fashion. Atherosclerotic plaques in the ICA and PPHA present with ischemic symptoms of both the carotid and vertebrobasilar systems. We report a case of a 53-year-old female who presented with a transient episode of left lower extremity numbness and weakness. Work-up with computed tomography (CT) and magnetic resonance imaging (MRI) showed a small watershed infarct in the right middle cerebral artery (MCA)/posterior cerebral artery (PCA) territory. Diagnostic angiography revealed severe proximal stenosis of the cervical ICA and presence of a PPHA just above the stenosis with retrograde filling from the vertebrobasilar junction to the distal cervical ICA. The patient underwent a carotid endarterectomy with intraoperative EEG monitoring. Intraoperative blood flow measurements were made before and after endarterectomy showing evidence of reversal of blood flow to a normal antegrade fashion. The postoperative angiogram showed resolution of the right ICA stenosis and persistence of the PHA. To our knowledge this is the first case report of a PPHA exhibiting reversal of blood flow from the posterior into the anterior circulation. Awareness of this embryological anomaly and its interaction with acquired atherosclerotic disease will minimize misinterpretation of vascular diagnostic studies.

The use of an expandable cage for corpectomy reconstruction of vertebral body tumors through a posterior extracavitary approach: a multicenter consecutive case series of prospectively followed patients

Background context Posterior decompressions in the form of laminectomies for vertebral body tumors have poor outcomes. Surgical management typically requires anterior decompression and reconstruction; however, these procedures can be associated with significant morbidity and mortality. Purpose To evaluate the feasibility of anterior spinal column reconstruction using an expandable cage through a posterior approach. Study design/setting Multicenter consecutive case series of 21 prospectively followed patients. Patient sample Twenty-one patients with vertebral body tumors treated with anterior and posterior resection and reconstruction from a single posterior approach were followed prospectively. Outcome measures Pre- and postoperative neurologic status, number of levels instrumented and fused, length of surgery, length of stay after surgery, and complications related directly or indirectly to surgery were analyzed. In addition, pre- and postoperative radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans were evaluated for involvement of the vertebral body and associated posterior elements. Particular attention was paid to the presence of either unilateral or bilateral pedicle and/or middle column involvement. Methods Patients were placed in a prone position on a rotating radiolucent table. Corpectomy was performed from an extracavitary approach, and anterior column reconstruction was completed with an expandable cage. The posterior tension band and spinal fusion was completed with segmental pedicle screw fixation and performed through the same posterior exposure. No patient required a separate anterior procedure. Results Patients' average age was 60.3 years (range, 17–78); there were 12 women and 9 men. Eighteen underwent single-level corpectomies (11 thoracic and 7 lumbar), and 3 underwent two-level corpectomies (T4–T5, T11–T12, and T12–L1). Average estimated blood loss (EBL) and length of surgery per level were 1,360 cc (range, 200–2,500) and 5.3 hours (range, 2.7–8.6), respectively. Average postoperative stay was 4.7 days. Nine patients had at least one partial motor grade improvement. One patient had postoperative left lower extremity weakness after surgical decompression and reconstruction secondary to iatrogenic nerve root traction but remained ambulatory. No chest tubes or postoperative bracing was required. At the most recent follow-up, six patients were alive at an average of 16.1 months (range, 3–33). For the 15 patients who died, the average life span after surgery was 6.8 months (range, 1–16). In addition to the iatrogenic nerve root injury, one cage required repositioning on postoperative Day 2 and one cage demonstrated radiographic evidence of settling but did not require surgical intervention; there were no deep venous thromboses (DVTs), pneumothoraces, pneumonias, ileus, or other complications, with a total complication rate of 14.3%. Conclusions This is the largest study that specifically examines the use of an expandable cage through a posterior extracavitary approach for reconstruction after vertebral body tumor resection. The use of an expandable cage combined with an extracavitary approach is feasible and allows the surgeon to address both the anterior and posterior columns through a single incision. Although technically challenging, both one- and two-level corpectomies in the thoracic and/or lumbar spine can be performed with this technique. Furthermore, insertion of the expandable cage in the collapsed position and then expansion in situ after implantation allowed for all lumbar reconstructions to be completed without sacrificing any of the lumbar nerve roots. Our 14.3% complication rate is similar to those reported in anterior-alone and circumferential spinal procedures.

