T2-weighted imaging (g) performed part of the lesion buy discount urispas 200mg online spasms after stroke, an area hypointensive on Т2-weighted imaging and on the back (supine) and on the abdomen (prone) (h) visualises the hyperintensive on Т1-weighted imaging is seen—sedimentation phe- displacement of blood components into the hematoma’s cavity 710 Chapter 7 Fig order urispas with visa muscle relaxant recreational use. Т2-weighted perintensive signal in all sequences in the right half of the bottom imaging (а cheap urispas 200 mg muscle relaxant used during surgery,b) and Т1-weighted imaging (c) identifes a small cellular of fossa rhomboidea. Tis area is encircled by a hypointensive ring (heterogeneous) area consisting of zones of hypointensive and hy- better seen on Т2-weighted imaging Fig. It has a patchy picture and is located forward Т2-weighted imaging (b) and Т1-weighted imaging (c) shows an an- of the haemorrhage gioma with signs of subacute haemorrhage (hyperintensive signal on Infratentorial Tumours 711 Fig. Haemosiderin deposits are visualised around the haemor- a mass lesion in the pons is revealed, which has hyperintensive on rhage (on T2 and gradient echo imaging). Perifocal oedema may be absent even in metastases, meningiomas have clear borders with brain tissue, larger–sized tumours, which is characteristic for metastases and a vascular matrix seen in the tumour stroma. The frst type of picture in terms of lesion borders, as they reveal only mass efect, dis- is seen if metastases contain melanin, which has a para- location of adjacent cerebellar hemispheres, and brainstem. The latter type is seen in dis- The fourth ventricle is displaced to the opposite to the side semination of so-called amelanotic melanoma (Fig. Tumour nodes with central necrosis and enhancing peripheral parts are seen in both cerebellar hemispheres (а–c) Infratentorial Tumours 713 Fig. Perifocal oedema is seen around the tumour, which is hyperin- A mass lesion, which intensively accumulates contrast medium, is tensive on T2-weighted imaging seen in the right cerebellar hemisphere. Т2-weighted imaging (а) reveals an abnormal hyperintensive lesion in the lateral parts of the posterior fossa rightwards; brainstem is displaced on the lef. Tere is no invasion of the tumour into the meatus acousticus internus; however, abnormal tissue grows along the apex of the pyramid with passage into the medial parts of the middle cranial fossa rightwards Fig. A tumour hypointensive on Т2-weighted imaging and hyperintensive on Т1-weighted imaging in the central zone is seen. Mi- crocysts perifocal oedema is found on the periphery—obstructive hydrocephalus Fig. Tere is a homogenous and hyperdensive mass lesion in the lateral parts of the posterior fos- sa lefwards. Т2-weighted imag- ing (а,b) and Т1-weighted imaging (c–f) show a hypointensive area of irregular shape and heterogeneous structure Fig. In the lateral parts of the right half of the posterior fossa, a mass lesion is identifed that is heterogeneous hyperdensive and encircled by perifocal oedema 716 Chapter 7 Fig. A large mass lesion of heterogeneous structure with signal on Т2-weighted imaging and marked hyperintensive signal microcalcifcations, hyperdensive foci, and cysts is seen in the right on Т1-weighted imaging (due to methaemoglobin in the cavities of cerebellar hemisphere. Т2-weighted imaging (b) and Т1-weighted cavernoma) Infratentorial Tumours 717 References al-Mefy O, Borbe L (1997) Skull base chordomas: a management Konovalov A et al (1993) Brainstem tumours: indications to surgery, challenge. New York: Raven Press Konovalov A et al (2003) Gene expression patterns in ependymo- Ball W (1997) Infratentorial neoplasms in children. Lippincott-Raven, Philadelphia, pp Pathol 5:1721–1727 319–368 Konovalov A, Huhlaeva E, Ozerova V (1991) Clinics, diagnostics and Barkovich A (2000) Pediatric neuroimaging, 3rd edn. J Vopr Neurosurg Williams & Wilkins, Philadelphia 1:3–6 (in Russian) Barkovich A et al (1990) Brainstem gliomas: a classifcation sys- Konovalov A, Kornienko V, Pronin I (1997) Magnetic-resonance to- tem based on magnetic resonance imaging. Radiographics 11:1087–1100 Konovalov A, Kornienko V, Pronin I (2001b) Hematomas and latent Bilaniuk L (1990) Adult infratentorial tumors. Neurosurgery 48:55–63 factor for patients with intracranial ependymomas treated in the micronerosurgical era. Cancer 100:1230–1237 Daglioglu E et al (2003) Tectal gliomas in children: the implications for natural history and management strategy. Am J Neuroradiol Gerosa M, Visca A, Rizzo P et al (2006) Glomus jugulare tumours: the 21:1757–1765 option of gamma knife radiosurgery. Neurosurgery 59:3:561–569 Meyers S, Khademian Z, Biegel J et al (2006) Primary intracranial Guillamo J et al (2001) Brainstem gliomas in adults. Prognostic fac- atypical teratoid/rhabdoid tumours of infancy and childhood: tors and classifcation. Nerv Syst 14:1613–1673 In: McLaurin R, Schut L, Venes J, Epstein F (eds) Pediatric neu- Rumboldt Z, Camacho D, Lake D et al (2006) Apparent difusion rosurgery: surgery of the developing nervous system. In many cases, meningioma has no clinical symptoms, and it may be an accidental fnding in radiological examination or autopsy (Konovalov 1997). Epileptic seizures, movement, and sensitivity disorders are typical for convex or parasagittal tumours. Visual feld changes are the feature of meningioma of sphenoid bone wings, whereas cavernous si- nus tumours, as a rule, cause involvement of the third to sixth cranial nerves. Tumours of the second cranial nerve sheath in the orbit or in the optic nerve canal leads to visual loss up to 8. Neoplasm of the anterior cranial fossa (meningiomas of olfactory fossa) may reach very large Meningioma is one of the most frequent intracranial tumours sizes due to the mainly asymptomatic clinical course, with the of nonglial origin (Buetow et al. Usually meningiomas are well delimitated Our data included about 5,000 patients with meningioma of from neighbouring brain tissue. The surface of the majority of a various locations, which, according to the statistics of the tumours is even; usually there is an arachnoid fssure between Moscow Neurosurgical Institute makes up about 23. Usually meningioma is diagnosed in adults, and the inci- Meningioma consistency varies from sof up to cartilagi- dence peak is between 40 and 60 years old, and women are nous density, depending on expressiveness of the fbrous tis- afected more frequently; the ratio of men to women is from sue and the presence of calcifcations. Only 1–2% of meningiomas are observed in chil- and xanthomatous changes (Burger 1991). As a rule, a reac- dren less than 16 years of age; more ofen they are located in tive thickening of the dura matter is observed around the atypical places, for example, in the posterior cranial fossa or meningioma. In children, tion were mainly carried for creation of a more simplifed meningioma is accompanied by neurofbromatosis. The majority of meningiomas originate from of and (3) malignant, 1–2% of all observations. In rare cases, the tu- the Moscow Neurosurgical Institute statistical data, the inci- 720 Chapter 8 Fig. The borders of (c) tumour are clearly visible on a background of hyperintensive signal Fig. The tumour is mainly supplied matrix remain dark on the background of the hyperintensive signal from the branches of hypertrophied ophthalmic artery. Tere is a clearly expressed sub- supplying the tumour, with clearly detectable matrix arachnoid fssure around the tumour, which contains the dislocated dence of these types of meningiomas does not difer from the ingiomas are divided into supra- and subtentorial. Among mentioned data: typical (93%), atypical (5%), and malignant all, those meningiomas of parasagittal (17%), convex (11%), (2%). Rarely are tumours this group: fbroblastic, meningotheliomatous, secretory, tran- of intraventricular location, pineal area, sheaths of the optic sitional, and psammomatous. Extracranial Atypical meningiomas (more ofen mixed meningothe- meningiomas (paranasal sinuses of nose and cranial vault liomatous structure) are characterised by marked polymor- bones) made up 1%. Benign forms may have a more developed vas- combined with this factor (Ildan 1999). On angiograms, such cular net, whereas ones more malignant have less developed tumours are characterised by marked early contrast accumu- nets (Figs. Tus, is a general table of the most frequently supplying meningeal more ofen meningioma is revealed as a formation of round, arteries, depending on the primary location of meningioma oval, or lobular shape, with well-diferentiated contours due (Table 8. In a quarter of cases, men- may be additionally supplied from pial branches of intracra- ingiomas poorly accumulate contrast substance, or do not ac- nial arteries.
The multiple effects of Thionamides (thiourea derivatives) antithyroid drugs include inhibition of thyroid hormone synthesis and a reduction in both intrathyroid immune carbimazole order urispas in india muscle relaxant histamine release, methimazole buy urispas online now muscle relaxant 5mg, dysregulation and (in the case of propylthiouracil) the peripheral propylthiouracil conversion of thyroxine to tri-iodothyronine purchase 200 mg urispas with visa muscle relaxant elderly. Tyrosine-Tg, tyrosine residues in thyroglobulin; 1þ, the iodinating Mode of action (Fig. New England The major action of thionamides is to reduce the formation Journal of Medicine 352:905–917. With high dose, reduced hormone synthesis not recommended in children because of the increased risk leads to hypothyroidism. Carbimazole and methimazole (the active metabolite of carbimazole) (t½ 6 h) and propylthiouracil (t½ 2 h) are Immunosuppression commonly used, but the t½ matters little because In patients taking antithyroid drugs, serum concentra- the drugs