Peritumoural glutamate correlates with post-operative seizures in supratentorial gliomas.

To examine the impact of glutamate on post-operative seizures and survival in a cohort of patients with grade II to IV supratentorial glioma. A retrospective analysis was performed on 216 patients who underwent surgery for supratentorial gliomas. Primary explanatory variables were peritumoural and/or tumoural glutamate concentrations, glutamate transporter expression (EAAT2 and SXC). Univariate and multivariate survival analysis was performed with primary outcomes of time to first post-operative seizure and overall survival. Subgroup analysis was performed in patients with de novo glioblastomas who received adjuvant chemoradiotherapy. 47 (21.8 %), 34 (15.8 %) and 135 (62.5 %) WHO grade II, III and IV gliomas respectively were followed for a median of 15.8 months. Following multivariate analysis, there was a non-significant association between higher peritumoural glutamate concentrations and time to first post-operative seizure (HR 2.07, CI 0.98-4.37, p = 0.06). In subgroup analysis of 81 glioblastoma patients who received adjunct chemoradiotherapy, peritumoural glutamate concentration was significantly associated with time to first post-operative seizure (HR 3.10, CI 1.20-7.97, p = 0.02). In both the overall cohort and subgroup analysis no glutamate cycle biomarkers were predictive of overall survival. Increased concentrations of peritumoural glutamate were significantly associated with shorter periods of post-operative seizure freedom in patients with de novo glioblastomas treated with adjuvant chemoradiotherapy. No glutamate cycle biomarkers were predictive of overall survival. These results suggest that therapies targeting glutamate may be beneficial in tumour associated epilepsy.

Ischaemic monomelic neuropathy: A rare cause of unilateral foot drop.

Ischaemic neuropathy is a rare phenomenon given the rich arterial collateral supply afforded to peripheral nerves by the vasa nervorum. We report an unusual case of unilateral foot drop secondary to long-segment popliteal artery occlusion. Without expedient vessel imaging and revascularisation of the occluded artery, this reversible cause of neurological deficit would likely have resulted in a poor functional outcome for our patient.

Familial intracranial ependymoma mimicking an extra-lesion: A case report and review of the literature.

Familial occurrence of intracranial ependymoma, in the absence of neurofibromatosis type 2 (NF2), is very rare with only a few cases reported in the literature. We report a 62-year-old man, who presented with a posterior fossa ependymoma with the majority of the lesion in the cerebellopontine angle, mimicking an extra-axial tumour. His two brothers also had 4th ventricular ependymomas requiring surgical resection. Such cases add weight to the suggestion of a genetically predisposing mutation in familial cases of intracranial ependymomas. Further genetic testing may help to elucidate the location of the genetic abnormality in patients with non-NF2 familial intracranial ependymomas and promote a better understanding of this rare pathological entity.

Intracranial multiple myeloma with intraparenchymal involvement: Case report and literature review.

Intraparenchymal extension of multiple myeloma is a rare manifestation of the disease. Here, we present a case of a patient with multiple myeloma lesions situated adjacent to the meninges and intraparenchymally.

Is establishing a specialist back pain assessment and management service in primary care a safe and effective model? Twelve-month results from the Back pain Assessment Clinic (BAC) prospective cohort pilot study.

OBJECTIVES: To report on the design, implementation and evaluation of the safety and effectiveness of the Back pain Assessment Clinic (BAC) model. DESIGN: BAC is a new, community-based specialist service for assessing and managing neck and low back pain (LBP). The BAC pilot was supported by a Victorian Department of Health and Human Services grant and was evaluated using the Victorian Innovation Reform Impact Assessment Framework (VIRIAF). Data were obtained by auditing BAC activity (22 July 2014 to 30 June 2015) and conducting surveys and interviews of patients, stakeholders and referrers. SETTING: Tertiary and primary care. PARTICIPANTS: Adult patients with neck and LBP referred for outpatient surgical consultation. MAIN OUTCOME MEASURES: VIRIAF outcomes: (1) access to care; (2) appropriate and safe care; (3) workforce optimisation and integration; and (4) efficiency and sustainability. RESULTS: A total of 522 patients were seen during the pilot. Most were referred to hospital services by general practitioners (87%) for LBP (63%) and neck pain (24%). All patients were seen within 10 weeks of referral and commenced community-based allied health intervention within 2-4 weeks of assessment in BAC. Of patients seen, 34% had medications adjusted, 57% were referred for physiotherapy, 3.2% to pain services, 1.1% to rheumatology and 1.8% for surgical review. Less MRI scans were ordered in BAC (6.4%) compared with traditional spinal surgical clinics (89.8%), which translated to a cost-saving of $52 560 over 12 months. Patient and staff satisfaction was high. There have been no patient complaints or adverse incidents. CONCLUSION: Evaluation of the BAC pilot suggests it is a potentially safe and cost-saving alternative model of care. Results of the BAC pilot merit further evaluation to determine the potential cost-effectiveness, longer term and broader societal impact of implementing BAC more widely.