Multiple sclerosis, brain radiotherapy, and risk of neurotoxicity: The Mayo Clinic experience

The aim of this study was a retrospective assessment of neurotoxicity in patients with multiple sclerosis (MS) receiving external beam radiotherapy (EBRT) to the brain. We studied 15 consecutively treated patients with MS who received brain EBRT. Neurologic toxicity was assessed with the Common Toxicity Criteria v.3.0. Median follow-up for the 5 living patients was 6.0 years (range, 3.3-27.4 years). No exacerbation of MS occurred in any patient during EBRT. Five patients had Grade 4 neurologic toxicity and 1 had possible Grade 5 toxicity. Kaplan-Meier estimated risk of neurotoxicity greater than Grade 4 at 5 years was 57% (95% confidence interval, 27%-82%). Toxicity occurred at 37.5 to 54.0 Gy at a median of 1.0 year (range, 0.2-4.3 years) after EBRT. Univariate analysis showed an association between opposed-field irradiation of the temporal lobes, central white matter, and brainstem and increased risk of neurotoxicity (p < 0.04). Three of 6 cases of toxicity occurred in patients treated before 1986. External beam radiotherapy of the brain in patients with MS may be associated with an increased risk of neurotoxicity compared with patients without demyelinating illnesses. However, this risk is associated with treatment techniques that may not be comparable to modern, conformal radiotherapy.

Retroperitoneal False Aneurysm Presenting as Anterior Thigh Pain and Weakness: A Case Report

Dholakia M, Kupfer M, Sher L, Dimuzio P, Freedman MK. This case highlights the importance of considering retroperitoneal pathology in the differential diagnosis of anterior thigh pain and weakness. We describe a woman in her mid seventies with a history of a left total hip arthroplasty and lumbar decompression who presented with left anterior thigh pain and left lower-extremity weakness. A computed tomography scan of the retroperitoneum revealed a mass along the left iliopsoas muscle. An arteriogram revealed a large false aneurysm that communicated with the left common femoral artery. Surgery to resect the aneurysm revealed exposed parts of the hip replacement that may have contributed to the formation of the aneurysm. We concluded that imaging of the retroperitoneum should be considered in any patient presenting with anterior thigh pain and weakness.

Images in Emergency Medicine

A 58-year-old man presented to the emergency department complaining of acute onset of interscapular and left shoulder pain, with associated left lower extremity weakness. Vital signs included a blood pressure of 240/112 mm Hg. Physical examination revealed complete paresis of the left lower extremity, moderate weakness of the left hand and forearm, and decreased pinprick sensation on the right extending to the C8/T1 level. Peripheral vascular and cardiopulmonary examination results were normal. Ancillary study results were unremarkable. Computed tomography revealed no evidence of thoracic aortic dissection. Magnetic resonance imaging (MRI) of the cervical and thoracic spine was obtained (Figure).

Metastatic Melanoma Presenting as a Massive Abdominal Mass with Lower Extremity Radiculopathy