accumulate in the thyroid and act there for tions of antithyrotropin receptor antibodies decrease 30–40 h; thus a single daily dose suffices. There T4to T3, but only at high doses used in treatment of thyroid is an increased number of circulating suppressor T cells storm (see p. Antithyroid in its apparent radio-protective effect when used prior to drugs may also induce apoptosis of intrathyroidal radioiodine treatment. Patients • Carbimazole 40 mg total/day is given orally (or must be given written warning to stop the drug and have methimazole 30 mg) until the patient is euthyroid a leucocyte count performed if symptoms of a sore throat, (usually 4–6 weeks). Any suggestion of regimen) by decrements initially of 10 mg every anaemia should be investigated. Surgery in the second trimester may be preferred It is probable that no patient is wholly refractory to these to continued drug therapy. Failure to respond is likely to be due to the patient rendered euthyroid prior to pregnancy. The aim of drug therapy is to control the hyperthyroidism Clinical improvement is noticeable in 2–4 weeks, and the until anaturalremission takes place. Longertreatmentisusual The best guides to therapy are the patient’s symptoms foryoungpatientswithlarge,vasculargoitres,becauseofthe (decreased nervousness and palpitations), increased higher risk of recurrence (2–3 years). Symptoms and signs are, of course, less valuable as Most patients enter remission, but some will relapse – usu- guides if the patient is also taking a b-adrenoceptor blocker, ally during the first 3 months after withdrawal from treat- and reliance then rests on biochemical tests. Approximately 30–40% of patients remain With optimal treatment the gland decreases in size, but euthyroid 10 years later. If hyperthyroidism recurs, there over-treatment leading to low hormone concentrations in is little chance of a second course of thionamide achieving the blood activates the pituitary feedback system, inducing long-term remission. Adverse reactions The use of levothyroxine concurrently with an antithy- The thionamide drugs are all liable to cause adverse effects. Major effects include agranulocytosis, effects of carbimazole, and no compensatory reduction in aplastic anaemia, thrombocytopenia, acute hepatic necro- the incidence of relapse. Therefore, the ‘titration’ (see sis, cholestatic hepatitis, lupus-like syndrome, vasculitis. Routine leuco- ity to catecholamines in hyperthyroidism with a rise in ei- cyte counts to detect blood dyscrasia before symptoms ther the number of b-adrenoceptors or the second- messenger response (i. Therefore, some of the unpleasant therapy may impair the response to radiation (Velkeniers B, Cytryn R, symptoms are adrenergic. Vanhaelst L, Jonckheer M H 1988 Treatment of hyperthyroidism with radioiodine: adjunctive therapy with antithyroid drugs reconsidered. Quick relief can be obtained with a b-adrenoceptor Lancet i: 1127–1129) (see Mode of action of thionamides, above). Potassium iodate in doses of 85 mg orally 8-hourly (lon- on the myocardium, and the basal metabolic rate is ger intervals allow some escape from the iodide effect) pro- unchanged. For this reason, b-blockade is not used as sole duces some effect in 1–2 days, maximal after 10–14 days, therapy except in mild thyrotoxicosis in preparation for after which the benefit declines as the thyroid adapts. Any effect on thyroid hormonal Iodine therapy maximises iodide stores in the thyroid, action on peripheral tissues is clinically unimportant. Prophylactic iodide though atenolol is widely used, it is preferable to choose a (1 part in 100 000) may be added to the salt, water or bread drug that is non-selective for b1 and b2 receptors and lacks where goitre is endemic. The usual contraindications prophylaxis is to inject iodised oil intramuscularly every to b-blockade (see p. Iodine (iodide and radioactive iodine) As an antiseptic for use on the skin, povidone–iodine Iodide is well absorbed from the intestine, distributed like (a complex of iodine with a sustained-release carrier, povi- chloride in the body, and rapidly excreted by the kidney. It done or polyvinyl–pyrrolidone) can be applied repeatedly is selectively taken up and concentrated (about Â 25) by and used as a surgical scrub. It acts as an expectorant (see Cough, thyroid hormone produced; this stimulates the pituitary to p. The result is hyperplasia and increased vascu- larity of the gland, with eventual goitre formation. It is essential to ask patients specifically whether they are allergic to iodine before such Effects contrast media are used. Severe anaphylaxis, even deaths, The effects of iodide are complex and related to the dose occur every year in busy imaging departments; iodine- and thyroid status of the subject. But a substantial excess inhibits hor- mone release and promotes storage of hormone and invo- Adverse reactions lution of the gland, making it firmer