Covert invader- atypical presentation of neuronal migration disorder

Nadhim Rizvi1,*, Aslesha Vijaay Sheth2

1MRCEM Resident – 3rd year, Department of Emergency Medicine, Kauvery Hospital, Chennai, India

2Consultant and Clinical Lead, Department of Emergency Medicine, Kauvery Hospital, Chennai, India

*Correspondence: [email protected]

Abstract

Importance of MRI Brain as the investigation of choice in emergency department in Epilepsy is illustrated in this case report. Antenatal history/developmental history is relevant for diagnosis, even for adults.

Keywords: Epilepsy, MRI Brain, Neuronal migration disorder, Heterotopia

 

Case Presentation

A patient, 20/F, was brought to the ER with H/O first episode of generalized tonic – clonic seizures (GTCS), witnessed by the parents at her residence.

The patient was brought in post-ictal state to the Emergency department.

Initial vitals of the patient were as follows:

BP: 120/80 mmHg

Pulse: 110 bts/min

SPO2: 99%

CBG: 135 mg/dl

 

Clinical Examination

CVS: S1S2 heard, no murmurs

RS: NVBS heard, No added sounds

ABD: Soft, Non tender, no organomegaly

CNS: Patient was in a post ictal state

Patient, after initial stabilization, was shifted for MRI BRAIN epilepsy protocol.

MRI Brain

Multiple nodular areas of grey matter signal intensities in subependymal region of both lateral ventral ventricles with predominant involvement of left side- causing scalloping of ventricular borders of focal FLAIR hyper intensity noted in right periventricular region.

MRI-Brain

Discussion

Neuronal Migration Disorder

(a). Corpus callousness a genesis

(b). Lissencephaly

(c). Polymicrogyria

(d). Hetrotopias

(e). Schizencephaly

Usual presentation

(a). Mental disabilities

(b). Spasticity

(c). Childhood seizure

(d). Congenital deformities

(e). Developmental delays

Our patient

(a). Patient was asymptomatic until adolescence

(b). The mother only gave history of one episode of vacant stare by the daughter 3 months back which was neglected.

(c). The antenatal period of the mother was apparently normal.

(d). There was no developmental delay in milestones of the patient.

Key points

(a). MRI plays an important role in localizing new onset seizure

(b). Structural abnormalities can remain dormant till even adolescence

(c). Patient was discharged on oral Anti-epileptics

Acknowledgement

I would like to thank, Dr. Bhuvaneswari, Consultant Neurologist, Dr. Aslesha, Consultant & Clinical Lead, for guiding me to prepare this article.

References

[1]Sidman RL, Rakić P. Neuronal migration, with special reference to developing human brain: a review. Brain Res. 1973;62:1-35.

[2]Levitt P, Cooper ML, Rakić P. Coexistence of neuronal and glial precursor cells in the cerebral ventricular zone of the fetal monkey: an ultrastructural immunoperoxidase analysis. J Neurosci. 1981;1:27-39.

[3]Angevine JB, Sidman RL. Autoradiographic study of cell migration during histogenesis of cerebral cortex of the mouse. Nature 1961;192:766-8.

[4]Berry M, Rogers AW. The migration of neuroblasts in the developing cerebral cortex. J Anat. 1965;99:691-709.

[5]Marin Padilla M. Dual origin of the mammalian neocortex and evolution of the cortical plate. Anat Embryol. 1978;152:109-26.

[6]Ramón, Cajal, S. Histologie du Systí¨me Nerveux de l’Homme et des Vertébrés. Paris: Maloine. 1911;2:847-61.

[7]Rakić P. Mode of cell migration to the superficial layers of fetal monkey neocortex. J Comp Neurol. 1972;145:61-84.

[8]Levitt P, Rakić P. Immunoperoxidase localization of glial fibrilary acidic protein in radial glial cells and astrocytes of the developing rhesus monkey brain. J Comp Neurol. 1980;193:417-48.

[9]Antanitus DS, Choi BH, Lapham LW. The demonstration of glial fibrillary acidic protein in the cerebrum of the human fetus by indirect immunofluorescence. Brain Res. 1976;103:613-6.

 

Dr-Nadhim-Rizvi

Dr. Nadhim Rizvi

MRCEM Resident

Dr-Aslesha-Vijaay-Sheth

Dr. Aslesha Vijaay Sheth

Consultant & Clinical Lead

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