Purpose: The purpose of this case report is to highlight the unusual and often vague presentations of melanoma metastatic to the abdomen. Case: A 63 year old male with past history of prostrate cancer and surgically resected left arm melanoma, presents with left lower extremity pain and weakness, one month after finishing brachytherapy for prostrate cancer. In the following months patient was evaluated for sciatica, claudication and DVT with normal doppler studies and x-rays of the lumbar spine and pelvis. The lower extremity parasthesias and paresis progressively worsened in this 8 month period requiring the patient to use a cane for ambulation. Patient also had 40-lb weight loss with anorexia but no other gastrointestinal complaints. At admission the abdominal exam revealed a large palpable mass extending from the midline to the left flank. Catscan of abdomen/ pelvis revealed a massive 11×14 left abdominal mass with multiple nodular masses in the mesentery. FNA biopsy showed a poorly differentiated non-small cell carcinoma with following immunochemistry: HMB-45: positive Vimentin: strongly positive S-100: focal weak positive PSA: negative CK7: negative Cytokeratin: negative The above findings were consistent with metastatic melanoma. An MRI of the spine done for worsening paraparesis showed cauda equina compression requiring radiation therapy. However the patient was unable to undergo further treatment due to his deteriorating clinical status and succumbed to complications of the malignancy. Discussion: Malignant melanoma metastastic to the abdomen has a clinical diagnostic rate of just 2%, in contrast to 60% of autopsies that are found to have gastrointestinal involvement in patients that died with disseminated disease. Most cases of metastatic melanoma to the gastrointestinal tract present with vague symptoms of weakness, fatigue, abdominal pain and anemia. Our case report is very unusual in that it presented as a huge abdominal mass with mesenteric invovlement and lower limb radiculopathy. It also highlights the need for early imaging which is effective in ascertaining the extent of disease and the potential benefit of surgery as complete resection of metastasis is associated with prolonged survival. Conclusion: The presentation of melanoma metastatic to the gastrointestinal tract is vague and requires early investigation of symptoms as curative surgery can prolong survival.

Poster 150: Sciatic Nerve Palsy Secondary to Spontaneous Large Gluteal Hematoma With Enoxaparin: A Case Report

Setting: Tertiary care hospital. Patient: A 43-year-old lady with multiple medical problems including SLE, antiphospholipid syndrome, history of multiple deep venous thrombosis, and pulmonary embolisms, on enoxaparin, with low back pain (LBP) and history of hemorrhagic cerebrovascular accident. Case Description: The patient (weight, 127kg) was on 120mg of enoxaparin subcutaneously BID for anticoagulation. She was admitted to medicine floor with 1 week of worsening LBP radiating to left lower extremity and new onset of left lower-extremity weakness. She denied any traumatic event to her low back and left leg. Magnetic resonance imaging of lumbar spine showed mild disk bulging and facet and ligamentous hypertrophy at L4-5, without significant neural compression. Routine admission blood test revealed decreased hemoglobin and hematocrit to 5.7 and 17.4 from 13.1 and 38.2 one week earlier and physical exam found large ecchymosis at left buttock, thigh and groin regions, and complete sciatic nerve palsy. Computed tomography of left thigh revealed a large left gluteal hematoma extending inferiorly within the biceps femoris compartment. Enoxaparin was discontinued, and the patient was transferred to acute inpatient rehab unit. Assessment/Results: Electromyography confirmed left sciatic nerve lesion with signs of increased insertional activity in the tibialis anterior, peroneus longus, and medial head gastrocnemius, significant 3+ fibs/positive sharp waves in the peroneus longus and gastrocnemius medial head. Left semimembranosus and vastus medialis showed decreased recruitment with normal insertional activity. Patient’s function improved in spite of left sciatic nerve palsy. Discussion: This is the first reported case, to our knowledge, of intermuscular hematoma causing complete sciatic nerve palsy with therapeutic dose of enoxaparin. Conclusions: Spontaneous intermuscular bleeding is one of potential adverse effects, needing close surveillance and vigilance.

