Letters to Editor
images revealed intense enhancement of the tentorium and falx cerebri which resembled the appearance of Eiffel tower at night [Figure 1c]. Magnetic resonance venogram revealed pansinus thrombosis [Figure 1d]. After 4 weeks of treatment anticoagulants she recovered completely which was evident radiologically as disappearance of the Eiffel tower appearance [Figure 1e] and recanalization of superficial and deep venous sinuses [Figure 1f]. It is interesting that this is the first time we are describing a reversible “Eiffel by Night” sign in cortical sinus venous thrombosis adding on to the differential diagnosis of ‘Eiffel by Night’ sign.
pelvis through the greater sciatic notch and inserts into the piriformis fossa on the greater trochanter of the femur. Since the sciatic nerve also leaves the pelvis through the greater sciatic notch, any pathology of the piriformis muscle could result in the entrapment to the sciatic nerve, the piriformis syndrome.[1] Pyomyositis of the piriformis muscle can produce swelling of the muscle, resulting in compression of the sciatic nerve, thus can present with piriformis syndrome.[2,3] We report a rare case of pyomyositis of piriformis muscle presenting as sciatica.
Any condition affecting the dura with more focal involvement at falco-tentorial junction can give rise to this appearance. Infective, inflammatory, auto immune and neoplastic etiology should be considered in differential diagnosis of “Eiffel by night” sign. The pathophysiology regarding involvement of falco tentorial dura in cortical venous thrombosis with radiological appearance of “Eiffel by night” sign still remains elusive. However, reversibility of this sign may help us in assessing the response to the given treatment.
A 42‑year‑old female nurse presented with severe right‑sided sciatica. The pain worsened limiting her ambulation. With a diagnostic possibility of lumbar disc herniation, she was referred to our facility. On admission, the body temperature was 38.4°C. Due to severe sciatica, she was unable to ambulate. Freiberg test could not be performed because of severe pain. Laboratory evaluation revealed elevated white blood cell count (12, 500/mm3) and C‑reactive protein level (13.9 mg/dl). Magnetic resonance imaging (MRI) of lumbar spine performed at the other facility showed no obvious abnormality. MRI of the pelvis revealed high intensity change and swelling of piriformis muscle in T2‑weighted image [Figure 1a]. Contrast enhanced computed tomography (CT) also showed swelling of piriformis muscle and rim‑enhanced low density mass lesion within piriformis muscle [Figure 1b]. The diagnosis of piriformis syndrome secondary to pyomyositis of piriformis muscle was considered.
Lakshmanarao Chittem, Sridhar Ganti1, Alugolu Rajesh Department of Neurosurgery, Nizam’s Institute of Medical Sciences, Panjagutta, 1Department of Neurology, SKS Neuro and Polytrauma Centre, Kacheguda, Hyderabad, India Email: [email protected]
References 1. 2.
Thomas B, Thamburaj K, Kesavadas C. ‘Eiffel‑by‑Night’: A new MR sign demonstrating reactivation in idiopathic hypertrophic pachymeningitis. Neuroradiol J 2007;20:194‑5. Riku S, Kato S. Idiopathic hypertrophic pachymeningitis. Neuropathology 2003;23:335‑44. Access this article online Quick Response Code:
In spite of intravenous antibiotic, the pain worsened. Under general anesthesia, in the lateral decubitus
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.125288
a
b
c
d
Received: 30‑10‑2013 Review completed: 30‑10‑2013 Accepted: 05‑12‑2013
Sciatica caused by pyomyositis of the piriformis muscle Sir, The piriformis muscle has endopelvic origin, exits the 668
Figure 1: Pre- and post-operative magnetic resonance imaging (MRI) and computed tomography (CT). Pre-operative T2-weighted axial MRI (a) and enhanced CT (b) at the greater sciatic notch show muscle swelling (arrowheads) of right side piriformis muscle. MRI shows intramuscular T2 high lesion (a, arrow) and enhanced CT shows intramuscular rim-enhancement (b, arrow), both suggesting abscess formation in piriformis muscle. Post-operative T2-weighted axial MRI (c) and plain CT at the greater sciatic notch show no abscess in the piriformis muscle (d)
Neurology India | Nov-Dec 2013 | Vol 61 | Issue 6
Letters to Editor
2. 3. 4. a
b
Figure 2: Intra-operative photography. After dissecting gluteus maximus muscle, dark-colored and swelled piriformis muscle (a, arrow) entrapped the sciatic nerve. After dissection of the piriformis muscle (b, arrow), sciatic nerve was released (b, arrowheads)
