A case of giant cell arteritis lacking typical symptoms presenting with recurrent cerebellar infarctions: A case report and case-based review.

Giant cell arteritis (GCA) occasionally presents with ischaemic stroke. Generally, symptoms related to GCA or elevated levels of inflammation markers would be a clue for the diagnosis of GCA. However, we encountered a rare case of GCA that presented with recurrent cerebellar infarctions without symptoms related to GCA (headache, fever, or jaw claudication). Furthermore, C-reactive protein levels, measured at the time of two of the stroke attacks, were within the normal range. On physical examination, the temporal arteries were prominent and weakly pulsatile. Temporal artery ultrasonography showed halo signs, and temporal artery biopsy revealed GCA. To our knowledge, this is the first case of GCA presenting with recurrent ischaemic stroke lacking GCA features but diagnosed before death. Considering this case-based review, we suggest that GCA may have been missed in elderly patients with ischaemic stroke, especially in those with posterior circulation infarction. Therefore, physical examination of the temporal arteries, temporal artery ultrasonography, and vessel wall magnetic resonance imaging may be useful in those patients.

Analysis of risk factors for infection in coplacement of percutaneous endoscopic gastrostomy and ventriculoperitoneal shunt.

Patients with severe neurological impairment requiring tube feeding may have concomitant hydrocephalus. Coplacement of percutaneous endoscopic gastrostomy (PEG) and ventriculoperitoneal (VP) shunting is currently standard in such cases. The present study investigated the risk factors for shunt infection in such patients. The medical records of 23 patients with PEG and VP shunting were retrospectively reviewed. Correlations between shunt system infection and potential risk factors were analyzed including order of PEG and VP shunting, position of abdominal shunt catheter, diabetes mellitus, tracheostomy, and activities of daily living. Twelve patients underwent VP shunting after PEG and 11 underwent PEG after VP shunt placement. Four patients experienced shunt infection, and three required shunt revision. Three of these four patients underwent VP shunting after PEG. The period between PEG and VP shunt placement was 18, 19, and 25 days, shorter than the mean period of 29.3 days. VP shunting can be combined with PEG, but a larger study is required to clearly identify the risk factors. Administration of prophylactic antibiotics and a period of at least 1 month between the procedures are recommended, particularly if the shunt is placed after the PEG tube.

Internal carotid artery occlusion following correction of atypical aortic coarctation-- case report--.

An 11-year-old boy developed occlusion of the left internal carotid artery (ICA) following surgical correction of atypical coarctation of the aorta. The patient was admitted to our hospital after presenting with severe hypertension secondary to abdominal aortic hypoplasia and renal artery stenosis. Reconstruction of the abdominal aorta with bypass grafting was performed without complication. However, in the postoperative period, the patient experienced recurrent transient ischemic attacks manifesting as paresthesia of the right upper limbs, dysarthria, and right-sided weakness. Cerebral angiography revealed occlusion of the C(2) portion of the left ICA and decreased resting cerebral blood flow in the left hemisphere. Extracranial-intracranial arterial bypass was performed, and the patient suffered no further adverse neurological events. Coarctation of the aorta is an uncommon congenital condition that may result in cerebral ischemic disease. The cerebrovascular circulation should be evaluated, even in patients without a pre-existing history of cerebral ischemic symptoms.

Metastatic leiomyosarcoma of the brain manifesting as multiple hemorrhages. Case report.

A 74-year-old man presented with a rare metastatic leiomyosarcoma of the brain manifesting as subacute development of multiple cerebral hemorrhages. Cerebral angiography demonstrated no tumor staining or vascular malformation. Whole body computed tomography revealed abnormal masses in the liver, left adrenal gland, and duodenum. Histological examination of an open biopsy specimen identified the lesion as metastatic leiomyosarcoma. Whole brain irradiation controlled the intracranial lesions, but the patient's general condition progressively deteriorated and he died of pneumonia. Metastatic leiomyosarcoma is a very uncommon tumor in the central nervous system with a poor response to existing treatment options. Consequently, new approaches to the treatment of this disease are needed.

[A case of aqueductal stenosis with acute progressive hydrocephalus during pregnancy].

The authors present a case of aqueductal stenosis (AS) with acute progressive symptoms during pregnancy. A 39-year-old pregnant woman in 19th gestation week was admitted with headache, nausea and deterioration of consciousness. On admission, computed tomography (CT) scan showed acute hydrocephalus. Ventricular drainage was performed on emergency and her symptoms were resolved in a few days. Postoperative T2-weighted MR images showed enlargement of the lateral and third ventricles with membranous occlusion of the aqueduct. Endoscopic third ventriculostomy was performed uneventfully. A healthy baby was delivered by Cesarean section in 36th gestation week considering her previous extirpation of hysteromyoma. In this case of pregnant woman, increase of total body water, cardiac output, and central venous pressure, and decrease in plasma osmotic pressure might contribute to development and sudden worsing of symptoms of pre-existed hydrocephalus due to aqueductal stenosis. Endoscopic third ventriculostomy, especially in the pregnant case, should be recommended in hydrocephalus due to aqueductal stenosis to avoid shunt malfunction caused by increasing intraabdominal pressure and shunt infecton during Cesarean section.

Infundibuloneurohypophysitis presenting a large sellar-juxtasellar mass: case report.

BACKGROUND: Infundibuloneurohypophysitis (INH) is reported to be a self-limiting inflammatory disease involving neurohypophysis. The authors experienced a case of INH presenting a large mass compressing the brain stem. CASE PRESENTATION: The patient exhibited polyuria followed by left hemiparesis and dysarthria lasting a year. Magnetic resonance imaging showed a large sellar mass extending into the right cavernous sinus and prepontine cistern and compressing pons. Endocrinologically, diabetes insipidus was diagnosed and anterior pituitary function was almost normal. Microscopic examination of the surgical specimen obtained by a transsphenoidal route demonstrated diffuse infiltration of lymphoid cells with predominance of B cells over T cells and the granulation tissue. The patient underwent 40 Gy local radiation because of initial misinterpretation of histologic findings as malignant lymphoma and short-term corticostertoid administration. CONCLUSION: The mass gradually shrank and the patient has become neurologically intact in 6 months. At this moment, 67 months after the onset, the patient is free from disease and has no other lesion. INH seems to be a clinical entity possessing a wide spectrum from infundibular tumorlet to an aggressive sellar mass trespassing on surrounding structures.

Relationship between intratumoral hemorrhage and overexpression of vascular endothelial growth factor (VEGF) in pituitary adenoma.

The authors investigated the relationship between hemorrhage and the expression of vascular endothelial growth factor (VEGF) in pituitary adenomas. The subjects were 39 patients with pituitary adenomas. Surgically obtained tumor tissue was immunohistochemically stained using antibodies against VEGF, CD-34, Ki-67, and anterior pituitary hormones. The expression of VEGF was graded as 0, 1+, and 2+. The relationship between intratumoral hemorrhage and factors such as tumor size, Ki-67 labeling indices, number of CD-34 positive vessels, and VEGF expression was examined by multivariate analysis. High-grade VEGF expression was the sole independent factor correlated with intratumoral hemorrhage. The number of CD-34 positive vessels had no effect on the incidence of hemorrhage in patients with pituitary adenomas. In conclusion, a positive relationship between VEGF expression and hemorrhage in pituitary adenoma was observed. The patho-mechanical significance of this correlation is under investigation.