and less vascular so Patients vary enormously in their tolerance of iodine; some that surgery is easier. The effect is transient and its mecha- are intolerant or allergic to it both orally and when it is ap- nism uncertain. In euthyroid subjects with normal glands an excess of Symptoms of iodism include: a metallic taste, excessive iodide from any source can cause goitre (with or without salivation with painful salivary glands, running eyes and hyperthyroidism), e. A euthyroid subject with an autonomous adenoma (hot Goitre can occur (see above) with prolonged use of io- nodule) becomes hyperthyroid if given iodide. Iodide (large dose) is used for thyroid storm (crisis) and in Topical application of iodine-containing antiseptics to preparation for thyroidectomy because it rapidly benefits neonates has caused hypothyroidism. Iodide intake the patient by reducing hormone release and renders sur- above that in a normal diet will depress thyroid uptake gery easier and safer (above). With a fatality rate of about 1 (Bondeson L, Bondeson A-G 2003 Michelangelo’s divine goitre. Journal per 50 000 in patients receiving the older agents, hospitals are faced of the Royal Society of Medicine 96:609–611). Pregnant women should not be treated with radioiodine (131I) because it 131 Radioiodine ( I) crosses the placenta. It is contrain- dicated in children and pregnant or breast-feeding women, Radioiodine uptake can be used to test thyroid function, al- and can induce or worsen ophthalmopathy. Scanning the gland may be useful to identify solitary nod- In hyperthyroidism, the beneficial effects of a single dose ules and in the differential diagnosis of Graves’ disease may be felt in 1 month, and patients should be reviewed at from the less common thyroiditides, e. In thyroiditis, excessive thyroid hormone release imal effect of radioiodine may take 3 months to achieve. Very rarely radiation thyroiditis causes excessive release Choice of treatment of hyperthyroidism of hormone and thyroid storm. They may be radioiodine for thyroid uptake and to hasten excretion used in pregnancy. It may be Radioiodine offers the advantages that treatment is sim- preferred to antithyroid drugs in patients with large or ple and carries no immediate mortality, but it is slow in act- multinodular goitres, and in patients with a single ing and the dose that will render the patient euthyroid is hyperfunctioning adenoma (‘hot nodule’). In the first year after treatment, 20% of with antithyroid drugs is recommended in severe patients will become hypothyroid.
Corticosteroids may with brainstem aura to be made buy 200 mg urispas with mastercard gastrointestinal spasms, the aura must include two reduce the risk of headache recurrence but are associated brainstem symptoms such as dysarthria buy cheap urispas 200mg on line muscle relaxant pictures, vertigo purchase urispas in united states online gastric spasms, tinnitus, with gastritis and, rarely, avascular necrosis. Intravenous hypacusis, diplopia, ataxia, or decreased level of conscious- valproic acid is an option if there is no contraindication ness. The child has intermittent episodes of abdomi- nal pain without gastrointestinal pathology. A two of the following symptoms are present with the pain: anorexia, nausea, vomiting, or pallor. Headache does Patients with benign paroxysmal torticollis of infancy not occur with the episodes. Intermittent episodes of unsteadiness Children with benign paroxysmal torticollis have or vertigo are seen. Other symptoms include nystagmus, recurrent episodes of head tilt with pallor, irritability, vomiting, pallor, and fearfulness. Medication-overuse headache is defned as headache that Cluster headaches are associated with severe orbital, occurs at least 15 days per month in a patient with a his- supraorbital, and/or temporal pain with ipsilateral auto- tory of headache and overuse of medication for longer nomic symptoms such as conjunctival injection, lacrima- than 3 months. Clonazepam or phenobarbital can be used to The pain lasts from 15 minutes to 3 hours if untreated. Hypnic headaches are another type of painful head- Cluster headache Oxygen by nonrebreather, aches that wake the patient from sleep. In contrast to sumatriptan cluster headaches, the pain in hypnic headache is bilat- Hemicrania continua Indomethacin eral, there are no autonomic symptoms, and the patient is not restless or agitated. Trigeminal neural- Arnold-Chiari I malformation, which is a common gia usually causes pain in the distribution of the maxil- cause of cough headache, needs to be ruled out. Also, lary or mandibular division of the trigeminal nerve, but cerebrovascular disease and cerebral aneurysms can cause it can involve the ophthalmic division. Sometimes the pain in trigeminal neuralgia is elec- Orthostatic headache is characteristic of intracranial tric or shock-like. Connective tissue disorders such as Marfan be triggered by touching