The Yin and Yang of Operating on a Posterior Fossa Meningioma: The Schmahmann Syndrome.

The cerebellum is classically linked with control of motor function, such as coordination, balance, and regulation of movement. There is an increasing awareness, now, of the non-motor functions of the cerebellum, and the occurrence of behavioral anomalies with cerebellar disorders. We present the first report of Schmahmann syndrome (cerebellar cognitive affective syndrome [CCAS]) occurring secondary to posterior fossa meningioma excision. A 35-year-old lady with a posterior fossa meningioma developed an infarct of the right posterosuperior cerebellar hemisphere and ipsilateral superior vermis, following suboccipital craniotomy and tumor resection. Few days after the surgery, she presented with aggressive and emotional behavior, irrelevant talk, and emotional lability. The CCAS scale was administered, and she scored poorly on almost all parameters. A neuropsychological evaluation was also done. The occurrence of CCAS, posterior fossa syndrome (PFS), and behavioral abnormalities like abnormal pathological laughter/crying provides further clinical evidence of the "affective" functions of the cerebellum, modulated mainly by the posterior lobe and vermis of the cerebellum.

Meningioma can lead to pre-operative cognitive alterations even if localized in sensorimotor areas: A multimodal MRI-neuropsychological study in a series of 46 patients.

Brain tumors are generally associated with cognitive changes. Little is known about cognition in patients with meningioma - a lesion that usually shifts and compresses the brain parenchyma with a low probability of infiltrate it. We investigated the cognitive functioning in a consecutive series of 46 patients with a meningioma in the sensorimotor area in the left (LH, N = 27) or in the right (RH, N = 19) hemisphere. All the patients underwent a pre-operative neuropsychological assessment and structural MRI. Clinical symptoms varied between LH and RH meningioma patients. Impaired performance was seen in naming (19.23% noun and 35% verb naming), short-term (18.18%) and working (14.24%) memory in the LH group, and in visuo-spatial tasks (25% neglect, 21.42% visuospatial planning) in the RH group. Both groups were impaired on a sensorimotor mental imagery task (LH, 66.66% of the LH 70% of the RH meningioma patients), while only the RH meningioma group was impaired on the visuo-spatial mental imagery task. The lesion MRI maximum overlap occurred in the postcentral and paracentral lobules. Edema was maximally localized on the left superior longitudinal fasciculus and the superior part of the right superior corona radiata. We found that only the meningioma mass, and not the edema, is a predictive variable in determining patients' performance. Patients with meningioma could present with cognitive alterations at pre-surgical evaluation even if the meningioma occurs in sensorimotor areas. In the present series, a large meningioma vs. a large edema is more relevant for cognitive performance.

Pathologic Laughter as an Early and Unusual Presenting Symptom of Petroclival Meningioma: a Case Report and Review of the Literature.

BACKGROUND: Pathologic laughter is inappropriate, involuntary, and unmotivated laughter episodes that may or may not be associated with mirth or amusement. Although associated with many diffuse brain pathologies, its association with intracranial focal mass lesions causing ventrolateral brainstem compression, like petroclival meningioma, is very rare. The exact pathophysiology of this interesting and unusual clinical symptom is unknown, but probably involves disinhibition and release of the so-called coordination center located in the upper brainstem due to compression by the tumor. CASE DESCRIPTION: A 26-year-old woman presented with recurrent episodes of inappropriate and involuntary laughter, which significantly affected her quality of life, for 2 years. These episodes did not resolve, and a magnetic resonance imaging of the brain showed a giant petroclival meningioma causing upper brainstem compression. Near-total excision of the tumor was done using an extended middle fossa approach. To our surprise, the pathologic laughter subsided immediately after surgery. CONCLUSIONS: Pathologic laughter may be the only symptom of a focal mass lesion causing ventrolateral upper brainstem compression, like petroclival meningioma, well before other neurological sign/symptoms appear. Tumors causing ventral brainstem compression must be ruled out before the patient is sent for a psychiatric evaluation.

Nasopharyngeal glial heterotopia with delayed postoperative meningitis.

