A Rare Case of Hemorrhagic Melanotic Schwannoma in a 38-year-old Female.

Melanotic schwannoma is a rare form of nerve sheath tumor composed of melanin-producing neoplastic Schwann cells. Less than 200 cases have been reported worldwide. The entity has been associated with Carney complex, a rare genetic disorder characterized by multiple benign tumors. A 38-year-old female presented to our unit with sudden-onset lower back pain and radiculopathy triggered by a mechanical injury. Imaging demonstrated a lesion within the left L5/S1 neural exit foramen with remodeling of bony architecture typical of a chronic, benign process. She proceeded for resection and histology revealed a psammomatous melanotic schwannoma. The patient recovered well with improvement in symptomology. Due to the aggressive nature of the disease, she remains under surveillance for local recurrence and distant metastasis. Clinicians should be aware of this malignant entity, despite its possible presentation with radiological features of a chronic, benign process. Unusual characteristics such as hemorrhage should be treated with a high index of suspicion.

Delayed Fragmentation and Distal Embolization of Retained Microcatheter Causing Lower Limb Ischemia: Case Report and Review of the Literature.

BACKGROUND: Endovascular microcatheter adherence and retention is an uncommon complication during brain arteriovenous malformation (AVM) embolization with glue or ethylene-vinyl alcohol copolymer that has previously reported, although there are sparse reports of symptomatic complications thereafter. CASE DESCRIPTION: We present a unique complication 6 years after initial embolization of a cerebral AVM. The patient presented with acute lower limb insufficiency with computed tomography angiogram revealing fragmentation of the microcatheter and associated popliteal aneurysm. The patient underwent an emergency grafting and removal of the retained fragment and recovered without deficit postoperatively. CONCLUSIONS: Fragmentation over retained microcatheters remains a concern that may be worth monitoring in the long term, although there are no recommendations for timing.

Extensive Pulmonary Metastases 13 Years after Initial Resection of Intracranial Meningioma.

BACKGROUND: Extracranial metastasis from intracranial meningioma is a very rare condition. A current literature review reveals that only few cases are documented with extensive pulmonary involvement >10 years after initial intracranial meningioma resection. Diagnosis of pulmonary meningioma is often confirmed by computed tomography chest-guided core biopsies. The prognosis of extensive metastatic pulmonary meningioma, however, is unknown and there is no gold standard treatment option. CASE DESCRIPTION: We present a case of multiple pulmonary meningioma metastases developing 13 years after initial resection of left occipital parafalcine World Health Organization Grade I intracranial meningioma. CONCLUSION: There are no established guidelines for the optimal management or surveillance of extensive pulmonary metastatic meningioma. In patients with high-grade meningioma and multiple cannonball pulmonary lesions, metastatic meningioma should be considered as part of the differential diagnosis. Metastatic meningioma may occur even a decade after initial tumour resection.

Endovascular Treatment of Vertebral-Venous Fistula with Flow-Diverting Stent.

BACKGROUND: Vertebral-venous fistulas (VVFs) are a rare vascular condition and are commonly associated with trauma but may also be idiopathic, spontaneous, or congenital. A current literature review reveals there is no level 1 evidence or established guidelines on optimal treatment for VVF. Diagnosis is often confirmed by catheter cerebral angiogram. Treatment goals are complete occlusion of the fistula, which can be achieved by both endovascular closure and/or surgical ligation treatment. Telescopic Pipeline flow-diversion stents are a common treatment modality for aneurysms and have also been described to successfully treat different types of cranial arteriovenous fistulas including carotid-cavernous fistulas.There is, however, no English literature available regarding its use in the management of VVFs, which are rare entities. CASE DESCRIPTION: The authors present a case of VVF, which is the first reported case to their knowledge whereby a Pipeline flow-diverting stent has been used to successfully treat a VVF while preserving the parent vertebral artery. The authors describe both the advantages and limitations of this approach. CONCLUSIONS: This case report highlights the potential of flow-diversion stents in the treatment of VVF. This technique was shown to be a safe and effective method of treatment for VVF. Important limitations, however, need to be considered before this form of treatment for VVF, including the need for multiple devices, extended duration of treatment, and associated increased costs involved.

Invasive sinonasal adenocarcinoma with an absent olfactory bulb: a case report.

