Nerve coblation for treatment of trigeminal neuralgia: A case report

BACKGROUND Trigeminal neuralgia(TN) is a severe type of neuropathic pain which is often inadequately managed using conventional therapies. In this report, we present the first case of TN treated with gasserian ganglion nerve coblation(NC).CASE SUMMARY A 58-year-old man presented with right facial pain, mostly localized in the right zygomatic zone, alveolar region, and jaws. Similar to acupuncture and shock pain, the pain lasted about five seconds after each attack before resolving unaided. A diagnosis of TN was made, after which treatment with acupuncture therapy and oral carbamazepine was given. However, the pain was not satisfactorily controlled. Subsequently, gasserian ganglion NC of the right trigeminal nerve guided by computed tomography(CT) was performed on the patient. Following this procedure, the right zygomatic, alveolar, submandibular,and cheek pain disappeared completely. The right zygomatic and alveolar areas experienced mild numbness(level II). At 1-, 2-, 3-, and 6-mo follow-ups after surgery, the patient was painless and the numbness score was level I.CONCLUSION CT-guided gasserian ganglion(NC) is an effective treatment for TN and is associated with less or no postoperative numbness or hypoesthesia in comparison with current standard-of-care approaches.     

Trigeminal neuralgia secondary to giant Virchow-Robin spaces: A case report with neuroimaging

Virchow-Robin spaces are pial-lined, interstitial, fluid-filled structures that accompany penetrating arteries and arterioles as they enter the cerebral substance. Occasionally they may enlarge and become giant Virchow-Robin spaces (GVRS) and produce mass effect. Various neurological symptoms have been described in association with GVRS, however, trigeminal neuralgia has not yet been reported in this context. We present a case of trigeminal neuralgia secondary to dorsal pontine giant Virchow-Robin spaces (GVRS) and highlight the diagnostic radiologic features. Routine 1.5 T MRI sequences were sufficient to diagnose the GVRS and a diffusion tensor imaging (DTI) study revealed distortion of the intrinsic trigeminal pathway. This study highlights the utility of routine MRI to study the intrinsic anatomy of the trigeminal pathway in pathological conditions.     

Early-onset ophthalmoplegia,cervical dyskinesia,and lower extremity weakness due to partial deletion of chromosome 16: A case report

BACKGROUNDWe explored the genotype-phenotype correlation of the novel deletion 16p13.2p12.3 in an 8-year-old child with progressive total ophthalmoplegia, cervical dyskinesia, and lower limb weakness by comparing the patient’s clinical features with previously reported data on adjacent copy number variation (CNV) regions.CASE SUMMARYSpecifically, we first performed whole-exome sequencing, CNV-sequencing, and mitochondrial genome sequencing on the patient and his parents, then applied “MitoExome” (the entire mitochondrial genome and exons of nuclear genes encoding the mitochondrial proteome) analysis to screen for genetic mitochondrial diseases. We identified a de novo 7.23 Mb deletion, covering 16p13.2p12.3, by both whole-exome sequencing and CNV sequencing. We also detected 16p13.11 in the deleted region, which is the recurrent distinct region associated with neurodevelopmental disorder. However, the patient only displayed features of progressive total ophthalmoplegia, cervical dyskinesia, and weakness in his lower limbs without neurodevelopmental disorder. The “MitoExome” sequencing was negative. Brain magnetic resonance imaging revealed non-specific sporadic changes in the occipital parietal lobe and basal ganglia.CONCLUSIONTaken together, these results indicated that 16p13.2p12.3 deletion causes a syndrome with the phenotype of early-onset total ophthalmoplegia. The “MitoExome” analysis is powerful for the differential diagnosis of mitochondrial diseases. We report a novel copy number variant in this case, but further confirmation is required.     

Vasopressin-induced hyponatremia in an adult normotensive trauma patient: A case report

BACKGROUND Arginine vasopressin is a neuropeptide produced in the hypothalamus and released by the posterior pituitary gland. In addition to maintaining plasma osmolarity, under hypovolemic or hypotensive conditions, it helps maintain plasma volume through renal water reabsorption and increases systemic vascular tone. Its synthetic analogues are widely used in the intensive care unit as a continuous infusion, in addition to hospital floors as an intravenous or intranasal dose. A limited number o...     

