Sinonasal renal cell-like adenocarcinoma: Easily misdiagnosed sinonasal tumor.

BACKGROUND: Sinonasal renal cell-like adenocarcinoma is rare and exhibits unique pathological and clinical manifestations. Correct diagnosis and treatment of this newly described entity are challenging for both clinicians and pathologists. METHODS: We report a female patient with sinonasal renal cell-like adenocarcinoma who initially presented with right intermittent epistaxis. RESULTS: A 26-year-old woman presented with a 1-year history of right intermittent epistaxis and hyposmia. Nasal endoscopy revealed a reddish tumor in the right nasal cavity. An MRI revealed a hyperintense tumor arising from the right olfactory cleft accompanied by prominent feeding vessels originating from the anterior ethmoid artery (AEA). We performed a bicoronal incision with ligation of the AEA followed by endoscopic resection of the skull base tumor. The patient is currently free of recurrence. CONCLUSION: This is the first study to review the clinical features of sinonasal renal cell-like adenocarcinoma. We recommend surgical resection as the mainstay of treatment.

Effects of antiepileptic drugs on thyroid hormone function in epilepsy patients.

PURPOSE: Patients with epilepsy are frequently required to take antiepileptic drugs (AEDs) for a long period of time. Many studies have shown that AEDs have a negative influence on endocrine function including the thyroid gland, however the risk factors for the development of low thyroid function in these patients are unclear. This study aimed to determine the potential risk factors of low thyroid function in patients with epilepsy. METHOD: This was a cross-sectional study including 298 patients with epilepsy. Patients with previous thyroid disease were excluded. Epidemiologic data, type of epilepsy, etiology, the age of seizure onset, duration of epilepsy, intractable epilepsy, and number and dosage of AEDs were recorded. Levels of free thyroxine (fT4) and thyroid stimulating hormone (TSH) were measured. RESULTS: Fifty-two of the 298 (17.4%) patients had low fT4. Older age (P=0.004), female sex (P=0.014), longer duration of epilepsy (P=0.001), and intractable epilepsy (P=0.009) were significantly associated with low fT4. Regarding individual AEDs, carbamazepine (30.1%), topiramate (28.6%), and levetiracetam (24.3%) were significantly associated with the presence of low fT4. After stepwise logistic regression of all significant variables, female sex, older age, three or more AEDs, and carbamazepine were independent risk factors for low fT4. CONCLUSIONS: Female patients with epilepsy and an older age, AED polytherapy, and carbamazepine treatment had a higher risk of low fT4. Thyroid function in these patients should be monitored closely.

Predictors and outcomes of shunt-dependent hydrocephalus in patients with aneurysmal sub-arachnoid hemorrhage.

BACKGROUND: Hydrocephalus following spontaneous aneurysmal sub-arachnoid hemorrhage (SAH) is often associated with unfavorable outcome. This study aimed to determine the potential risk factors and outcomes of shunt-dependent hydrocephalus in aneurysmal SAH patients but without hydrocephalus upon arrival at the hospital. METHODS: One hundred and sixty-eight aneurysmal SAH patients were evaluated. Using functional scores, those without hydrocephalus upon arrival at the hospital were compared to those already with hydrocephalus on admission, those who developed it during hospitalization, and those who did not develop it throughout their hospital stay. The Glasgow Coma Score, modified Fisher SAH grade, and World Federation of Neurosurgical Societies grade were determined at the emergency room. Therapeutic outcomes immediately after discharge and 18 months after were assessed using the Glasgow Outcome Score. RESULTS: Hydrocephalus accounted for 61.9% (104/168) of all episodes, including 82 with initial hydrocephalus on admission and 22 with subsequent hydrocephalus. Both the presence of intra-ventricular hemorrhage on admission and post-operative intra-cerebral hemorrhage were independently associated with shunt-dependent hydrocephalus in patients without hydrocephalus on admission. After a minimum 1.5 years of follow-up, the mean Glasgow outcome score was 3.33 ± 1.40 for patients with shunt-dependent hydrocephalus and 4.21 ± 1.19 for those without. CONCLUSIONS: The presence of intra-ventricular hemorrhage, lower mean Glasgow Coma Scale score, and higher mean scores of the modified Fisher SAH and World Federation of Neurosurgical grading on admission imply risk of shunt-dependent hydrocephalus in patients without initial hydrocephalus. These patients have worse short- and long-term outcomes and longer hospitalization.