position, a skin incision from just posterior to the greater trochanter to the middle of the buttock was made. The piriformis muscle was exposed by the blunt dissection of the gluteus maximus muscle. The sciatic nerve was then exposed under the piriformis muscle [Figure 2a]. The piriformis muscle was tight and tense especially on internal rotation of the hip joint. The piriformis muscle was incised at the tendinons portion with which the tension of the piriformis muscle decreased and compression over the sciatic nerve got relieved [Figure 2b]. There was no apparent pus discharge intraoperatively. After the surgery, she had dramatic relief of pain. She returned to her work as a nurse 2 months after the surgery. Follow‑up MR and CT images showed normalized right piriformis muscle [Figure 1c and d]. Chiedozi divided pyomyositis into three stages according depending on the progression of the disease: invasive stage showing myositis without abscess formation, suppurative stage with abscess formation and late stage with sepsis.[4] Pyomyositis in suppurative stage, requires aspiration by the percutaneous route or open drainage. This case illustrates that the possibility of piriformis pyomyositis should be considered in patients with sciatica of undetermined causes, more so when signs of inflammation are present. Masao Koda1,2, Chikato Mannoji1, Hitoshi Watanabe1, Arata Nakajima3, Toshiyuki Yamada1, Tomoyuki Rokkaku1, Ken‑Ichi Murakami2, Masazumi Murakami1, Osamu Ikeda2, Masashi Yamazaki4, Takeo Furuya2, Departments of Orthopedic Surgery, 1Chiba Aoba Municipal Hospital, 2Chiba University Graduate School of Medicine, Chiba, 3Toho University Sakura Medical Center, Sakura, 4 University of Tsukuba, Tsukuba, Japan E‑mail: [email protected]
References 1.
Filler AG, Haynes J, Jordan SE, Prager J, Villablanca JP, Farahani K, et al. Sciatica of nondisc origin and piriformis syndrome: Diagnosis by magnetic resonance neurography and interventional magnetic resonance
Neurology India | Nov-Dec 2013 | Vol 61 | Issue 6
imaging with outcome study of resulting treatment. J Neurosurg Spine 2005;2:99‑115. Chen WS. Sciatica due to piriformis pyomyositis. Report of a case. J Bone Joint Surg Am 1992;74:1546‑8. Nakai I, Yano Y, Naramatsu M, Hashimoto N. Piriformis syndrome due to piriformis pyomyositis: report of a case. Seikeigeka 2012;63:949‑51. Chiedozi LC. Pyomyositis. Review of 205 cases in 112 patients. Am J Surg 1979;137:255‑9. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.125291
Received: 30‑10‑2013 Review completed: 30‑10‑2013 Accepted: 05‑12‑2013
A rare cause of dural venous sinus thrombosis Sir, Poisoning resulting from ingestion of crushed seeds of the plant Abrus precatorius (AP) can occasionally cause neurological manifestations. However, dural venous sinus thrombosis is a rare and hitherto unreported complication of AP poisoning. A 22‑year‑old unmarried lady was admitted after suicidal ingestion of about 20 crushed seeds of AP. She developed abdominal pain, recurrent vomiting, profuse watery diarrhea and subsequently bloody diarrhea from second till seventh day of ingestion. Laboratory evaluation on day‑3 revealed hypernatremia (serum sodium: 154 mEq/l), hypokalemia (serum potassium: 3.1 mEq/l), neutrophilic leucocytosis (leucocyte count: 16.2 × 109/l, neutrophils: 83%), normal hematocrit, platelet count, coagulation tests, hepatic and renal function. On day‑7, she suffered multiple episodes of generalized tonic clonic seizures and developed altered sensorium. Examination revealed right sided hemiplegia and papilledema in both eyes. Unenhanced computerized tomography (CT) of the brain revealed thrombosis of the superior sagittal sinus (SSS), left parieto‑occipital hemorrhagic infarct with midline shift [Figure 1]. She was started on antiepileptic drugs, osmotic therapy and subcutaneous enoxaparin. Magnetic resonance imaging (MRI) and MR‑venography confirmed the thrombosis of SSS and left transverse sinuses [Figure 1]. Subsequently she underwent left parieto‑occipitotemporal craniotomy for cerebral decompression [Figure 1]. Urine pregnancy test was negative. Work‑up for pro‑coagulant states and 669
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
images revealed intense enhancement of the tentorium and falx cerebri which resembled the appearance of Eiffel tower at night [Figure 1c]. Magnetic resonance venogram revealed pansinus thrombosis [Figure 1d]. After 4 weeks of treatment anticoagulants she recovered completely which was evident radiologically as disappearance of the Eiffel tower appearance [Figure 1e] and recanalization of superficial and deep venous sinuses [Figure 1f]. It is interesting that this is the first time we are describing a reversible “Eiffel by Night” sign in cortical sinus venous thrombosis adding on to the differential diagnosis of ‘Eiffel by Night’ sign.
