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References

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b Figure 3: (a) Sagittal T2‑weighted image shows tumor size and intramedullary high‑signal area were decreased after radiotherapy.  (b) Axial T2‑weighted image shows tumor size and intramedullary high‑signal area were decreased after radiotherapy

As whole body imaging technologies, PET/CT could be used to detect ISCM. Nevertheless, it requires radiation use. Takahara et al., [3] reported a unique whole body DWI concept which had the advantages of a wider coverage range and without radiation exposure. In the present case, whole body DWI allowed lesions of the primary lung cancer [Figure 2c], subcarinal [Figure 2d], mediastinal, [Figure 2e] bilateral hilar lymph nodes [Figure 2f and g] and entire spinal cord, including distant metastases in the conus medullaris to be imaged simultaneously compared to MRI and CT. The mean apparent diffusion coefficient (ADC) values for the conus medullaris on whole body DWI were lower than those elsewhere in the spinal cord (0.781 × 10‑3 mm²/s vs. 0.825 × 10‑3 mm²/s), consistent with results in the literature. The diagnosis of ISCM seems reliable. The patient’s clinical history and rapidly progressing neurological symptoms allowed us to distinguish ISCM from a primary intramedullary tumor, which typically presents with slower symptom progression.[4] Optimal treatment for ISCM remains controversial. We adopted a treatment approach of chemoradiotherapy combined with TCM. The patient died in 2009 June, 9 months from the diagnosis of ISCM. In summary, this report shows that early diagnosis by whole body DWI allows detection of the suspected ISCM, enabling timely treatment prior to the development of neurological symptoms which might improve the patients’ prognoses. However, further large‑scale studies are needed to come up with general conclusions concerning the value of whole body DWI in ISCM.

Yan Zhang1,2, Yongbo Huang3, Xixing Wang4, Jun Wang1 1

Departments of Radiology and 3Orthopedics, The Second Hospital of Shanxi Medical University, Taiyuan, 2Departments of Radiology and 4Oncology, Shanxi Province Hospital of Traditional Chinese Medicine, Taiyuan, Shanxi, China. E‑mail: [email protected]

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1. Sari O, Kaya B, Kara Gedik G, Ozcan Kara P, Varoglu E. Intramedullary metastasis detected with 18F FDG‑PET/CT. Rev Esp Med Nucl Imagen Mol 2012;31:299‑300. 2. Pellegrini D, Quezel MA, Bruetman JE. Intramedullary spinal cord metastasis. Arch Neurol 2009;66:1422. 3. Takahara T, Imai Y, Yamashita T, Yasuda S, Nasu S, Van Cauteren M. Diffusion weighted whole body imaging with background body signal suppression (DWIBS): Technical improvement using free breathing, STIR and high resolution 3D display. Radiat Med 2004;22:275‑82. 4. Madhukar M, Maller VG, Choudhary AK, Iantosca MR, Specht CS, Dias MS. Primary intramedullary spinal cord germinoma. J Neurosurg Pediatr 2013;11:605‑9. Access this article online Quick Response Code:

Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.121954

Received: 27‑08‑2013 Review completed: 01‑09‑2013 Accepted: 13‑10‑2013

Spontaneous rupture of hydrocephalic head Sir, A 6‑month‑old female child, a product of non‑consanguineous marriage, and born at full term by normal vaginal delivery, presented to us with a large head and a swelling over the lower back region since birth. She was diagnosed to have hydrocephalous in the antenatal period at 8 months of gestation, but termination of pregnancy could not be done. She was born with a large head and the head size kept on increasing gradually. She also had weakness in both lower limbs (power 0/5). She was diagnosed to have meningomyelocele (MMC) and congenital hydrocephalous and was advised repair of MMC and ventriculoperitoneal shunt. Parents did not give consent for surgery and the child was taken back home. While at home, she developed dehiscence of the skin over the vertex with cerebrospinal fluid (CSF) leakage from it without any form of preceding trauma.  [Figures 1a, b and 2]. There was big skin defect over the vertex when she was brought to emergency department. She was running fever and her total leucocyte count was raised. Non‑contrast computed tomography head revealed bilateral large subdural hematoma with pneumocephalous and pneumoventricle. The brain tissue was protruding out through the ruptured skin [Figure 3]. Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5

Letters to Editor

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Figure 1: (a) Clinical photograph of the patient showing large head size (as compared to body) with sunken anterior fontanelle and downward deviation of eyeballs, (b) Superior view of vertex showing sunken anterior fontanelle with large skin defect in left posterior quadrant, (c) Enlarged view of skin defect with the exposed brain tissue (white arrow)

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Figure 2: Magnetic resonance imaging (MRI) head T1‑WI and T2‑WI axial images showing hydrocephalous with extremely thin cortical mantle (a and b), MRI whole spine T1‑WI and T2‑WI sagittal section showing extremely thin spinal cord with extension of thecal sac into the lumbar region swelling

Despite the widespread awareness and availability of neurosurgical services these days, few cases of hydrocephalous still remain untreated. Spontaneous rupture of hydrocephalous is an odd phenomenon. Long standing tension hydrocephalus can occasionally lead to formation of ventricular diverticula[1] or ventricular rupture. It can rupture into the cisterns leading to spontaneous ventriculostomy[2] or it can rupture through the skin leading to “Spontaneous brain rupture”. Spontaneous brain rupture might only appear in infantile hydrocephalus if the sutures are not closed and the skull is able to expand.

cerebral mantle. There is also associated thinning of the skin and the subcutaneous tissues. Due to the weight of the head and problems with its positioning, skin atrophy or even ulcers and local infection might also occur. This could be the principal external mechanical factor, which causes weakening of the skin and promotes CSF leakage in cases of untreated ventricular distension in infants. A combination of internal biomechanical forces as a result of ventricular expansion and external mechanical irritation due to trauma to thinned skin leads to spontaneous rupture of brain.

Ventriculomegaly in infants, whose cranial sutures have not closed, is manifested by enlargement of the head size due to separation of the sutures. However, ventricular enlargement occurs at the expense of the thinning

Kanwaljeet Garg, Hitesh Kumar Gurjar, Pankaj Kumar Singh, Guru Dutt Satyarthee, Manmohan Singh, P. Sarat Chandra, Bhawani Shankar Sharma

Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5

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