Intracranial white epidermoid cyst with dystrophic calcification - A case report and literature review.

White epidermoids are a rare variant of an intracranial epidermoid cyst that do not exhibit typical 'near- cerebrospinal fluid (CSF)' CT density or MRI intensity. Here, the authors present the case of a 58year old man with an acute onset of aphasia and altered consciousness, due to a large heterogeneous cranial mass in the left frontal region with unusual signal intensity. Subsequent histopathological analysis identified the lesion as an epidermoid cyst.

Pilomyxoid astrocytoma in the adult cerebellum.

Pilomyxoid astrocytoma (PMA) is a recently recognised World Health Organization (WHO) Grade II tumour that was previously characterised as a subtype of the WHO Grade I pilocytic astrocytoma (PA). PMA has a histological appearance distinct from PA and a poorer prognosis due to its greater propensity for local recurrence and cerebrospinal dissemination. Although originally considered a paediatric tumour involving mainly the hypothalamic and chiasmatic region, reports of the lesion occurring in the adult population and other areas of the neuroaxis are emerging. We review the literature on PMA within the adult population and present the first case of PMA in the cerebellum of an adult female.

Persistence of Bioglue in spinal dural repair.

Bioglue is an organic surgical adhesive commonly used in vascular and cardiopulmonary repair surgery. It has been used in neurosurgical procedures to minimise the risk of cerebrospinal fluid leak. We report a case which demonstrates persistence of Bioglue at the repair site two years after its successful use in aiding dural closure after a lumbar decompressive procedure.

Intracranial epithelioid schwannoma - a case report.

We report a case of an intracranial epithelioid schwannoma. Epithelioid schwannoma is a low-grade malignant peripheral nerve sheath tumor that occurs most commonly in the limbs and inguinal region. Association with cranial nerves has been reported to be rare and in almost all cases has only involved extracranial distal branches.

Mycotic intracavernous carotid aneurysm.

Intracavernous carotid mycotic aneurysms are rare and management is dictated by clinical presentation. This case involved a patient presenting with a symptomatic expanding proximal internal carotid artery aneurysm treated with antibiotics and balloon occlusion but with thromboembolic complications resulting in a fatal outcome. Points of discussion include difficulties faced in reaching a diagnosis, management options for mycotic aneurysms and the rationale in this case for choosing endovascular rather than surgical treatment. The use and limitations of trial balloon occlusion are discussed as well as complications of vessel occlusion, in particular thromboembolism. Also discussed is the importance of surveillance imaging and the impact of sepsis on overall management.

Glutamate is associated with a higher risk of seizures in patients with gliomas.

OBJECTIVE: To investigate the relationship of glutamate and glutamate transporter expression in human gliomas and surrounding peritumoral brain to the presence of tumor-associated seizures (TAS). METHODS: We studied a retrospective (group 1: 190 patients) and then a prospective (group 2: 98 patients) cohort of patients who underwent a craniotomy for a supratentorial glioma. Tumor and peritumor tissue specimens were assayed for glutamate concentration and expression of glial glutamate transporters. Differences between the seizure (TAS) and seizure-free (non-TAS) groups were compared. RESULTS: A total of 42% of patients had TAS, with 95% of seizures first occurring preoperatively. Clinical factors independently associated with risk of TAS were younger age, temporal lobe location, and tumors with oligodendroglial components. Molecular features in tumor specimens associated with TAS were higher glutamate concentrations, reduced EAAT2 expression, and increased system X(c)(-) expression. In group 2, these results were also replicated in the peritumor tissue. Logistic regression analysis identified raised glutamate concentrations in tumor and peritumor tissue, increased expression of peritumor system X(c)(-), younger age, temporal lobe location, and tumors with oligodendroglial components as independently predictive of preoperative seizures. CONCLUSION: Relative increased glutamate concentration in gliomas, and altered glutamate transporter expression, are associated with the presence of TAS and may play a mechanistic role in their pathogenesis.