Management of middle cerebral artery dissecting aneurysm.

BACKGROUND: Dissecting aneurysms of the intracranial carotid circulation were previously thought to occur primarily in young people presenting with cerebral infarction caused by arterial stenosis and occlusion. The appropriate management of dissecting aneurysms in the anterior circulation remains controversial, especially in patients who also present with cerebral infarction. However, recent studies have reported better outcomes for patients with middle cerebral artery (MCA) dissecting aneurysms involving surgically treated subarachnoid hemorrhage (SAH). The purpose of this study is to describe a case of spontaneous SAH from rupture of a dissecting aneurysm in the M2 segment observed in a 79-year-old man with no sign of an ischemic neurological deficit, and also to review the clinical and radiological features of cases reported since 1990. METHODS: Our review of the literature identified 24 cases of MCA dissecting aneurysms after 1990. RESULTS: Of the patients in these cases, 15 (63%) presented with pure bleeding and 7 (29%) with ischemia, and two were detected incidentally. Our review also found that the outcome of patients presenting with pure bleeding differed from those with ischemia. Patients with an MCA dissecting aneurysm who presented with pure bleeding showed better outcomes if they had surgery than if they did not. In contrast, the appropriate management of patients with a dissecting aneurysm who present with ischemia remains controversial. CONCLUSION: Our review found that the clinical course of patients presenting with ischemia differed from that of patients presenting with pure bleeding. Most of the patients with ischemia underwent progressive deterioration. However, while the outcome for patients with ischemia treated surgically was relatively good, it remained poor compared to the outcome for patients who had been bleeding.

A clinicopathological study of the significance of the proportion of choroid morphology in chordoid meningioma.

Chordoid meningiomas (CM) account for approximately 0.5% to 1.0% of intracranial meningiomas. This tumor has a strong risk of recurrence and aggressive growth (World Health Organization grade II). Histological analysis of CM tumors shows that the tissue is often dominated by chordoid morphology; however, the exact relationship between the percentage of the chordoid component and other clinicopathological features is unknown. We collected 26 surgical specimens from 17 patients who had a histological diagnosis of CM between January 1986 and June 2010. The chordoid elements constituted 30% to 98% of the area of the tumor. In 12 of 17 (70.6%) primary tumors, over 50% of the area displayed the chordoid pattern. Recurrence was noted in nine of these patients and five underwent a second operation. These five patients showed a histopathological progression of aggressive features. The proportion of chordoid elements in each recurrent tumor also increased. Thus, the chordoid proportion in CM is associated with a greater likelihood of recurrence.

Infected spinal dermal sinus tract with meningitis: a case report.

PURPOSE: Congenital dermal sinus tract (DST), an uncommon entity of cranial or spinal dysraphism, occurs along the midline neuraxis that may arise from nasion and occiput down to the lumbar and sacral region. It is often diagnosed in infants and children for skin signs, neurological deficits, local infection, meningitis, or abscess. For spinal DST, there is a paucity of case or series report in Taiwan. CASE REPORT: In this paper, we report a case in a 6-year-old girl. The girl presented with midline lumbar skin dimple, hypertrichosis, and history of bacterial meningitis. She was successful treated by surgical excision of the DST with local infection that ended within the subarachnoid space between L2-3 vertebrae. CONCLUSION: This case highlights the importance of a thorough examination of the midline craniospinal axis in children with meningitis or history of meningitis.

Cerebellar bacterial brain abscess: report of eight cases.

