Central Nervous System Tuberculoma in the Corpus Callosum Mimicking a Butterfly Glioma: Literature Review of Radiological Findings and Our Experience.

CONTEXT: Central nervous system (CNS) tuberculoma is the most common form of intracranial parenchymal tuberculosis (TB) which accounts for approximately 40% of misdiagnosed brain lesions mimicking intracranial tumors. The most common sites are the cerebral hemispheres, basal ganglia, cerebellum, and brainstem. MATERIALS AND METHODS: Radiological findings of corpus callosum tuberculomas have been described and set in relation with the available literature. RESULTS: Corpus callosum tuberculomas are extremely rare, with only five cases reported in the current literature. Even though isolated CNS tuberculoma of the corpus callosum without systemic TB in immunocompetent patients occurs rarely, as in our case, it should be considered in the differential diagnosis of solitary corpus callosum lesions. CONCLUSIONS: Careful evaluation of the neuroradiological images with adequate clinicoradiological correlation allows for accurate diagnosis and ensures the proper and timely care.

Giant tuberculoma of the corpus callosum, the unforeseen diagnosis.

OBJECTIVE: Isolated intracranial tuberculomas are rare, especially in adults and it is not uncommon that they are easily confused with other diseases. To address this issue, we reported a case of a tuberculoma of the corpus callosum focusing on clinical characteristics, diagnostic clues, and outcome. CONCLUSIONS: Intracranial masses are frequently targeted as neoplastic pathology with surgical treatment in most cases. It is important to distinguish between neuro tuberculoma and brain tumors because of their different management and prognosis. Therefore even in absence of a known history of primary TB and in immunocompetent patients, tuberculoma must be in the differential diagnosis of solitary intracranial lesions also in countries where TB is not endemic.

Intramedullary Metastasis to the Cervical Spinal Cord from Malignant Pleural Mesothelioma: Review of the Literature and Case Reports.

CONTEXT: Malignant mesothelioma is an aggressive tumor; median survival of patients following diagnosis is 12 months. AIMS: Pleural malignant mesothelioma tends to spread along preexisting tissue planes and has the rare ability to spread along the nerve root into the spinal cord. In our case, there is an evidence of exceptional direct hematogenous spread to the spinal cord by the spinal branch of the intercostal arteries or the veins of Batson's plexus. SETTINGS AND DESIGN: The authors report a case of intramedullary hematogenous metastasis to the cervical spinal cord from malignant mesothelioma, with a review of the literature. MATERIALS AND METHODS: A 68-year-old male was admitted to our department because of a slowly progressive mild weakness of both low extremities, more pronounced on the left side. The patient has been treated for a malignant mesothelioma with left thoracotomy and subsequently underwent radiotherapy. Magnetic resonance imaging of the cervical-thoracic spine revealed a contrast-enhancing intramedullary expansive lesion of the left half of the spinal cord at the C6-C7 level. RESULTS: The patient underwent surgical treatment through a C6-C7 laminectomy. Through a median posterior spinal cord incision, an intramedullary grayish lesion was completely removed. The paraparesis progressively improved and 20 days after surgery, the patient had regained normal lower extremity function. CONCLUSIONS: Malignant mesothelioma can spread to the spinal canal by the direct extension through the intervertebral foramina, by hematogenous spread to the spinal meninges, and by perineural growth along a single nerve root. The cleavage plane of the tissue may determine whether a successful gross total resection can be achieved with a good outcome for the patient.

Endodermal Cysts of the Central Nervous System: Review of the Literature and a Case Report.

CONTEXT: Endodermal cysts are rare benign developmental cysts lined by mucin-secreting and/or ciliated, cuboidal, or columnar epithelium of probably endodermal origin. AIMS: Endodermal cysts are rarely intracranial, frequently located in the posterior fossa. Supratentorial location is the most infrequent and only few cases are reported in the literature, included our case. SETTINGS AND DESIGN: The authors report a case of intracranial supratentorial endodermal cyst with a review of the literature. SUBJECTS AND METHODS: A 40-year-old woman was admitted to our department because of progressive gait disorder for 3 months due to right brachial and crural motor deficit associated to right crural sensory disorder (tactile hypesthesia) and right Babinski response at neurological examination due to an endodermal cyst located in the left frontoparietal convexity. DISCUSSION: Total resection of endodermal cysts is recommended, despite their location and adhesion to the surrounding structures, due to its high risk of recurrence. Fenestration of the cystic content into the subarachnoid cistern may cause obstructive hydrocephalus or chemical meningism. RESULTS: Although rare, surgeons should be aware that these lesions must be differentiated clinically, radiologically, and histologically from other supratentorial cystic lesions.

