Letters to Editor with typical MRI findings help to confirm the diagnosis. The neurobiology of TS involves frontal subcortical Melanin produces stable free radicals, causing circuits and neurotransmitter systems.[2] The usefulness paramagnetic effect that shortens T1 and T2 relaxation of antipsychotics in the treatment of TS has been values on MRI. This results in hyperintensity of the documented, but is often associated with incapacitating [5] lesion on T1W and hypointensity on T2W images. side-effects. There are a few case reports of Tardive dyskinesia (TD) in TS after treatment with typical Treatment of isolated brain metastasis from malignant antipsychotics unlike with atypical antipsychotics. We melanoma includes total surgical excision of the lesion discuss the case of a 24-year-old male who first exhibited followed by postoperative adjuvant radiotherapy and repetitive head and neck twisting movements that chemotherapy as in our case. In spite of all the possible started at 15 years of age. Nine years after the onset of management, long-term prognosis for metastatic symptoms when a definitive diagnosis of TS was made, choroidal melanoma remains poor. his symptoms included motor and phonic tics [Yale Global Tic Severity Scale (YGTSS) = severe] as well as Sachin A. Borkar, G. D. Satyarthee, Prasenjit Das1, obsessional thoughts [Yale-Brown Obsessive Compulsive Vaishali Suri1 Scale (Y-BOCS) = mild). There was no movement other Departments of Neurosurgery and 1Neuropathology, than tics. His biochemical and neuromaging tests were All India Institute of Medical Sciences, New Delhi, India. normal. Initially he was treated with oral sertraline E-mail: [email protected] 50 mg and haloperidol 0.5 mg daily, but was lost to DOI: 10.4103/0028-3886.48798 follow-up and reported for treatment after a year with References identical symptoms. Oral risperidone was started as well as maintained at 1 mg with dinner and fluoxetine was 1. Lorigan JG, Wallace S, Mavligit GM. The prevalence and location of increased to 40 mg with breakfast. Although his tics were metastases from ocular melanoma: Imaging study in 110 patients. AJR minimal at this dose (YGTSS = mild), he developed Am J Roentgenol 1991;157:1279-81. 2. Abramson DH, Servodidio CA. Metastatic choroidal melanoma to severe TD of the lower jaw (oro-mandibular dyskinetic the contralateral orbit 40 years after enucleation. Arch Ophthalmol movements) after four months of treatment [Abnormal 1997;115:134. Involuntary Movement Scale (AIMS) rating = severe]. 3. Achtaropoulos AK, Mitsos AP, Detorakis ET, Georgakoulias NV, This movement was entirely different from the initial Drakonaki EE, Kozobolis VP. Late isolated brain metastasis following enucleation for choroidal melanoma. Ophthalmic Surg Lasers Imaging symptoms both anatomically and phenomenologically. 2005;36:151-4. Following this, risperidone was stopped and patient 4. Zimmerman LE, McLean IW. The pathogenesis of metastases from was started on vitamin E and clonazepam. In about uveal melanomas. Ophthalmic Forum 1983;1:28-9. 45 days there was significant improvement in the 5. Gomori JM, Grossman RI, Shields JA, Ausberger JJ, Joseph PM, dyskinetic movements (AIMS score = mild) but the DeSemione D. Choroidal melanomas: Correlation of NMR spectroscopy and MR imaging. Radiology 1986;158:443-5. TS worsened significantly causing severe distress (YGTSS = severe). Risperidone has a higher affinity for Accepted on 06-02-2009 5-hydroxytryptamine 2A receptors and lower dopamine D2 receptor binding than haloperidol.[3] As the 5-HT2A receptor has been implicated in the pathophysiology Tardive dyskinesia following of TS, risperidone may be of theoretical benefit in TS, especially if the patient has OCD/OCS where 5-HT has risperidone treatment in been implicated. Several reports illustrate efficacy[4] and lack of extrapyramidal side-effects in TS patients Tourette’s syndrome treated with risperidone.[5] To our knowledge, this is the first report of TD complicating the use of risperidone Sir, in the treatment of TS. We wish to highlight the need Tics are involuntary, sudden, repetitive, stereotyped for awareness among clinicians and patients about the motor movements or phonic productions. Tourette’s potential risk of getting new movement disorders during syndrome (TS) is diagnosed when multiple motor the course of treatment with risperidone for tic disorders. tics and at least one phonic tic is present during the course of the illness. Obsessive-compulsive disorder/ symptoms (OCD/OCS) typically manifest as own, Naveen Thomas, Paul Swamidhas, Sudhakar Russell, egodystonic and involuntary intrusive thoughts, Hareesh Angothu ideas or images accompanied by ritualized, overt, or Department of Child and Adolescent Psychiatry, Christian Medical College, Vellore - 632 002, Tamil Nadu, India. covert behaviors. The frequent association of TS with E-mail: [email protected] obsessive-compulsive symptoms (OCS) and obsessive- compulsive disorder (OCD) is widely recognized.[1] DOI: 10.4103/0028-3886.48799