A male infant, who underwent radical resection of a large glial heterotopia at the nasopharynx at 8 days, developed delayed postoperative bacterial meningitis at 9 months. Neuroradiological examination clearly demonstrated that meningitis had occurred because of the intracranial and extracranial connections, which were scarcely seen in the perioperative period. A transsphenoidal extension of hypothalamic hamartoma is possible because the connection started from the right optic nerve, running through the transsphenoidal canal in the sphenoid bone and terminating at the recurrent mass in the nasopharyngeal region.

Bilateral supratentorial epidural hematomas: a rare complication in adolescent spine surgery.

A 14-year-old girl presented with a rare case of spontaneous bilateral supratentorial epidural hematomas which developed rapidly following cervical surgery. The hematomas presumably resulted from dural dynamics changes secondary to cerebrospinal fluid loss and intracranial hypotension. Intracranial epidural hemorrhage after spinal surgery is extremely uncommon with only one previous case report. Spontaneous intracranial epidural hematoma is an extremely rare complication, but should be considered as a possible complication of spine surgery, especially in adolescents complicated by delayed consciousness and breathing restoration from anesthesia. This case report expands the presently known clinical spectrum of this uncommon complication.

Motor cortex stimulation: functional magnetic resonance imaging-localized treatment for three sources of intractable facial pain.

Neuropathic facial pain can be a debilitating condition characterized by stabbing, burning, dysesthetic sensation. With a large range of causes and types, including deafferentation, postherpetic, atypical, and idiopathic, both medicine and neurosurgery have struggled to find effective treatments that address this broad spectrum of facial pain. The authors report the use of motor cortex stimulation to alleviate 3 distinct conditions associated with intractable facial pain: trigeminal deafferentation pain following rhizotomy, deafferentation pain secondary to meningioma, and postherpetic neuralgia. Functional MR imaging was used to localize facial areas on the precentral gyrus prior to surgery. All 3 patients experienced long-lasting complete or near-complete resolution of pain following electrode implantation. Efficacy in pain reduction was achieved through variation of stimulation settings over the course of treatment, and it was assessed using the visual analog scale and narrative report. Surgical complications included moderate postsurgical incisional pain, transient cerebral edema, and intraoperative seizure. The authors' results affirm the efficacy and broaden the application of motor cortex stimulation to several forms of intractable facial pain.

Posterior spinal cord stimulation in a case of painful legs and moving toes.

A 59-year-old woman with a 5-year history of right lower limb pain is reported. Symptoms developed initially when walking and progressively became bilateral, appeared at rest and involuntary movements of the toes became evident. A diagnosis of painful legs and moving toes was made. As several drug therapies proved unsuccessful, a therapeutic test with a tetrapolar epidural lead to stimulate the spinal cord dorsal tracts was performed. Due to the marked improvement the device and generator were implanted and she has responded satisfactorily to this therapy for the past 13 months.

Lumbar spinal cord stimulation for cervical-originated central pain: a case report.

This case presents a patient with neuropathic pain in a lower extremity, which appeared subsequent to the removal of a C1 meningioma and which was successfully treated by lower thoracic spinal cord stimulation.

Erythropoietin-augmented isovolemic hemodilution in skull-base surgery. Case report.

Human erythropoietin in concert with intraoperative hemodilution, tumor embolization, and surgical staging was used to manage a red blood cell mass in an anemic Jehovah's Witness patient with a hypervascular meningioma. Erythropoietin (3000 U thrice weekly) and oral iron (1300 mg daily) were given for 1 month prior to surgery, raising the hemoglobin level from 11.8 to 14.1 gm/100 ml. A posterior fossa craniectomy combined with a temporal craniectomy was then performed so that partial petrosectomy, section of the transverse sinus, incision of the tentorium, and exposure of the lesion could be carried out. The first stage of the surgery was terminated immediately prior to tumor mobilization. Isovolemic hemodilution was initiated just before the skin incision. Postoperatively, the hemoglobin concentration dropped to 11.5 gm/100 ml. The erythropoietin dose was doubled and administration of oral iron continued, leading to a hemoglobin level of 14.0 gm/100 ml at 1 month after the first operation. The tumor was embolized using superselective catheterization. The next day, at the second stage of the surgery, the tumor was extirpated, again employing isovolemic hemodilution. By the 4th postoperative day, the hemoglobin level had dropped to 9.4 gm/100 ml. The patient made an uncomplicated recovery. Erythropoietin therapy contributed substantially to the successful outcome of this case. Since erythropoietin has the potential to augment all other forms of autologous banking, its role in elective neurosurgery may become increasingly important in an era of heightened concern about heterologous transfusion.