Neurosurgical Management of Parasagittal and Falcine Meningiomas: Judicious Modern Optimization of the Results in a 100-Case Study.

CONTEXT: The management of parasagittal and falcine meningiomas centers around the relationship between the tumor and the venous anatomy of the superior sagittal sinus (SSS) and the bridging veins. AIMS: The present study aims to address neurosurgical outcomes in a cohort of patients with parasagittal and falcine meningiomas >2.0 cm in the largest diameter, in which a neurosurgical/multidisciplinary treatment was considered. SETTINGS AND DESIGN: The clinical outcomes of patients undergoing neurosurgical management for parasagittal and falcine meningiomas at the authors' institution over a 15-year period were analyzed. Analysis was limited to those tumors (primary, residual, or recurrences) >2.0 cm in the largest diameter. SUBJECTS AND METHODS: The authors identified 100 patients with parasagittal/falcine meningiomas >2.0 cm in their largest diameter, who underwent neurosurgical treatment at their institution between 1999 and 2013. STATISTICAL ANALYSIS USED: Tumor control was assessed using Kaplan-Meier analysis, and specific attention was paid to the relationship between the tumor and the SSS and its impact on tumor control and outcome. RESULTS: There was no difference in rates of tumor control in patients who received subtotal resection for a WHO Grade I tumor, followed by close observation, compared with those undergoing gross-total resection, primarily because no cases were observed in which the tumor remnant in the SSS demonstrated interval growth on serial imaging studies. Of patients in this series, 13% experienced at least one neurological, medical, surgical, or radiosurgical complication, and the mortality was 0%. CONCLUSIONS: These data provide a more judicious optimization of the expected outcome that can be obtained with treatment of these tumors, in which a combination of image guidance, advanced microsurgical techniques, and conformal radiation treatments is used.

World Health Organization Grade III Supratentorial Extraventricular Ependymomas in Adults: Case Series and Review of Treatment Modalities.

CONTEXT: Supratentorial ependymomas and their anaplastic variants are relatively uncommon central nervous system neoplasms that afflict both adults and children. AIMS: Discuss the clinical and pathological features of patients with anaplastic ependymomas involving an extraventricular supratentorial location and review modalities and options of treatment for those rare tumors. SETTINGS AND DESIGN: Whereas the treatment algorithm in the pediatric population is well established, however, treatment in the adult population is less defined. Treatment options are exposed through the author's cases and review of the literature. SUBJECTS AND METHODS: In our case series of two adult patients with supratentorial ependymomas World Health Organization (WHO) Grade III (anaplastic variant), patients presented in both cases in the emergency room after having a generalized tonic-clonic seizure at home the first case, and mild hemiparesis the second case. RESULTS: Patients underwent surgical treatment, and a gross total resection was achieved in both cases. The histopathological examination revealed a diagnosis of anaplastic ependymoma (WHO Grade III). Both patients had additional radiotherapy, and in the first case, adjuvant platinum-based chemotherapy was administered due to leptomeningeal gliomatosis. CONCLUSION: In our experience, gross total resection was achieved in all patients with supratentorial extraventricular ependymomas WHO Grade III with additional radiotherapy and platinum-based chemotherapy. Patients require initial close serial imaging follow-up. The role of chemotherapy is still uncertain but may be necessary in younger patients and in tumors that behave more like the pediatric ependymomas.

Infection with Spinal Instrumentation: A 20-Year, Single-Institution Experience with Review of Pathogenesis, Diagnosis, Prevention, and Management.

