Diffuse alveolar hemorrhage: a rare manifestation of trauma.

OBJECTIVE: Fat emboli syndrome (FES) is a disorder associated with both acute lung injury and acute respiratory distress syndrome. Both FES and diffuse alveolar hemorrhage (DAH) are bronchoscopically definable entities that may share a common etiology. We conducted a chart review analysis to examine the relationship between FES and DAH. METHODS: Retrospective chart review. RESULTS: Three cases of concurrent FES and DAH were identified. Long bone fracture and/or orthopedic procedures preceded all the events and were the likely inciting source for eventual acute lung injury. Bronchoalveolar lavage-evident DAH and FES was found in all these cases in association with hemoptysis and lung-attributed blood loss. Lung-protective ventilation and standard supportive care approaches proved sufficient in attaining good outcomes. CONCLUSION: Combined FES and DAH can occur in association with orthopedic injury and repair and are likely an under-recognized entity.

Primary anaplastic glio-neuronal tumor of the pineal gland: a new type of pineal neoplasm?

BACKGROUND: Tumors of the pineal gland are relatively rare. Most are solid, infiltrative lesions characterized by either germ cell, glial, or pineal parenchymal origin. To our knowledge, none have been described that contain an admixture of both anaplastic glial and neuronal elements. CASE REPORT: The authors present a case of a primary anaplastic glio-neuronal tumor of the pineal gland in a 78-year-old gentleman who presented with hydrocephalus. The patient underwent an endoscopic third ventriculostomy for treatment of his hydrocephalus as well as tumor biopsy under endoscopic visualization. RESULTS: Sections of the tumor displayed a modestly to moderately cellular neoplasm infiltrating the residual pineal gland. The majority of the nuclei appeared hyperchromatic, spindle-shaped, and pleomorphic, with fibrillary cytoplasmic processes. Rare nuclei were round with vesicular chromatin and red nucleoli. Mitotic figures were easily identified, despite small sample size. GFAP immunostaining highlighted the fibrillar background and cytoplasmic processes while synaptophysin immunostains revealed intense, dot-like positivity in the rounder nuclei with vesicular chromatin. Although the different nuclear morphologies seen on the hematoxylin-eosin stained slides suggested both glial and neuronal origin, immunostains were required to confirm the presence of dual differentiation. CONCLUSION: We present the first case of a primary anaplastic glio-neuronal neoplasm of the pineal gland. Increased use of immunostaining may unveil additional cases in the future. Furthermore, additional research will be required to determine whether the dual differentiation has prognostic significance.

Role of proton magnetic resonance spectroscopy in the diagnosis of gliomatosis cerebri: a unique pattern of normal choline but elevated Myo-inositol metabolite levels.

A patient with histologically proven gliomatosis cerebri presented with a normal choline level but a markedly abnormal elevated myo-inositol level on magnetic resonance (MR) spectroscopy. We describe the case presentation, imaging findings (in particular, the unique MR spectroscopic pattern), and their significance regarding the diagnosis of this relatively rare neoplasm.

Intramedullary spinal cord astrolipoma: case report.

OBJECTIVE AND IMPORTANCE: Reported is a case of a thoracic intramedullary astrocytoma with a lipomatous component, a so-called astrolipoma. This is the only known case of a single intraspinal astrolipoma in an otherwise healthy patient. CLINICAL PRESENTATION: The patient was a 36-year-old woman with dorsal thoracic pain of more than 1 month's duration, mild lower extremity weakness, and incomplete sensory loss to the T10 level. INTERVENTION: Magnetic resonance imaging of the thoracolumbar spine revealed a fusiform mass at the T9-T11 level. The patient underwent T9-T11 laminectomies and complete resection of the tumor. In the initial postoperative period, the patient's symptoms worsened. However, 3 months after surgery, the patient was clinically improved and was able to walk without assistance. Twelve months after surgery, imaging revealed no evidence of tumor. CONCLUSION: The current treatment plan and recommendation, assuming this tumor will behave like a low-grade glioma or lipoma, is continued radiographic surveillance after gross total resection. Reresection is recommended for tumor recurrence or significant regrowth. The long-term prognosis for astrolipoma is unknown.

Computed tomography's ability to predict sacrifice of hypoglossal nerve at resection.

OBJECTIVE: To assess whether preoperative computed tomography (CT) scan can determine if the hypoglossal nerve (cranial nerve XII) will be sacrificed in floor-of-mouth, oral tongue, and tongue base tumor resections. STUDY DESIGN: Retrospective review. METHODS: Patients who underwent resection of floor-of-mouth, oral tongue, and tongue base tumors from 1990 to 1999 were identified. Preoperative CT scans were reviewed by a neuroradiologist. The postoperative status of cranial nerve XII was predicted to be "saved" or "sacrificed." Hypoglossal nerve "sacrifice" was predicted if the fat planes surrounding the takeoff of the proximal lingual artery were obliterated by tumor. The nerve was determined to be sacrificed or spared during resection by review of the operative report. RESULTS: Of the 45 patients, 14 tumors were predicted radiographically to involve the hypoglossal nerve. Twenty-seven of 31 nerves that were predicted to be saved were saved at the time of surgery. Seven of 14 nerves that were predicted to be sacrificed were sacrificed at the time of surgery. The sensitivity was 0.64 (95% confidence interval [CI], 0.35-0.86) with a specificity of 0.79 (95% CI, 0.70-0.87). The positive predictive value was 0.50 (95% CI, 0.27-0.68) with a negative predictive value of 0.87 (95% CI, 0.77-0.95). CONCLUSIONS: The ability to predict preoperatively whether a tumor can be resected without sacrificing the hypoglossal nerve would be an important factor in determining management of these tumors. The results indicate that CT scan accurately predicts the ability of the surgeon to spare the hypoglossal nerve (negative predictive value, 87%) with a specificity of 0.79.

Primary splenic lymphoma complicated by hematemesis and gastric erosion.

Gastrosplenic fistula resulting from erosion of a primary splenic lymphoma is a rare cause of massive upper gastrointestinal hemorrhage associated with benign peptic ulcer disease, gastric Crohn's disease, gastric adenocarcinoma, and primary gastric and splenic lymphomas. Upper intestinal hemorrhage can be successfully treated with splenic artery embolization, followed by splenectory and gastric resection.