Trigeminal extracranial thermocoagulation along with patient-controlled analgesia with esketamine for refractory postherpetic neuralgia after herpes zoster ophthalmicus: A case report

BACKGROUNDPrimary trigeminal neuralgia can achieve satisfactory results through clinical treatment and intervention. The pathogenesis of neuralgia caused by varicella-zoster virus infection of the trigeminal nerve is more complex, and it is still difficult to relieve the pain in some patients simply by drug treatment or surgical intervention.CASE SUMMARYA 66-year-old woman was hospitalized with herpetic neuralgia after herpes zoster ophthalmicus (varicella-zoster virus infects the ophthalmic branch of the trigeminal nerve). On admission, the patient showed spontaneous, electric shock-like and acupuncture-like severe pain in the left frontal parietal region, and pain could be induced by touching the herpes area. The numerical rating scale (NRS) was 9. There was no significant pain relief after pulsed radiofrequency and thermocoagulation of the ophthalmic branch of the trigeminal nerve. Combined with patient-controlled intravenous analgesia (PCIA) with esketamine, neuralgia was significantly improved. The patient had no spontaneous pain or allodynia at discharge, and the NRS score decreased to 2 points. The results of follow-up 2 mo after discharge showed that the NRS score was ≤ 3, and the Pittsburgh Sleep Quality Index score was 5 points. There were no adverse reactions.CONCLUSIONTrigeminal extracranial thermocoagulation combined with esketamine PCIA may be a feasible method for the treatment of refractory herpetic neuralgia after herpes zoster ophthalmicus.     

Extrapontine myelinolysis caused by rapid correction of pituitrin-induced severe hyponatremia: A case report

BACKGROUND Severe hyponatremia is considered a rare complication of pituitrin,which is widely used for the treatment of pulmonary hemorrhage.However,the management of pituitrin-associated hyponatremia can be challenging because a rapid correction of hyponatremia may cause the development of osmotic demyelination syndrome,resulting in life-threatening neurological injuries.CASE SUMMARY A 20-year-old Chinese man with massive hemoptysis developed symptomatic hyponatremia(116 mmol/L)after therapy by a continuous intravenous drip of pituitrin.To normalize his serum sodium,a hypertonic saline infusion was applied for 3 d,and the pituitrin administration was stopped concurrently.Then,an overly rapid increase in serum sodium level(18 mmol/L in 24 h)was detected after treatment.One day later,the patient experienced a sudden onset of generalized tonic-clonic seizures,as well as subsequent dysarthria and dystonia.Magnetic resonance imaging revealed increased signal intensity in the bilateral symmetric basal ganglia on the T2-weighted images,compatible with a diagnosis of extrapontine myelinolysis.The patient received an intravenous administration of high-dose corticosteroids,rehabilitation,and neurotrophic therapy.Finally,his clinical abnormalities were vastly improved,and he was discharged with few residual symptoms.CONCLUSION Physicians should be fully aware that pituitrin can cause profound hyponatremia and its correction must be performed at a controlled rate to prevent the development of osmotic demyelination syndrome.     

Inflammatory complications of CGRP monoclonal antibodies: a case series

BackgroundCalcitonin gene-related peptide (CGRP) is expressed throughout the body and is a known mediator of migraine, exerting this biological effect through activation of trigeminovascular, meningeal and associated neuronal pathways located in close proximity to the central nervous system. Monoclonal antibodies (mAb) targeting the CGRP pathway are an effective new preventive treatment for migraine, with a generally favourable adverse event profile. Pre-clinical evidence supports an anti-inflammatory/immunoregulatory role for CGRP in other organ systems, and therefore inhibition of the normal action of this peptide may promote a pro-inflammatory response.CasesWe present a case series of eight patients with new or significantly worsened inflammatory pathology in close temporal association with the commencement of CGRP mAb therapy.ConclusionThis case series provides novel insights on the potential molecular mechanisms and side-effects of CGRP antagonism in migraine and supports clinical vigilance in patient care going forward.     