Compression of the intracranial optic nerve mimicking unilateral normal-pressure glaucoma.

A 66-year-old man developed progressive visual field loss in the inferior arcuate region of the right eye with normal central visual acuity. Intraocular pressures were normal on all but one occasion. The right optic disk showed extensive glaucomalike cupping; the left optic disk was normal. Magnetic resonance imaging revealed a tumor of the right medial sphenoid wing impinging upon the intracranial portion of the right optic nerve. It was resected via a frontotemporal craniotomy. Histopathologic examination revealed a meningothelial meningioma. The visual field and optic disk cupping remained unchanged postoperatively. To our knowledge, this is the first report in which both glaucomalike cupping and visual field loss occurred as the result of a compressive lesion of the anterior visual pathway.

[Preoperative nutritional status of neurosurgery patients]. / Präoperativer Ernährungszustand neurochirurgischer Patienten.

In a prospective trial anthropometric and biochemical data of 24 neurosurgical patients with primary intracranial tumors were measured to assess preoperative malnutrition in this special group of patients. In spite of starving because of invasive diagnostic procedures, high-dose dexamethasone therapy of peritumoral edema, and changes in food intake because of psychical alterations and repeated vomiting resulting from elevated intracranial pressure no abnormalities were found in the data measured. The authors conclude that in general preoperative malnutrition is absent in neurosurgical patients and preoperative nutrition to improve postoperative outcome is not indicated in this group.

Meningeal osteomas and chronic renal failure.

Osteomas, although usually found in the frontal and ethmoid sinuses or the mandible, may be located on the inner table of the skull. We report the incidence, distribution, histologic features, and clinical correlates of intracranial osteomas arising in the dura mater and the falx cerebri in 200 consecutive adult autopsies. Ten patients (5 per cent of autopsies) were found to have meningeal osteomas. The tumors were usually located at the dural-falx junction at the superior longitudinal sinus. Histologically, they resembled osteomas arising from other sites, but undecalcified sections generally demonstrated histologic features of active bone remodeling--namely, the presence of abundant osteoid and numerous osteoclasts, and, in some instances, osteitis fibrosa. The age and sex distributions were similar among autopsied patients with meningeal osteomas (mean age, 66 years; 60 per cent female) and those without (mean age, 64 years; 58 per cent female). Although the incidence of uremia in the general autopsy population was only 13 per cent, 60 per cent of patients with osteomas died with concomitant renal failure. The authors consider these cases of meningeal ossifications and reports of meningeal calcifications to represent osteomas arising from the dura mater and the falx cerebri. Thus, intracranial osteomas may be more common than was previously recognized. In some instances, the abnormal biochemical state accompanying chronic renal failure may stimulate new bone formation in the osteogenic tissue of the dura mater.

[Mechanisms of cardiac rhythm disorder in hypothalamic lesions in basal meningiomas before and after surgery]. / Mekhanizmy narusheniia serdechnoi ritmiki pri porazheniiakh gipotalamusa u bol'nykh s bazal'nymi meningiomami do i posle operatsii.

Seventeen of 27 patients studied before and after surgical operations for basal meningioma frequently showed forms of cardial sinusal arythmia, sinusal tachycardia and ventricular extrasystolia. These pathological changes in cardiac rhythmics appeared and were aggravated during the postoperational period. Their possible pathophysiological mechanisms, due to the effect of the tumor and operative injury to the hypothalamo-diencephalic apparatus are discussed.