PURPOSE: To analyze the clinical characteristics and therapeutic outcome of patients with solely cerebellar bacterial brain abscess (BBA). CASE REPORT: Eight patients with solely cerebellar BBA, collected during a period of 23 years from 210 BBA patients, were included in this study. The eight patients were five men and three women, aged 5-54 years (mean, 36.6 years). Six of them were adults, one was a child, and one was an adolescent. Six patients had underlying medical/surgical problems. Of the clinical presentations, dizziness was the most common (87.5%, 7/8), followed by headache (62.5%, 5/8), altered consciousness (62.5%, 5/8), fever (50%, 4/8), ataxia (25%, 2/8), hearing impairment (12.5%, 1/8), dysarthria (12.5%, 1/8), and hemiparesis (12.5%, 1/8). The Image Severity Index (ISI) scores of these eight patients ranged from 6 to 12 points. All eight patients received both medical and surgical treatment. One patient died owing to a complication in the neurosurgical procedure and the remaining patients survived. The therapeutic outcome was quantified one month after discharge by modified Rankin scale (mRS) and the result showed six of the seven survivors had good outcomes, while the other one had a poor outcome (ataxic gait). CONCLUSION: Cerebellar BBA accounted for 3.8% (8/210) of the overall BBA. In cerebellar BBA, dizziness is a frequent symptom. Early diagnosis and a combination of antimicrobial and neurosurgical intervention is important for its treatment. The small case number is a limitation of this study; therefore, further large-scale study of cerebellar BBA is needed for better delineation of the clinical characteristics, therapeutic outcome, and prognostic factors.

Supratentorial deep-seated bacterial brain abscess in adults: clinical characteristics and therapeutic outcomes.

PURPOSE: Supratentorial deep-seated bacterial brain abscess (BBA) in adults is rarely examined solely in the literature. This retrospective study is conducted to examine the clinical characteristics and therapeutic outcome of this specific group of BBA. METHODS: Eight adult patients with supratentorial deep-seated BBA, collected during a study period of 14 years (1994-2007), were enrolled. Their microbiological data derived from cerebrospinal fluid (CSF), blood or pus cultures, clinical features and therapeutic outcome were analyzed. RESULTS: The eight adult cases were six men and two women, aged 41 to 80 years (mean=61). Preceding medical conditions were found in five of these eight cases, while preceding neurosurgical event was found in one. Of the clinical presentations, hemiparesis (6) was the most common, followed by fever (5), altered consciousness (4), headache (3), septic shock (1), and seizure (1). The main locations of the BBA were the left basal ganglia in five, the left thalamus in two, and the right basal ganglia in one. Causative pathogens were found in six cases and the isolated pathogens were all cultured from CSF specimens. Positive bacteremia which grew K. pneumoniae was found in one case. Seven of these eight cases contracted the infection in a community-acquired state. Besides antibiotic treatment, seven of them received a neurosurgical intervention (stereotactic aspiration and/or ventriculoperitoneal shunt). The therapeutic result showed six cases survived and two expired. Five of the six survivors had variable degree of neurologic deficits. CONCLUSIONS: Besides the common clinical features of BBA, supratentorial deep-seated BBA has a high incidence of hemiparesis in the early stages of disease. Most of the involved patients have community-acquired infections and are preceded by a medical condition. Stereotactic aspiration for therapeutic and diagnostic purposes, as well as shunting surgery, is the most common neuro-surgical procedures used for treatment. But despite therapeutic efforts, high mortality and morbidity remain.

Predictors and long-term outcome of seizures after bacterial brain abscess.

BACKGROUND: Seizures are one of the most important neurological complications of bacterial brain abscesses. A better understanding of the risk factors of seizures following bacterial brain abscesses is needed to predict those who will require treatment. METHODS: A total of 205 patients were enrolled in this 22-year retrospective study. Prognostic variables were analysed based on Cox's proportional hazards model after a minimum of 18 months of follow-up. RESULTS: Seizures occurred in 48 patients who had bacterial brain abscesses, including acute symptomatic seizures in 17% (35/205) and unprovoked seizures in 6.4% (13/205). Altogether, 27 patients had early seizures and 21 had late seizures. The overall mortality rate in the seizure patients was 23% (11/48) and seven patients progressed to epilepsy. CONCLUSION: Cox's proportional hazards model demonstrated that valvular heart diseases as the underlying diseases and the presence of a fronto-parietal distribution of bacterial brain abscess were independently predictive of seizures, and the presence of late seizures was predictive of developing epilepsy. Most first seizures occurred within 3 y after bacterial brain abscesses.