pelvis through the greater sciatic notch and inserts into the piriformis fossa on the greater trochanter of the femur. Since the sciatic nerve also leaves the pelvis through the greater sciatic notch, any pathology of the piriformis muscle could result in the entrapment to the sciatic nerve, the piriformis syndrome.[1] Pyomyositis of the piriformis muscle can produce swelling of the muscle, resulting in compression of the sciatic nerve, thus can present with piriformis syndrome.[2,3] We report a rare case of pyomyositis of piriformis muscle presenting as sciatica.
Any condition affecting the dura with more focal involvement at falco-tentorial junction can give rise to this appearance. Infective, inflammatory, auto immune and neoplastic etiology should be considered in differential diagnosis of “Eiffel by night” sign. The pathophysiology regarding involvement of falco tentorial dura in cortical venous thrombosis with radiological appearance of “Eiffel by night” sign still remains elusive. However, reversibility of this sign may help us in assessing the response to the given treatment.
A 42‑year‑old female nurse presented with severe right‑sided sciatica. The pain worsened limiting her ambulation. With a diagnostic possibility of lumbar disc herniation, she was referred to our facility. On admission, the body temperature was 38.4°C. Due to severe sciatica, she was unable to ambulate. Freiberg test could not be performed because of severe pain. Laboratory evaluation revealed elevated white blood cell count (12, 500/mm3) and C‑reactive protein level (13.9 mg/dl). Magnetic resonance imaging (MRI) of lumbar spine performed at the other facility showed no obvious abnormality. MRI of the pelvis revealed high intensity change and swelling of piriformis muscle in T2‑weighted image [Figure 1a]. Contrast enhanced computed tomography (CT) also showed swelling of piriformis muscle and rim‑enhanced low density mass lesion within piriformis muscle [Figure 1b]. The diagnosis of piriformis syndrome secondary to pyomyositis of piriformis muscle was considered.
Lakshmanarao Chittem, Sridhar Ganti1, Alugolu Rajesh Department of Neurosurgery, Nizam’s Institute of Medical Sciences, Panjagutta, 1Department of Neurology, SKS Neuro and Polytrauma Centre, Kacheguda, Hyderabad, India Email: [email protected]
References 1. 2.
Thomas B, Thamburaj K, Kesavadas C. ‘Eiffel‑by‑Night’: A new MR sign demonstrating reactivation in idiopathic hypertrophic pachymeningitis. Neuroradiol J 2007;20:194‑5. Riku S, Kato S. Idiopathic hypertrophic pachymeningitis. Neuropathology 2003;23:335‑44. Access this article online Quick Response Code:
In spite of intravenous antibiotic, the pain worsened. Under general anesthesia, in the lateral decubitus
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.125288
a
b
c
d
Received: 30‑10‑2013 Review completed: 30‑10‑2013 Accepted: 05‑12‑2013
Sciatica caused by pyomyositis of the piriformis muscle Sir, The piriformis muscle has endopelvic origin, exits the 668
Figure 1: Pre- and post-operative magnetic resonance imaging (MRI) and computed tomography (CT). Pre-operative T2-weighted axial MRI (a) and enhanced CT (b) at the greater sciatic notch show muscle swelling (arrowheads) of right side piriformis muscle. MRI shows intramuscular T2 high lesion (a, arrow) and enhanced CT shows intramuscular rim-enhancement (b, arrow), both suggesting abscess formation in piriformis muscle. Post-operative T2-weighted axial MRI (c) and plain CT at the greater sciatic notch show no abscess in the piriformis muscle (d)
Neurology India | Nov-Dec 2013 | Vol 61 | Issue 6
Letters to Editor
2. 3. 4. a
b
Figure 2: Intra-operative photography. After dissecting gluteus maximus muscle, dark-colored and swelled piriformis muscle (a, arrow) entrapped the sciatic nerve. After dissection of the piriformis muscle (b, arrow), sciatic nerve was released (b, arrowheads)
