R K Anadure

Abstract

Aim: This study was designed to look at the unique clinical profile, neuro-imaging features and functional outcomes, of Intra-cranial dissections in the cerebral vasculature, seen at two tertiary stroke care centers in Southern India. Materials and Methods: In this retrospectivce study spanning five years (Dec 13 to Dec 18), a total of 496 patients underwent CT Brain with Angiography for evaluation of an Acute stroke syndrome/ Transient ischemic attack (TIA), at our two study centers. 21/496 (4.2%) of these patients had imaging evidence of intra-cranial dissections which was further confirmed by Contrst MR angiograpgy. The clinical and imaging data of these cases was recorded on a predesigned stroke proforma. The pattern of vessel involved and morphology of vessel dissection was analyzed as per standard radiology criteria. All cases had follow up data ranging from 1 to 3 years, which was used to classify the functional outcomes based on the modified Rankin Scale (mRS). Results: There were 15 males and 6 females in the study, and the mean age was 44.1 years (range 23 to 73 years). Focal neurological deficits, with or without raised intra cranial pressure symptoms occurred in all these patients. 10/21 (48%) dissections were in the anterior circulation, whereas 11/21 (52%) were in the posterior circulation. Subarachnoid or parenchymal hemorrhage at presentation was seen in 11/21 (52%). The Internal Carotid artery (C2-C4 segments) was the commonest vessel involved in the anterior circulation in 64% cases (7/11), while in the posterior circulation, Vertebral artery (V4 segment) was most frequently involved in 60% (6/10) cases. In the entire study cohort, a good functional outcome (mRS 1-2) was seen in 13/21 (62%) cases, and death (mRS-5) was seen in 2/21 (9.5%). Digital Subtraction Angiography (DSA) and stenting/coiling procedures were undertaken in 3/21 (14%) cases. Conclusion: This hospital based study brings out the unique clinical spectrum of intra-cranial dissections, with both ischemic and hemorrhagic forms of presentation. The dissections in the intra-cranial compartment of the cerebral vasculature commonly result in pseudo-aneurysm formation with Subarachnoid hemorrhage or parenchymal bleeds. CT angiography coupled with contrast MR angiography is sufficient in majority of cases to establish the diagnosis and plan management. An interval DSA may be needed in a small minority of cases for planning stenting/coiling procedures. Keywords: Cerebral Dissections, Angiography, Subarachnoid hemorrhage.

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Abstract

Introduction: We describe the short term and intermediate efficacy of direct intra-muscular injection of Botulinum toxin in Pyriformis Syndrome, along with its safety profile. Materials and Methods: A diagnosis of pyriformis syndrome was made by exclusion, only after careful clinical assessment & MR Imaging. Patients were selected for Botox infiltration if adequate symptom relief was not noted after conservative management. Patients were placed prone on the CT table with a pillow placed under the lower pelvis for elevation of the hip joints. Subsequently a total of 03 spinal needles (22 G) were placed in the pyriformis muscle belly, at a distance of 1 to 1.5 cm apart. Finally, freshly reconstituted 50U of Botox was injected through each of the needles into the muscle belly (total dose of 150 U). Results: A total of 26 procedures were performed on 25 patients (15 male, 10 female) with one patient receiving a second procedure 15 months after the initial treatment. The mean age of the patient population was 48.6 years. 88.5% (23/26) patients reported very good pain relief when assessed on a Visual analogue scale (VAS) at 3 months, which was sustained at 6 months in 77% (20/26) patients. No procedure related complications were noted. Conclusion: CT guided Botox infiltration into the pyriformis is a safe and effective modality for pain relief in pyriformis syndrome. Three needle technique with infiltration across the length of the muscle appears be more effective in symptom alleviation, as compared to the conventional single site injection. Keywords: Botox, Pyriformis.

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