Cerebral venous sinus thrombosis detected using diffusion-weighted magnetic resonance imaging during maintenance temozolomide chemotherapy in a patient with glioblastoma: illustrative case.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) sometimes occurs in the background of hypercoagulopathic disorders, including malignancy, chemotherapy, etc. Glioblastoma (GBM) is a malignancy found in the central nervous system, and reports on cases of GBM complicated by CVST are sparse. The authors herein report a case of GBM complicated by CVST during maintenance temozolomide (TMZ) chemotherapy and describe the utility of diffusion-weighted magnetic resonance imaging (MRI) for the detection of CVST. OBSERVATIONS: A 65-year-old male was treated for left temporal GBM. After surgical removal of the lesion, the patient was treated with chemoradiation therapy, which included 60 Gy local radiation with concomitant TMZ chemotherapy. He was subsequently received TMZ maintenance therapy. Routine MRI performed 7 months after surgery revealed no evidence of tumor recurrence. However, diffusion-weighted imaging (DWI) revealed a high-intensity signal at the posterior portion of the superior sagittal sinus, indicating the presence of a thrombus. In addition to the preexisting symptoms, the patient experienced some disorientation. Angiography revealed an obstruction in the superior sagittal sinus, right transverse sinus, right sigmoid sinus, and straight sinus. His symptoms improved with endovascular and anticoagulant therapy. LESSONS: Performing DWI during routine follow-up can help in the early diagnosis of CVST in patients with malignant gliomas.

Visual Impairment due to a large paraclinoid aneurysm treated with parent artery occlusion and bypass: A case report.

INTRODUCTION: Paraclinoid internal carotid artery (ICA) aneurysms can sometimes cause visual field disturbances due to their size, and it is challenging to treat either surgically or using endovascular techniques. Flow diverters generally have positive outcomes, but sometimes in symptomatic aneurysms, we see the thrombosed section becomes enlarged. Therefore, optimal treatment strategies are difficult to determine. CASE: A 68-year-old woman presented with a chief complaint of vision loss in the left eye. A large wide-necked saccular aneurysm was found on the left ICA paraclinoid portion. Under general anesthesia, a Pipeline Flex was inserted along with coil embolization. After treatment, the aneurysm showed thrombotic expansion, and the visual impairment worsened. One year later, aneurysm recanalization was evident; therefore, another Pipeline was inserted to overlap the stent. However, her visual impairment worsened again, and parent artery occlusion with high flow bypass was performed 20 months after her first treatment. Two weeks postoperatively, improved peripheral vision was confirmed. Further, no enlargement of the aneurysm was observed using magnetic resonance imaging 6 months later. CONCLUSION: This case examined a symptomatic, large paraclinoid aneurysm in a patient, which continued to enlarge after Pipeline stent placement, but was later treated successfully using direct parent artery occlusion in combination with high-flow bypass.

A Case of Telangiectatic Osteosarcoma in the Frontal Bone.

Telangiectatic osteosarcoma (TOS) is a subtype of osteosarcoma. TOS in the elderly and TOS in the skull are very rare. Here, we report a case of TOS in the frontal bone of an elderly patient. The patient was a 79-year-old woman who was identified as having a right frontal bone lesion. The patient was initially diagnosed with an intradiploic epidermoid cyst (IEC). A 60mm cystic lesion with bone destruction appeared 5 years later, which enlarged over 2 months. The fluid in the cyst seemed to be blood that had lost its clotting ability. Tumor and the surrounding tissue were resected. The postoperative course was favorable. Postoperative magnetic resonance imaging (MRI) showed no evidence of residual lesions. There was no metastases. Histopathologically, the cyst wall was composed of fibrous connective tissue and did not contain epithelial components. There were no skin appendages and keratinized tissues in the lesion. Based on these findings, the diagnosis changed to aneurysmal bone cyst (ABC). Subsequent immunohistochemical examinations confirmed that the MIB-1 index was 50% in some sections and there were atypical cells showing osteogenic properties in other sections. Based on these results, the patient was finally diagnosed with TOS. The differential diagnoses for cystic lesion presenting bone destruction include TOS, ABC, and IEC. In case of cystic lesion with bone destruction, early diagnosis based on histopathological study is important and complete resection with surrounding tissues is required, given the possibility of TOS.

Progressive Hydrocephalus after Endoscopic Third Ventriculostomy in Pediatric Patients with Blake's Pouch Cyst.

The pathophysiology and optimal treatment for hydrocephalus with Blake's pouch cyst (BPC) remain controversial. The authors present two pediatric cases of hydrocephalus associated with BPC, in which the patients' hydrocephalus progressed after endoscopic third ventriculostomy (ETV), despite a patent stoma of the third ventricular floor. Case 1: A 4-year-old girl with delayed gait development was diagnosed with BPC-associated hydrocephalus and received ETV. Postoperatively, the patient presented headaches and nausea. Computed tomography (CT) scans demonstrated larger ventricles than those observed on the preoperative images. Because phase-contrast cine magnetic resonance imaging (MRI) and constructive interference in steady state (CISS) MRI revealed patent cerebrospinal fluid (CSF) flow at the third ventricular floor level, a ventriculoperitoneal shunt (VPS) was placed using a programmable pressure valve to treat the hydrocephalus. Case 2: A 6-year-old girl with newly developed repeated convulsive seizures was diagnosed with BPC-associated hydrocephalus and received ETV. Phase-contrast cine MRI on the 5th postoperative day showed hyperdynamic CSF flow at the third ventricular floor level. She also developed vomiting and headache 6 weeks after ETV. CT scans demonstrated much larger tetraventricular hydrocephalus than that observed on the preoperative images. VPS placement improved her hydrocephalus. Referencing the previous literature, we discuss the CSF dynamics and the mechanism of BPC-associated hydrocephalus, focusing on the third ventricular floor bulging. We hope our experience will help elucidate the pathophysiology and treatment strategies for BPC-associated hydrocephalus.