Stroke-like events after brain radiotherapy: a large series with long-term follow-up.

BACKGROUND AND PURPOSE: Patients with a history of brain radiotherapy can experience acute stroke-like syndromes related to the delayed effects of brain radiation, including stroke-like migraine attacks after radiation therapy syndrome, peri-ictal pseudoprogression and acute late-onset encephalopathy after radiation therapy syndrome. The aim of this study was to collect evidence on the long-term outcome and treatment of these conditions, whose knowledge is undermined by their rarity and fragmented description. METHODS: Cases were collected, both prospectively and retrospectively, amongst six neuro-oncology departments. Inclusion criteria were as follows: (i) history of brain radiotherapy (completed at least 6 months before the acute episode); (ii) new onset of acute/subacute neurological symptoms; (iii) exclusion of all etiologies unrelated to brain irradiation. A review of current literature on stroke-like syndromes was performed to corroborate our findings. RESULTS: Thirty-two patients with acute neurological conditions attributed to the delayed effects of radiation were identified, including 26 patients with stroke-like syndromes. Patients with stroke-like syndromes commonly presented with a mosaic of symptoms, including focal deficits (77%), encephalopathy (50%), seizures (35%) and headache (35%). Seventy-three percent of them had acute consistent magnetic resonance imaging alterations. Treatment included high-dose steroids in 65% of cases. Twenty-two patients recovered completely (85%). Sixteen patients (62%) experienced relapses (median follow-up 3.5 years). A literature review identified 87 additional stroke-like cases with similar characteristics. CONCLUSIONS: Stroke-like events related to brain irradiation may be associated with permanent sequelae. Steroids are often administered on empirical grounds, as they are thought to accelerate recovery. Relapses are common, highlighting the need to elaborate adequate prevention strategies.

Mandibular osteosclerotic lesion of a parotid salivary duct carcinoma: demonstration of the neural tropism of these tumors.

INTRODUCTION: Salivary duct carcinoma (SDC) is an uncommon entity of salivary gland cancers with a poor prognosis due to local aggressiveness or distant recurrences involving lymph nodes, lung, and long bones, in which secondary lesions are usually osteolytic. The authors report the first case of mandibular SDC, atypical due to its osteosclerotic presentation and its site, attributed to aggressive neural spread of the tumor along the trigeminal nerve. CASE STUDY: This asymptomatic osteosclerotic bone involvement was diagnosed based on pathological enhancement of the trigeminal nerve demonstrated on MRI and was accompanied by facial nerve involvement up to its third intracranial portion. Radical surgery ensured disease control with continued good quality of life at the 4-year follow-up visit. CONCLUSION: Nerve enhancement on MRI and determination of specific tumor markers (HER-2/neu and p53) should be taken into account to evaluate the prognosis of SDC and to propose appropriate surgical treatment.

[Primitive intracranial trigeminal nerve germinoma. Case report]. / Localisation trigéminale d'un germinome intracrânien primitif. A propos d'un cas.

A 22-year-old man presented headache, asthenia, body weight loss and trigeminal hypoesthesia worsening quickly. Radiological analysis showed an enhanced lesion that originated from the cavernous sinus and extended into the Meckel cave, owing to the fifth cranial nerve's course. The lesion was explored by a temporo-pterional approach and was partially removed. On the basis of histological analysis and negativity of tumor marker levels in serum and cerebrospinal fluid (alpha-fetoprotein alpha, human beta-chorionic gonadotropin), a primitive non-secreting intracranial germinoma was diagnosed. Under combined chemotherapy (carboplatine, ifosfamide, etoposide) followed by focal fractionated radiotherapy delivering 40 Gy to the initial tumor volume, the outcome was excellent. Five years later, the patient was in complete clinical and radiological remission. Primitive intracranial germinomas are rare malignant tumors involving mainly pineal and hypothalamic regions. We report a case of intracranial trigeminal nerve germinoma. To the best of our knowledge, no case of primitive germinoma was previously described in this location. Aspects of diagnosis and treatment are discussed in the light of previous publishing data.

[Chronic intramedullary abscess (Streptococcus sanguis). A case report and review of the literature]. / Abcès intramédullaire chronique (Streptococcus sanguis). Cas clinique et revue de la littérature.

OBJECTIVE: Chronic intramedullary spinal cord abscesses are very rare. We present here a new case of this pathology, revealed by a progressive spinal cord compression. This case is particular because of the long follow up before surgery (two years). CASE REPORT: This 69-year-old patient presented a gradually progressive paraparesis and sensory loss associated with leg pain. The past medical history was dominated by a epidermoid cancer of the tongue. MRI showed an intramedullary mass at T10. On the T1-weighted sequences, the lesion was isointense with the spinal cord, Gadolinium infusion showed homogeneous enhancement of the lesion. T2-weighted sequences showed decreased signal within the lesion and an increased signal peripherally (edema). Corticosteroid infusions relieved the symptoms so the patient declined surgery. Two episodes of regressive paraplegia were treated by the same infusions. The patient accepted surgery after a third episode. RESULTS: The intervention was performed two years after the first signs and revealed a hard white mass attached to the spinal cord. Pathologic examination showed infectious inflammation. Bacteriological cultures found a Streptococcus sanguis. Two years later the patient could walk; a minimal deficit persists. CONCLUSION: First, the diagnosis was evoked but not retained because of the long course. The corticosteroid infusions gave relief and did not increase the deficit. The MRI findings remained unchanged. Intramedullary spinal cord abscesses are very rare. This pathology must be recognized because without treatment morbidity is high with a potentially fatal outcome.

[MRI aspects of spinal cord abscesses. Report of 5 cases and review of the literature]. / Les abcès médullaires, aspects en IRM. A propos de 5 cas et revue de la littérature.

The spinal canal is an uncommon site for abscess formation resulting from bloodstream disseminated infection. Prognosis is often unfavorable. Rapid treatment is essential for satisfactory neurological recovery. Abscesses within the spinal canal are thus diagnostic and therapeutic emergencies. The neuro-infectious and inflammatory manifestations and laboratory findings vary considerably and are insufficient for diagnosis. MRI plays a decisive role. The most commonly reported signs are the presence of an intramedullary collection giving a low-intensity signal on T1-weighted images and a high-intensity signal on T2-weighted images with peripheral contrast uptake and generally extended adjacent medullary edema. We report here five cases of spinal canal abscesses diagnoses with MRI at different stages of development (pre-suppurative myelitis in two cases, constituted abscess in three cases). For each case we reviewed the clinical course and describe the details of the imaging findings. In our series, the collected abscesses presented as round lesions within the canal with contrast uptake. It is noteworthy that the periependymal gray matter adjacent to the lesion also took up the contrast agent in all patients with a collected abscess. This sign has not been described previously and appears to be a going argument orienting the diagnosis towards an infectious rather than tumoral formation.