Cerebrospinal fluid lavage in the treatment of inadvertent intrathecal vincristine injection.

Vincristine, a widely used antineoplastic agent, is extremely toxic to the central nervous system. If given intrathecally, it produces a rapidly ascending, usually fatal, neuromyeloencephalopathy. We report a case of this complication in a 7-year-old girl with acute lymphoblastic leukemia who was receiving maintenance chemotherapy. During one treatment 0.5 mg of vincristine was erroneously injected into the lumbar subarachnoid space. Cerebrospinal fluid lavage was established within 2 h and continued for 24 h. After 7 days she developed a progressive sensorimotor paraplegia, which eventually stabilized as a paraparesis. Neurophysiological studies were consistent with an axonal type sensorimotor neuropathy. Magnetic resonance imaging of the spine was normal. Vincristine binds to cells, blocking mitosis, thus causing cell death. The associated central nervous system lesions are those of an ascending chemical leptomeningitis and ventriculitis. Cerebrospinal fluid lavage dilutes and removes the drug, thus limiting neural damage. At present this is the only treatment for intrathecal vincristine injection, and its early use in such an event is considered mandatory.

Diastematomyelia in adults. A review.

A consecutive series of 45 cases of diastematomyelia in adults is analyzed. The majority of patients were females with a 3.4:1 female to male ratio. The ages ranged from 19 to 76 with a mean of 37.8 years. The lesion was usually located in the lumbar region. In 17 patients the development of symptoms was associated with specific incidents or events, usually trauma. Twelve patients had pre-existing static musculoskeletal or neurologic abnormalities and 20 had cutaneous spinal lesions suggesting dysphraphism. The symptoms and signs included pain and a variety of sensorimotor and/or sphincteric abnormalities. Metrizamide CT scanning proved to be the most useful diagnostic procedure. Only 4 patients were investigated by MRI and from the information available its role in the diagnosis of adult diastematomyelia is not established. Twenty-three of 24 patients treated by surgery showed marked improvement.

Intraarterial mitomycin-C for recurrent brain metastases.

Fifteen consenting patients with brain metastases recurrent after cranial irradiation were treated with intraarterial mitomycin-C, 15 mg/m2, administered in a total final volume of 100 ml 0.45% saline over 20 min through a transfemoral catheter with a 0.2-mu in-line filter. There were 2 early deaths (one probably drug-related). Of the 13 evaluable patients, 6 (46%) responded, with both computed tomography (CT) scan and neurological improvement. Median response duration was 25 weeks, and median survival of all 15 patients was 17 weeks. Neurological, ocular, and local skin toxicity were dose-limiting. The degree of toxicity was comparable to that we have noted with other intracarotid regimens, and it appears to be less toxic when infused into the vertebral artery than are most other drugs (although experience is still limited and caution still needs to be exercised). We do not recommend that this replace or be added to cranial irradiation as front-line treatment of brain metastases, but we feel that it is an effective and reasonably well-tolerated regimen for treatment of brain metastases that have recurred after cranial irradiation. We are currently initiating studies of intraarterial mitomycin-C combined with intraarterial cisplatin and teniposide (VM-26) as treatment for recurrent brain metastases.

Metrizamide CT scanning in spinal nerve root cysts.

Two cases of lumbosacral root cysts of different etiology are reported. Their specific radiographic features are described using the combined technique of metrizamide myelography followed by computerized tomography of the spine. The terminology of intraspinal cysts is reviewed and their distinguishing features discussed.

Intraspinal cysts: a classification and literature review.

Advances in radiologic technology have allowed the identification of a variety of cystic lesions of spinal nerve roots. Failure to appreciate the different characteristics of these cysts has led to a confusion in terminology, with different terms often being used to describe the same lesion. In an attempt at clarification, the literature is reviewed and a simplified classification of spinal cysts presented. The distinguishing features of each type of cyst, its investigation, and appropriate treatment are discussed.

Hypopituitarism resulting from an intrasellar carotid aneurysm.

We report a 74 year old lady who presented with an exceedingly rare combination of an internal carotid artery aneurysm which was almost entirely intrasellar and associated with hypopituitarism but no neurological deficits. Such a lesion could be misdiagnosed as a pituitary tumour with serious consequences, if surgery is attempted without prior carotid angiography.

Spinal epidural lipomatosis: a complication of glucocorticoid therapy.

A 21-year-old woman receiving prolonged high dosage glucocorticoids developed spinal cord compression due to excessive accumulation of epidural fat. Computerized tomographic scanning confirmed the diagnosis and revealed a peculiar pattern of spinal cord displacement which we believe to be unique to compression by fat. Laminectomy did not afford relief, possibly because of prolonged neural compression or because of compression at a higher spinal level. Although an unusual complication of Cushing's syndrome, epidural lipomatosis should be considered when such a patient develops symptoms of spinal cord or cauda equina compression.

Familial intracranial gliomas.

The pedigree of two interrelated families with 10 affected members suffering from malignant supratentorial gliomas is reported. In addition, three other unrelated families with two members each who were treated for different types of brain tumors are described. Genetic implications are discussed.

Treatment of carotid cavernous fistula by intravascular occlusion using a balloon catheter.

The surgical treatment of carotid cavernous fistula gradually evolved into a "trapping" technique. This technique includes ligation of the cervical internal carotid artery, clipping of the intracranial portion distal to the fistula and often embolization of the isolated segment. The development of embolization techniques using intravascular balloon catheters greatly simplified this treatment. The authors report a case of spontaneous carotid cavernous fistula in which obliteration was achieved by an intracarotid balloon catheter. This was inserted by direct puncture of the carotid artery, which had been exposed by a simple neck incision. The patient's visual acuity was preserved. The efficacy, ease and safety of this method are emphasized.

Cerebellar abscess due to Blastomyces dermatitidis.

A case of cerebellar abscess due to Blastomyces dermatitidis is reported and the literature of central nervous system blastomycosis is reviewed. The case is of interest for two reasons: 1. No obvious site of primary blastomycotic infection was found, despite an extensive search. 2. The focal blastomycotic involvement of the CNS was not associated with meningitis. Only two other such cases are explicitly reported in the literature.