OBJECTIVE AND IMPORTANCE: Instrumentation has become an integral component in the management of various spinal pathologies. The rate of infection varies from 2% to 20% of all instrumented spinal procedures. Postoperative spinal implant infection places patients at risk for pseudo-arthrosis, correction loss, spondylodiscitis, and adverse neurological sequelae and increases health-care costs. MATERIALS AND METHODS: We performed a cohort study of 1065 patients who underwent instrumented spinal procedures in our institution between 1995 and 2014. Fifty-one patients (4.79%) contracted postoperative spinal infection. Isolated bacterial species, infection severity, diagnosis/treatment timing, surgical/medical strategy treatment, and patient's medical background were evaluated to assess their relationship with management outcome. RESULTS: Multiple risk factors for postoperative spinal infection were identified. Infections may be early or delayed. C-reactive protein and magnetic resonance imaging are important diagnostic tools. Prompt diagnosis and aggressive therapy (debridement and parenteral antibiotics) were responsible for implant preservation in 49 of 51 cases, whereas implant removal noted in two cases was attributed to delayed treatment and uncontrolled infection with implant loosening or late infection with spondylodesis. Infection in the setting of instrumentation is more difficult to diagnose and treat due to biofilm. CONCLUSION: Retention of the mechanically sound implants in early-onset infection permits fusion to occur, whereas delayed treatment and multiple comorbidities will most likely result in a lack of effectiveness in eradicating the infecting pathogens. An improved understanding of the role of biofilm and the development of newer spinal implants has provided insight into the pathogenesis and management of infected spinal implants. It is important to accurately identify and treat postoperative spinal infections. The treatment is multimodal and prolonged.

Antibody/receptor protein immunocomplex in human and mouse cortical nerve endings amplifies complement-induced glutamate release.

Previous studies have demonstrated that complement alone releases glutamate from human and mouse cortical terminals in an antibody-independent manner. In order to expand our knowledge on complement-mediated effects, we investigated whether the presence of an antigen-antibody complex in synaptosomal plasmamembranes could also trigger complement-induced functional responses that might affect neurotransmitter release. To this aim, we focused on the chemokine 5 receptor (CCR5) expressed in human and mouse cortical glutamate terminals, whose activation by CCL5 elicits [(3)H]D-aspartate ([(3)H]D-ASP) release. Preincubating synaptosomes with an antibody recognizing the NH2 terminus of the CCR5 protein (anti-NH2-CCR5 antibody) abolished the CCL5-induced [(3)H]D-ASP release. Similarly, enriching synaptosomes with an antibody recognizing the COOH terminus of CCR5 (anti-COOH-CCR5 antibody) prevented the CCL5-induced [(3)H]D-ASP release. The antagonist-like activity of the anti-NH2-CCR5 antibody turned to facilitation when anti-NH2-CCR5-treated synaptosomes were exposed to complement. In these terminals, the releasing effect was significantly higher than that elicited by complement in untreated synaptosomes. On the contrary, the complement-induced [(3)H]D-ASP release from anti-COOH-CCR5 antibody-entrapped synaptosomes did not differ from that from untreated synaptosomes. Preincubating synaptosomes with anti-beta tubulin III antibody, used as negative control, neither prevented the CCL5-induced releasing effect nor it amplified the complement-induced [(3)H]D-ASP release. Finally, serum lacking the C1q protein, i.e. the protein essential to promote the antibody-mediated activation of complement, elicited a comparable [(3)H]D-ASP release from both untreated and anti-NH2-CCR5 antibody-treated synaptosomes. Thus, we propose that antibodies raised against the outer sequence of a receptor protein can trigger the activation of the complement through the classic, C1q-mediated antibody-dependent pathway, which results in an abnormal release of glutamate that could be deleterious to central nervous system.

Petrous bone epidermoid cyst caused by penetrating injury to the external ear: Case report and review of literature.

Epidermoid cysts are histologically benign, slow-growing congenital neoplasms of the central nervous system that may arise from retained ectodermal implants. The epidermoid lesions are generally caused during the 3(rd) to 5(th) week of gestation by an incomplete cleavage of the neural tissue from the cutaneous ectoderm, though it can also happen later in life due to introduction of skin elements by skin puncture, trauma or surgery. We present this unique case of a petromastoid epidermoid cyst associated with ipsilateral cerebellar abscesses, presenting 20 years after a penetrating trauma to the external auditory canal. Radical excision of both lesions and revision of the previous fistulous tract was performed. We present the diagnostic challenge and the operative treatment of this unique case, which to our knowledge is the first where an epidermoid cyst and an adjacent brain abscess occurred as a result of a single traumatic event.

Characterization of glioma stem cells through multiple stem cell markers and their specific sensitization to double-strand break-inducing agents by pharmacological inhibition of ataxia telangiectasia mutated protein.

