A Rare Case of Isolated Cerebral Sarcoidosis Presenting as Suprasellar Mass Lesion with Salt-Wasting Hypopituitarism.

Background Sarcoidosis is a systemic disorder of unknown origin characterized by noncaseating granulomas. Clinical symptoms due to central nervous system (CNS) involvement occur in 5 to 7% of all cases; subclinical involvement is more frequent. Sole CNS involvement is very rare. Case Report A 25-year-old man presented with increasing polyuria and polydipsia over 8 weeks. Magnetic resonance imaging (MRI) revealed a supra- and infra-chiasmatic pre-thalamic mass lesion 1.0 × 1.4 × 1.4cm in diameter. Microsurgical biopsy verified a necrotizing noncaseating epithelioid cell tumor indicative for neurosarcoidosis. All symptoms dissolved within 3 months under stringent corticoid therapy. Conclusion Intracranial mass lesions as the primary and only manifestation of neuronal sarcoidosis are rare. Because conservative treatment is safe and effective, surgery is limited to biopsy and the alleviation of pressure-related symptoms to preserve neurologic function.

Ultra-early decompressive hemicraniectomy in aneurysmal intracerebral hemorrhage: a retrospective observational study.

BACKGROUND: The rupture of an intracranial aneurysm leading to subarachnoid hemorrhage (SAH) is frequently complicated by an extensive intracerebral hematoma (ICH). ICH represents a factor that worsens clinical outcome either due to early or delayed critical increase of intracranial pressure (ICP). Data on the management of aneurysmal ICH are lacking. Besides the securing of the ruptured aneurysm, there is the option of decompressive surgery to prevent secondary damage. The aim of this study was to analyze feasibility of decompressive hemicraniectomy (DHC) and the impact of timing in patients suffering from aneurysmal SAH with extensive ICH. METHODS: We retrospectively analyzed patients with aneurysmal ICH matched for age, sex, World Federation of Neurological Surgeons (WFNS) grade and ICH volume. All patients were treated via aneurysm clipping in conjunction with hematoma removal followed by either primary ultra-early DHC directly after admission or secondary, i.e. delayed DHC. We analyzed patient characteristics and management and the influence on postoperative care and outcome. Parameters were ICP, Glasgow Coma Scale (GCS), length of neurointensive care treatment and duration of mechanical ventilation. Outcome interviews were conducted as Extended Glasgow Outcome Scale (GOS-E). RESULTS: Nineteen consecutive patients with ruptured MCA-aneurysm and ICH were identified with median WFNS grade 5. Eleven patients were treated via primary, ultra-early DHC in mean 2.6 ± 1.4 hours after admission. Eight patients were treated via secondary DHC in 47.6 ± 34.2 hours after admission. In these patients, secondary DHC led to a significant decrease of peak ICP (50.2 mmHg preoperative vs. 10 mmHg postoperative). Mortality rate was six percent. In primary DHC group was a significantly better course of disease mirrored via reduced time of mechanical ventilation (14.4 ± 3.3 vs. 25.5 ± 3.4 days) and shorter hospital stay (18.7 ± 2.1 vs. 26.3 ± 3 days). Nevertheless there were no differences in long-term follow-up and most patients had a poor outcome. CONCLUSION: Our data demonstrate that DHC is feasible in aneurysmal ICH. Timing appears to be a crucial factor concerning early and long-term control of ICP and outcome. We are therefore in favor of ultra-early DHC to treat especially poor grade patients with intracerebral mass lesion in aneurysmal hemorrhage to facilitate the ICP management as well as care within the ICU.

A new approach for corticospinal tract reconstruction based on navigated transcranial stimulation and standardized fractional anisotropy values.

PURPOSE: To establish a novel approach for fiber tracking based on navigated transcranial magnetic stimulation (nTMS) mapping of the primary motor cortex and to propose a new algorithm for determination of an individualized fractional anisotropy value for reliable and objective fiber tracking. METHODS: 50 patients (22 females, 28 males, median age 58 years (20-80)) with brain tumors compromising the primary motor cortex and the corticospinal tract underwent preoperative MR imaging and nTMS mapping. Stimulation spots evoking muscle potentials (MEP) closest to the tumor were imported into the fiber tracking software and set as seed points for tractography. Next the individual FA threshold, i.e. the highest FA value leading to visualization of tracts at a predefined minimum fiber length of 110 mm, was determined. Fiber tracking was then performed at a fractional anisotropy value of 75% and 50% of the individual FA threshold. In addition, fiber tracking according to the conventional knowledge-based approach was performed. Results of tractography of either method were presented to the surgeon for preoperative planning and integrated into the navigation system and its impact was rated using a questionnaire. RESULTS: Mapping of the motor cortex was successful in all patients. A fractional anisotropy threshold for corticospinal tract reconstruction could be obtained in every case. TMS-based results changed or modified surgical strategy in 23 of 50 patients (46%), whereas knowledge-based results would have changed surgical strategy in 11 of 50 patients (22%). Tractography results facilitated intraoperative orientation and electrical stimulation in 28 of 50 (56%) patients. Tracking at 75% of the individual FA thresholds was considered most beneficial by the respective surgeons. CONCLUSIONS: Fiber tracking based on nTMS by the proposed standardized algorithm represents an objective visualization method based on functional data and provides a valuable instrument for preoperative planning and intraoperative orientation and monitoring.

Traumatic middle meningeal artery pseudoaneurysms: diagnosis and endovascular treatment of two cases and review of the literature.

Intracranial pseudoaneurysms are rare and mostly associated with a history of head trauma. Only little is known about their natural development. They are characterized by an unpredictable course with a possibility of causing secondary intracranial hemorrhage with significant morbidity and mortality. We present two cases of traumatic pseudoaneurysms of the middle meningeal artery (MMA) treated via endovascular coil occlusion and review of literature. Pseudoaneurysms of the middle meningeal artery carry a potential risk of rupture. They can be detected via a computed tomography angiogram (CT-A). An endovascular embolization followed by catheter angiography may represent a safe treatment of traumatic middle meningeal artery pseudoaneurysms. Considering the risk of secondary rupture and the potentially catastrophic consequences, we recommend a CT-A in all patients with skull base fractures and intracranial hemorrhage.