Cauda equina syndrome caused by the application of DuraSealTM in a microlaminectomy surgery: A case report

BACKGROUNDThe management of dural tears is important. While a massive dura can be repaired with absorbable suture lines, cerebrospinal fluid leakage can be attenuated by dural sealant when an unintended tiny durotomy occurs intraoperatively. DuraSeal is often used because it can expand to seal tears. This case emphasizes the need for caution when DuraSeal is used as high expansion can cause complications following microlaminectomy.CASE SUMMARYA 77-year-old woman presented with L2/3 and L3/4 lateral recess stenosis. She underwent microlaminectomy, foraminal decompression, and disk height restoration using an IntraSPINE^® device. A tiny incident durotomy occurred intraoperatively and was sealed using DuraSeal^TM. However, decreased muscle power, urinary incontinence, and absence of anal reflexes were observed postoperatively. Emergent magnetic resonance imaging revealed fluid collection causing thecal sac indentation and central canal compression. Surgical exploration revealed that the gel-like DuraSeal had entrapped the hematoma and, consequently, compressed the thecal sac and nerve roots. While we removed all DuraSeal^TM and exposed the nerve root, the patient’s neurological function did not recover postoperatively.CONCLUSIONDuraSeal expansion must not be underestimated. Changes in neurological status require investigation for cauda equina syndrome due to expansion.     

Cardiac myxoma shedding leads to lower extremity arterial embolism: A case report

BACKGROUNDLeft cardiac myxoma (CM) is the most common benign tumor of primary cardiac tumors, but because of its special position caused by pathological physiology change, caused by the complications of the heavier, the surface is often accompanied by blood clots, once fall out, it causes peripheral vascular embolization, such as acute lower limb artery embolization, harmfulness is large, high morbidity, and easy to occur repeatedly.CASE SUMMARYA 67-year-old male patient suddenly appeared numbness and weakness of the left lower limb and could not walk without obvious incentive. The patient was finally diagnosed as left CM complicated with acute lower limb arterial embolism after completing cardiac ultrasound, computer tomography angiography, and histopathological analysis, such as hematoxylin-eosin stain staining, immunohistochemistry and special staining including alcian blue staining and periodic acid schiff staining. Arterial thrombosis was removed successfully by femoral artery thrombectomy, postoperative numbness and weakness of the patient''s left lower limb disappeared, skin temperature became warm, and dorsal foot artery pulsation was accessible. The patient was readmitted to the hospital 8 mo after discharge for left atrial mass resection, and was diagnosed as CM by postoperative histopathological examination. CONCLUSIONAlthough CM is rare, it may be considered as the source of embolism in patients with acute limb ischemia. Repeated loss of thrombus on the tumor and its surface may lead to repeated embolism of peripheral vessels. Cardiac ultrasound is helpful for early diagnosis. Here, we use this case report to highlight left CM as an important cause of acute limb ischemia and to report our experience in the diagnosis and treatment of lower limb arterial embolism caused by CM detachment.     

Myotonic dystrophy presenting as new-onset hand weakness and recurrent pneumonia in a patient with paraplegia: a case report

We describe a previously independent T11 paraplegic patient who had delayed-onset hand weakness and recurrent pneumonia caused by myotonic dystrophy. A man in his late thirties suffered a thoracic spinal cord injury (SCI) from a gunshot wound at the age of 17 years, with resultant T11 American Spinal Injury Association class A paraplegia. He lived independently until the age of 36 years when he was hospitalized multiple times for pneumonia. During a rehabilitation stay after one of the acute hospitalizations, the patient's hand weakness and diffuse muscular atrophy were noted. Electrodiagnostic testing was performed, which showed myotonic discharges. Genetic testing was consistent with myotonic dystrophy. This case shows the importance of considering causes of weakness that affect the population as a whole when evaluating a patient with SCI who presents with delayed-onset weakness.     