position, a skin incision from just posterior to the greater trochanter to the middle of the buttock was made. The piriformis muscle was exposed by the blunt dissection of the gluteus maximus muscle. The sciatic nerve was then exposed under the piriformis muscle [Figure 2a]. The piriformis muscle was tight and tense especially on internal rotation of the hip joint. The piriformis muscle was incised at the tendinons portion with which the tension of the piriformis muscle decreased and compression over the sciatic nerve got relieved [Figure 2b]. There was no apparent pus discharge intraoperatively. After the surgery, she had dramatic relief of pain. She returned to her work as a nurse 2 months after the surgery. Follow‑up MR and CT images showed normalized right piriformis muscle [Figure 1c and d]. Chiedozi divided pyomyositis into three stages according depending on the progression of the disease: invasive stage showing myositis without abscess formation, suppurative stage with abscess formation and late stage with sepsis.[4] Pyomyositis in suppurative stage, requires aspiration by the percutaneous route or open drainage. This case illustrates that the possibility of piriformis pyomyositis should be considered in patients with sciatica of undetermined causes, more so when signs of inflammation are present. Masao Koda1,2, Chikato Mannoji1, Hitoshi Watanabe1, Arata Nakajima3, Toshiyuki Yamada1, Tomoyuki Rokkaku1, Ken‑Ichi Murakami2, Masazumi Murakami1, Osamu Ikeda2, Masashi Yamazaki4, Takeo Furuya2, Departments of Orthopedic Surgery, 1Chiba Aoba Municipal Hospital, 2Chiba University Graduate School of Medicine, Chiba, 3Toho University Sakura Medical Center, Sakura, 4 University of Tsukuba, Tsukuba, Japan E‑mail: [email protected]
References 1.
Filler AG, Haynes J, Jordan SE, Prager J, Villablanca JP, Farahani K, et al. Sciatica of nondisc origin and piriformis syndrome: Diagnosis by magnetic resonance neurography and interventional magnetic resonance
Neurology India | Nov-Dec 2013 | Vol 61 | Issue 6
imaging with outcome study of resulting treatment. J Neurosurg Spine 2005;2:99‑115. Chen WS. Sciatica due to piriformis pyomyositis. Report of a case. J Bone Joint Surg Am 1992;74:1546‑8. Nakai I, Yano Y, Naramatsu M, Hashimoto N. Piriformis syndrome due to piriformis pyomyositis: report of a case. Seikeigeka 2012;63:949‑51. Chiedozi LC. Pyomyositis. Review of 205 cases in 112 patients. Am J Surg 1979;137:255‑9. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.125291
Received: 30‑10‑2013 Review completed: 30‑10‑2013 Accepted: 05‑12‑2013
A rare cause of dural venous sinus thrombosis Sir, Poisoning resulting from ingestion of crushed seeds of the plant Abrus precatorius (AP) can occasionally cause neurological manifestations. However, dural venous sinus thrombosis is a rare and hitherto unreported complication of AP poisoning. A 22‑year‑old unmarried lady was admitted after suicidal ingestion of about 20 crushed seeds of AP. She developed abdominal pain, recurrent vomiting, profuse watery diarrhea and subsequently bloody diarrhea from second till seventh day of ingestion. Laboratory evaluation on day‑3 revealed hypernatremia (serum sodium: 154 mEq/l), hypokalemia (serum potassium: 3.1 mEq/l), neutrophilic leucocytosis (leucocyte count: 16.2 × 109/l, neutrophils: 83%), normal hematocrit, platelet count, coagulation tests, hepatic and renal function. On day‑7, she suffered multiple episodes of generalized tonic clonic seizures and developed altered sensorium. Examination revealed right sided hemiplegia and papilledema in both eyes. Unenhanced computerized tomography (CT) of the brain revealed thrombosis of the superior sagittal sinus (SSS), left parieto‑occipital hemorrhagic infarct with midline shift [Figure 1]. She was started on antiepileptic drugs, osmotic therapy and subcutaneous enoxaparin. Magnetic resonance imaging (MRI) and MR‑venography confirmed the thrombosis of SSS and left transverse sinuses [Figure 1]. Subsequently she underwent left parieto‑occipitotemporal craniotomy for cerebral decompression [Figure 1]. Urine pregnancy test was negative. Work‑up for pro‑coagulant states and 669
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