Control of refractory status epilepticus precipitated by anticonvulsant withdrawal using left vagal nerve stimulation: a case report

Objective To describe a case of left vagal nerve stimulation (VNS) resulting in immediate cessation of status epilepticus (SE) with good neurological outcome. Case Description A 30-year-old man with medically intractable seizures including episodes of SE was successfully treated using left VNS. After requiring discontinuation of phenytoin, valproic acid, carbamazepine, and topiramate because of severe allergic reactions resembling Stevens-Johnson syndrome, the patient required pentobarbital coma along with phenobarbital, tiagabine, and levetiracetam for seizure frequency reduction. He underwent left vagal nerve stimulator placement after nearly 9 days of barbiturate-induced coma, with stimulation initiated in the operating room. On the following day, electroencephalography revealed resolution of previously observed periodic lateral epileptiform discharges and the patient was free of seizures. Prestimulation seizure frequency was recorded at 59 times a day, with some seizures enduring 45 minutes despite barbiturate coma. Poststimulation, the patient has been free of seizures for 19 days and is presently taking only levetiracetam and phenobarbital, from which he continues to be successfully weaned without seizures. He is awake, alert, and can recall events leading up to his seizures, with good long-term memory and residual left upper extremity and lower extremity weakness. Conclusion This case illustrates the role of left vagal stimulation in the treatment of SE and otherwise medically intractable seizures caused by allergic reactions. To our knowledge, this is the first case in the world literature for adults reporting cessation of SE after VNS. Another case with a similar improvement has been reported in the pediatric population.

A Retroperitoneal Mass in an Elderly Woman

71-year-old nun living in a convent was seen by her primary physician because of persistent left abdominal flank discomfort during the previous 6 months. This was accompanied by a 15-lb weight loss and left lower extremity weakness, numbness, and pain on ambulation. Except for systemic hypertension, her past medical history was unremarkable. On physical examination, a tender mass was palpated in her left lower abdomen. The pain elicited by palpation radiated to the left hip and groin areas. There was also contracture of the left hip that was painful on straightening. Results of laboratory examinations were within normal limits. Computed tomographic scanning revealed a large enhancing left retroperitoneal soft tissue mass juxtaposed to the left iliac bone that involved the left iliopsoas and the inferior extent of the left psoas muscle (Figure 1). A subsequent computed tomography‐guided fine-needle aspiration biopsy of the retroperitoneal mass was consistent with a malignant neoplasm. The patient was referred to Loyola University Medical Center for surgical management, and the radiologic survey for metastatic lesion was negative. Preoperative embolization of 2 lumbar vessels and a branch of the iliac artery that supplied the tumor was performed. During the surgical resection, the retroperitoneal mass was noted to be closely associated with the left iliacus and left psoas muscles and to be encasing a segment of the left femoral nerve. Except for extrinsic compression, the adjacent visceral organs, including the lumbosacral vertebrae, were not involved by the tumor.

Dilute Infusion for Labor, Obscure Subdural Catheter, and Life-Threatening Block at Cesarean Delivery

Dilute Infusion for Labor, Obscure Subdural Catheter, and Life-Threatening Block at Cesarean Delivery

MIXED GERM CELL TUMOR OF THE TESTICLE PRESENTING WITH A SACROCOCCYGEAL MASS AND NO EVIDENCE OF RETROPERITONEAL ADENOPATHY

M. W., a 42-year-old man, presented with painless enlargement of the left testicle and right lower extremity weakness associated with low back pain. Physical examination revealed a firm mass in the left testicle and right lower extremity weakness associated with decreased sensation corresponding to spinal cord levels L4-S1. Lactic dehydrogenase and p human chorionic gonadotropin were elevated at 478 and 40, respectively, and (Y fetoprotein was normal. Scrotal ultrasound demonstrated a heterogeneous, solid left testiculac mass (fig. 1). Computerized tomography (CT) of the abdomen showed no evidence of retroperitoneal adenopathy. Magnetic resonance imaging of the spine revealed a sacral mass within the epidural space abutting the nerve roots SlS3. Left radical orchiectomy was performed. Pathological FIG. 2. CT guided fine needle aspiration reveals sacral mass evaluation &owed a mixed germ cell t~mor composed of seminoma, mature teratoma and embryonal cell carcinoma. CT guided aspiration of the sacral mass revealed cellular characteristics consistent with seminoma (fig. 2).