94 Neurology India | Jan-Feb 2009 | Vol 57 | Issue 1 Letters to Editor

References single tapering self-expanding nitinol 8>6 × 30 mm Protégé stent was deployed across the lesion by 7 h 1. Eapen V, Fox-Hiley P, Banerjee S, Robertson M. Clinical features and after the onset of stroke. Post-deployment angiogram associated psychopathology in a Tourette syndrome cohort. Acta Neurol Scand 2004;109:255-60. showed excellent recanalisation of the ICA with filling 2. Robertson MM, Stern JS. Tic disorders: New developments in Tourette of the left anterior cerebral artery (ACA) and superior syndrome and related disorders. Curr Opin Neurol 1998;11:373-80. division of the MCA [Figure 2]. Further thrombolysis 3. Leysen JE, Janssen PM, Gommeren W, Wynants J, Pauwels PJ, of the inferior division was not attempted. Diffusion Janssen PA. In vitro and in vivo receptor binding and effects on weighted magnetic resonance imaging (DWMRI) on monoamine turnover in rat brain regions of the novel antipsychotics risperidone and ocaperidone. Mol Pharmacol 1992;41:494-508. Day 3 showed only a periventricular infarction in the 4. Bruun RD, Budman CL. Risperidone as a treatment for Tourette’s left MCA territory [Figure 3]. CT angiography on Day syndrome. J Clin Psychiatry 1996;57:29-31. 3 demonstrated the stent in situ with recanalisation of 5. Robertson MM, Scull DA, Eapen V, Trimble MR. Risperidone in the treatment of Tourette syndrome: A retrospective case note study. J Psychopharmacol 1996;10:317-20.

Accepted on 05-02-2009

Primary stenting in acute carotid dissection

Sir, A 49-year-old man presented to us with aphasia and right hemiplegia of 6 h duration. On examination he had a gaze preference to the left side, global aphasia and dense right hemiplegia with Grade 0/5 power. He had no history of trauma or risk factors for stroke. Computerized tomography (CT) scan of brain showed a hyperdensity in the left sylvian fissure suggestive of thrombosis in middle cerebral artery (MCA) branches [Figure 1]. He was taken up for digital substraction angiography (DSA) which showed a tapering occlusion of the left internal carotid artery (ICA) 3 cm after the origin with absent intracranial flow and very poor collateral flow via the contralateral ICA at 6 h. In view of the mechanical occlusion and the elapsing of the time window for intra-arterial thrombolysis, primary stenting Figure 2: Top panel Þ rst image (from left to right) shows dissection of the LICA. Second image shows the absent intracranial flow. Bottom was offered as an option. A microcatheter and microwire panel first image shows the deployed stent in the LICA. Second were passed through the true lumen of the ICA and a image shows the recanalisation of ACA and superior MCA division

Figure 1: Initial CT showing hyperdense MCA branches in the left sylvian Þ ssure Figure 3: Post-stenting DWMRI showing a periventricular infarct

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