the trigger zone or chewing. There are many other possible ter headaches cause brief, recurrent unilateral head- etiologies. Sinus venous thrombosis is a common cause of aches with autonomic symptoms that are ipsilateral intracranial hypertension. It can have features of migraines or of tension-type a continuous headache with intermittent exacerbations. Autonomic symptoms are present during the exacerba- A thunderclap headache is a severe headache of tions of hemicrania continua. Patients with hemicrania abrupt onset that quickly reaches maximum intensity (in continua may have a foreign body sensation in the eye <1 minute). Other causes include intracerebral hemorrhage, Paroxysmal hemicrania and hemicrania continua cerebral venous thrombosis, unruptured vascular mal- respond to indomethacin. The gold standard for diagnosis of small-fber neurop- Initial imaging may be normal, so imaging may need athy is skin biopsy. Bare nerve endings are part of the spinothalamic sys- tem, which carries pain and temperature information. There are three types of these free endings: mechano- 1) B receptors, thermoreceptors, and polymodal nocicep- 2) C tors. Information from these receptors is transmitted 3) A by Aδ and C fbers to the dorsal horn of the spinal cord. They transmit pain and temperature infor- Nociceptive pain is the term for pain caused by direct mation, typically sharp pain. C fbers are small, unmy- activation of pain fbers as a result of tissue injury (see elinated nerves that are responsible for slow pain and Table 24. Small-diameter sensory fbers, such as Aδ and C fbers, enter the spinal cord in the tract of Lissauer. The spino- thalamic tract projects to the ventral posterolateral thala- Neuropathic pain results from lesions in the nervous mus and then to the primary somatosensory cortex. Neuropathic pain tends to be chronic and to increase with Patients with trigeminal neuralgia of no known etiol- time. There is sensitization of nociceptors in patients with ogy and those who may possibly have vascular compres- neuropathic pain: Nociceptors respond to subthreshold sion are considered to have classic trigeminal neuralgia. D example, patients with trigeminal neuralgia caused Neuropathic pain is more common in neuropathies by multiple sclerosis, a tumor, or an abnormality of involving C and Aδ nerve fbers, which are small fbers. Small-fber neuropathies tend to be painful and length These patients are more likely to have sensory def- dependent, causing a stocking-glove distribution, but cits, bilateral involvement, and abnormal trigeminal there are exceptions. Microvascular decompression can be performed in patients with trigeminal neuralgia due to vascular Pregabalin has the strongest evidence for treating painful compression. There is less evidence for amitrip- tyline, capsaicin, duloxetine, gabapentin, valproic acid, 24. Postherpetic neuralgia is continuation of the pain of her- Oxcarbazepine, mexiletine, clonidine, and lamotrigine pes zoster for longer than 3 months afer the rash resolves. A opioids, tricyclic antidepressants, gabapentin, pregaba- lin, and lidocaine patches. Topical afer the onset of herpes zoster symptoms can reduce the lidocaine is useful if allodynia is a problem. Evidence-based guideline sensory abnormalities, motor abnormalities, and trophic update: Pharmacologic treatment for episodic migraine preven- changes. Report of the Quality Standards Subcommittee of sympathetic dystrophy) occurs most ofen afer minor the American Academy of Neurology and the American Headache injury to a limb and is less commonly caused by central Society. A statement for healthcare profes- afer injury to a peripheral nerve that results in focal sionals from the American Heart Association/American Stroke defcits. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the cations such as gabapentin, pregabalin, and carbamaze- American Headache Society. Continuum Dejerine-Roussy syndrome is a thalamic syndrome (Minneap Minn) 2015;21:1041– 1057. Practice parameter: The characterized by pain on the contralateral side of the diagnostic evaluation and treatment of trigeminal neuralgia body with anesthesia to pinprick. An extramedullary Subcommittee of the American Academy of Neurology and tumor can cause radicular pain. An evidence-based report Mutations in the sodium channel can cause increased pain of the Quality Standards Subcommittee of the American Academy sensitivity. Report of the American Academy of Neurology, the American Association of red extremities. An infant with a cranial bruit over the posterior cra- The nasolabial folds are symmetric, and the patient nium and bounding carotid pulses develops congestive closes both eyes well. A bone survey shows calcifcations fetal movements has poor respiratory efort and is of the patellae. His mother has male-pattern baldness, pto- Which of the following is most likely to be present in sis, and a persistent grip.