Critical lower extremity ischemia after snakebite: A case report

BACKGROUNDGlobally, the estimated annual incidence of snakebites is approximately 5 million, and approximately 100000 deaths occur from snakebites annually. Local tissue reaction, haemorrhagic clotting disorder, nephrotoxicity, and neurotoxicity are very common effects of snake envenomation, but other rarer complications, such as thrombosis, may also occur as a result of underlying disease. In the treatment of snakebite patients, attention should be paid to the patient’s underlying diseases to avoid serious and catastrophic consequences secondary to snakebite.CASE SUMMARYWe report a 69-year-old man with critical right lower extremity pain after left foot snakebite 10 d prior without intermittent claudication or atrial fibrillation history. He was diagnosed with acute right lower extremity arterial thrombosis, which may have been caused by coagulopathy after snakebite and lower extremity atherosclerotic occlusive disease. Lower extremity computed tomography angiography at another hospital revealed that the aortoiliac and femoral arteries had neither filling defects nor atherosclerosis, but the right popliteal artery was occluded 2.3 cm below the tibial plateau. The patient received emergency catheter-directed thrombolysis, but amputation was carried out 11 d after admission because the patient had been admitted to the hospital too late to save the extremity.CONCLUSIONAcute ischaemia of the lower extremity due to snakebite is a rare event, and physicians should bear in mind the serious complications that may occur, especially in patients with atherosclerotic disease.     

Hyponatremic encephalopathy due to polyethylene glycol-based bowel preparation for colonoscopy: A case report

BACKGROUNDAdequate bowel preparation is critical for colonoscopy screening. At present, the most widely used intestinal cleaner recommended at home and abroad is Polyethylene glycol (PEG). Intestinal cleansers can cause electrolyte disturbances and hyponatremia. However, hyponatremic encephalopathy due to hyponatremia induced by PEG solution, although rare, can lead to serious irreversible sequelae and even death. CASE SUMMARYIn this report, we discuss a case of neurological dysfunction due to hyponatremia, also known as hyponatremic encephalopathy, observed in a 63-year-old woman who underwent PEG-based bowel preparation for colonoscopy. She was eventually transferred to our intensive care unit for treatment due to her Glasgow Coma Scale score of 9/15 (Eye opening 2; Verbal response 1; Motor response 6) and abnormal laboratory tests.CONCLUSIONPhysicians should be thoroughly familiarized with the patient''s history before prescribing PEG for bowel preparation, and timely identification of patients with hyponatremic encephalopathy is essential as delayed treatment is associated with poor neurological outcomes. An intravenous infusion of 3% sodium chloride is recommended at the onset of early symptoms. The goal of treatment is to adequately treat cerebral edema while avoiding serum sodium correction beyond 15 to 20 mEq/L within 48 h of treatment to prevent osmotic demyelination syndrome.     

Osteopathic manipulative treatment in pudendal neuralgia: A case report

Pudendal neuralgia is characterised by pain in the pudendal dermatome. It could be due to a stenosis of the pudendal canal, a compression along its pathway, or a pelvic trauma.Pudendal nerve entrapment (PNE) syndrome is frequently involved in pudendal neuralgia onset. This case report describes the osteopathic manipulative treatment (OMT) of a patient with functional PNE. A 40-year-old female presented with a 12-month history of intense pelvic pain resistant to 3 months of pharmacologic treatment that arose after three proctological surgeries. A perineal retracted painful scar was visible upon examination. PNE syndrome diagnosis was based on Nantes criteria. The electromyogram of the nerve showed an increased motor response latency of the left pudendal nerve. Visual analogue scale (VAS), female National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), Oswestry Disability Index (ODI) and Tampa scale of kinesiophobia (TSK) were used to assess patient's symptoms at baseline (T0), after pharmacologic treatment (T1), after OMT (T2), and at 6-month follow-up. Five treatments, including direct and indirect techniques, were performed over 1 month. OMT reduced pelvic neuralgia and disability indexes without any complications, maintaining a positive outcome at 6-month follow-up (VAS: T0 = 10, T1 = 10, T2 = 1.8, T3 = 1.5), (NIH-CPSI: T0 = 34, T1 = 30, T2 = 7, T3 = 6), (ODI: T0 = 48, T1 = 29, T2 = 9, T3 = 5) and (TSK: T0 = 51, T1 = 41, T2 = 20, T3 = 17). This is the first report of a patient diagnosed with functional PNE managed with OMT. A link between PNE, scar and pelvic somatic dysfunctions could suggest double crush syndrome.