SPONTANEOUS INTRACRANIAL HYPOTENSION Tanmayi Gadre, Raja Prahadeesh Saravanan, Catalina Negulescu; Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA.
Introduction: Spontaneous intracranial hypotension (SIH) is a disorder caused by depletion of cerebrospinal fluid (CSF) volume, most commonly from a spontaneous CSF leak. It is characterized by orthostatic headaches and occasionally associated with vestibular-cochlear symptoms like dizziness. SIH is a challenging diagnosis that confronts neurologists and clinicians alike. The uncertainty posed by various atypical and unconfirmed cases as well as treatment failures highlights the need for dedicated diagnostic and therapeutic strategies. Case: A 65-year-old male with chronic kidney disease, hypertension, and hypogonadism presented after a syncopal event. While working in his yard, he experienced acute dizziness upon bending over resulting in syncope. He also endorsed a positional headache. Notably he was a former smoker and alcohol user. Orthostatics deferred due to marked instability. Labs were normal, except for mild hyperglycemia. Work up for cardiogenic syncope including telemetry monitoring, echocardiogram and carotid ultrasound were unremarkable. The Computed Tomography of the head was negative, and Magnetic Resonance Imaging (MRI) of the brain showed no ventricular enlargement, hemorrhage, mass, or acute infarcts. Spine MRI
revealed mild multilevel degenerative changes. A trial of oral steroids for cluster headache failed. Given persistent positional headache and dizziness, there was a high clinical suspicion for spontaneous intracranial hypotension. He underwent epidural blood patch with significant symptomatic improvement. He was able to ambulate without any difficulty and was discharged. Discussion: The SIH is a distinct entity and requires a high index of suspicion for diagnosis. SIH can be managed conservatively as a minority cases have shown spontaneous resolution. A widely used intervention is a lumbar epidural blood patch in persistently symptomatic cases which has demonstrated improvement in almost 30-70% of SIH cases. Further invasive techniques aim at identifying CSF leak sites and employing targeted epidural patches or direct surgical closure of ventral dural tears and surgical ligations of leaking nerve root sleeves associated with meningeal diverticulae or CSF-venous fistulas. No randomized clinical trials however have assessed these treatment modalities. This necessitates further research to gain better understanding of SIH pathophysiology to refine diagnosis and treatment approaches and to evaluate clinical outcomes.
RETROPERITONEAL MALIGNANT MESOTHELIOMA Bhagyasri Challa MD, Maithri Vallabhaneni MD, Sneha Puvvada MD, Raja Saravanan MD, Michelle Arsenault MD, Sanjay Juneja MD; Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA.
Introduction: Malignant peritoneal mesothelioma (MPeM) is a rare, lethal, and highly aggressive tumor. It has an extremely low incidence rate of approximately 0.13 cases per 100,000 individuals. The median overall survival (OS) for untreated MPeM patients is reportedly < 12 mo. Case: A 39-year-old Caucasian male with a past medical history of long-standing tobacco use presented to hospital with hematuria and left sided flank pain. Review of systems was positive for exertional dyspnea and unintentional weight loss for a few months. Occupational exposure included inhalational exposure while volunteering as a firefighter. Work up with a Computed Tomography
(CT) of the abdomen/pelvis identified an 8.9 x 7.2 x 8.6 cm lesion in the left kidney with large volume ascites. Pan CT revealed multiple foci of thickening involving right hemothorax, pericardial lymph nodes with innumerable diffuse metastatic lesions throughout the liver. The clinical picture and renal mass initially suggested renal cell carcinoma, but his other findings—mesenteric lymph nodes and pleural effusions/plaques —were not consistent with the disease. This led us to explore further using interventional radiology guided therapeutic/ diagnostic thoracentesis and paracentesis in search of alternatives. Omental mass core biopsies resulted positive for malignant mesothelioma, epithelioid type. Immunohistochemical stains demonstrated 42
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