Previous studies have shown that tumor-driving glioma stem cells (GSC) may promote radio-resistance by constitutive activation of the DNA damage response started by the ataxia telangiectasia mutated (ATM) protein. We have investigated whether GSC may be specifically sensitized to ionizing radiation by inhibiting the DNA damage response. Two grade IV glioma cell lines (BORRU and DR177) were characterized for a number of immunocytochemical, karyotypic, proliferative and differentiative parameters. In particular, the expression of a panel of nine stem cell markers was quantified by reverse transcription-polymerase chain reaction (RT-PCR) and flow cytometry. Overall, BORRU and DR177 displayed pronounced and poor stem phenotypes, respectively. In order to improve the therapeutic efficacy of radiation on GSC, the cells were preincubated with a nontoxic concentration of the ATM inhibitors KU-55933 and KU-60019 and then irradiated. BORRU cells were sensitized to radiation and radio-mimetic chemicals by ATM inhibitors whereas DR177 were protected under the same conditions. No sensitization was observed after cell differentiation or to drugs unable to induce double-strand breaks (DSB), indicating that ATM inhibitors specifically sensitize glioma cells possessing stem phenotype to DSB-inducing agents. In conclusion, pharmacological inhibition of ATM may specifically sensitize GSC to DSB-inducing agents while sparing nonstem cells.

Peritumoral and intratumoral hemorrhage after stereotactic radiosurgery for renal cell carcinoma metastasis to the brain.

Stereotactic Radiosurgery (SRS), provides in a single session, a high dose of radiation to a localized brain tumor volume. Acute adverse reactions after treatment are not uncommon, but are usually transient and generally are well controlled by medication. The authors wish to report this rare complication of intratumoral and peritumoral hemorrhage immediately after LINAC SRS treatment of single temporal lobe metastasis from renal cell carcinoma and discuss plausible causes for this case and its management. A review of the literature on acute intracranial hemorrhage after radiosurgery for metastatic lesions is provided. A 68-year-old man underwent SRS treatment for a single left temporal lobe metastasis. No complications were noticed during frame fixation, treatment itself, or frame removal. Thirty minutes after the end of treatment session the patient acutely became aphasic and right hemiplegic. An urgent CT-scan revealed peritumoral and intratumoral hemorrhage. Patient underwent urgent surgical treatment during which was performed gross total excision of the brain metastasis and total removal of the clot. The patient had a good recovery after surgery and he was discharged with moderate aphasia but able to walk with no other neurological deficits. Stereotactic radiosurgery for metastatic brain tumors should not be considered as a risk-free procedure, especially in cases of neoplasms with high propensity for intratumoral bleeding and, while extremely rare, hemorrhagic complications can occur after treatment. The possibility of acute complications and their consequences have to be discussed with the patient and his or her relatives before radiosurgical treatment.

RANTES modulates the release of glutamate in human neocortex.

The effects of the recombinant chemokine human RANTES (hRANTES) on the release of glutamate from human neocortex glutamatergic nerve endings were investigated. hRANTES facilitated the spontaneous release of d [(3)H]D-aspartate ([(3)H]DASP-) by binding Pertussis toxin-sensitive G-protein-coupled receptors (GPCRs), whose activation caused Ca(2+) mobilization from inositol trisphosphate-sensitive stores and cytosolic tyrosine kinase-mediated phosphorylations. Facilitation of release switched to inhibition when the effects of hRANTES on the 12 mM K(+)-evoked [(3)H]D-ASP exocytosis were studied. Inhibition of exocytosis relied on activation of Pertussis toxin-sensitive GPCRs negatively coupled to adenylyl cyclase. Both hRANTES effects were prevented by met-RANTES, an antagonist at the chemokine receptors (CCRs) of the CCR1, CCR3, and CCR5 subtypes. Interestingly, human neocortex glutamatergic nerve endings seem to possess all three receptor subtypes. Blockade of CCR1 and CCR5 by antibodies against the extracellular domain of CCRs prevented both the hRANTES effect on [(3)H]D-ASP release, whereas blockade of CCR3 prevented inhibition, but not facilitation, of release. The effects of RANTES on the spontaneous and the evoked release of [(3)H]D-ASP were also observed in experiments with mouse cortical synaptosomes, which may therefore represent an appropriate animal model to study RANTES-induced effects on neurotransmission. It is concluded that glutamate transmission can be modulated in opposite directions by RANTES acting at distinct CCR receptor subtypes coupled to different transduction pathways, consistent with the multiple and sometimes contrasting effects of the chemokine.