Sinonasal adenocarcinomas are rare, locally invasive tumours. In this case the symptomatic profile was unusual and the diagnosis was missed at the primary care stage. Interestingly this would be the first documented case with an absent ipsilateral olfactory bulb. A 55-year old male presented with symptoms of behavioural change and mild headaches. He was later found to have a large Sinonasal adenocarcinoma which penetrated the skull base. This was treated by a combined craniotomy and endonasal approach. Sinonasal adenocarcinomas are unusual tumours and further research is required in order to clarify management strategies and prognosis. This interesting case was more unusual again given its presentation, extent and absence of the olfactory bulb. Importantly for primary care physicians the initial diagnosis was considered psychiatric rather than organic; despite there being specific features of the presentation which were suggestive of an intra-cranial lesion.

Intracranial abscess in Ectopia Cordis.

We present a case of intracranial abscess in a young female with Ectopia Cordis, an exceptionally rare cardiac condition. The neurosurgical implication is the predisposition to intracranial abscess formation. A heightened awareness of this association will aid diagnosis in similar clinical scenarios.

Epidural extension of infected chest wall haematoma and empyema causing spinal cord compression.

We report a case of thoracic epidural extension of an infected extra-pleural and chest wall haematoma with evidence of spinal cord compression and signs of cauda equina. Emergency spinal cord decompression with laminectomy followed by thoracotomy was performed.

Symptomatic delayed trans-dural herniation and strangulation of cauda equinae following resection of Myxopapillary ependymoma.

Pseudomeningocoele is a recognised complication of spinal surgery. It could be either asymptomatic or symptomatic. We present a 63-year-old male who developed a delayed pseudomeningocoele and symptomatic transdural herniation and strangulation of the cauda equinae following resection of a Myxopapillary ependymoma. He underwent successful operative re-exploration, un-tethering of the cauda equinae and re-closure of the dural defect with resolution of his symptoms. We discuss the clinical features, operative technical factors involved and the essential importance of neuroimaging with critical analysis of the imaging findings and correlation of the clinical symptoms, when such a diagnosis is being considered.

Pre-operative cerebellar mutism secondary to vagus nerve schwannoma.

Cerebellar mutism, also known as 'posterior fossa syndrome,' is an uncommon condition often reported after posterior fossa tumour resection in the paediatric population. It is infrequently associated with other intrinsic cerebellar pathologies. We hereby report a rare case of pre-operative cerebellar mutism associated with an extrinsic posterior fossa lesion - vagus nerve schwannoma.

Metastasis of breast cancer to a lumbar spinal nerve root ganglion.

STUDY DESIGN: A case report of a surgically treated metastasis of breast cancer to the L2 nerve root ganglion. OBJECTIVES: To report of an uncommon site of metastasis as the first manifestation of distant hematogenous spread of breast cancer mimicking a benign lesion. SUMMARY OF BACKGROUND DATA: Although metastatic disease is a common condition there are limited reports of metastases to the spinal nerve root ganglion. To our knowledge this is the fourth reported case and the first report of a metastasis of a breast carcinoma. METHODS: A 46-year-old female patient was admitted with severe right sided radicular pain and moderate weakness of hip flexion and knee extension. Magnetic resonance imaging revealed a small lesion of the L2 nerve root. Intraoperatively an intradural tumor was encountered and debulked. The procedure was followed by radiation therapy. RESULTS: The operative procedure resulted in complete pain resolution with improved motor function. The histologic examination confirmed the tumor to be a metastasis of breast cancer as determined by immunohistological staining. The patient remained recurrence free at 6 month follow-up. CONCLUSION: Although very rare, metastasis to the spinal nerve root ganglion can be the first manifestation of distant hematogenous metastases of breast cancer. The clinical course is characterized by increasing radicular symptoms-especially intractable pain. The radiologic appearance might mimic a benign lesion. Surgical intervention with tumor debulking followed by radiotherapy provides local tumor control and palliation from pain.

Utilization of dynamic CT perfusion in the study of intracranial meningiomas and their surrounding tissue.

OBJECTIVE: To use CT perfusion (CTP) to assess levels of ischemia in brain areas around intracranial meningiomas. MATERIALS AND METHODS: Fifteen patients with intracranial meningiomas were analysed preoperatively with CTP study. The cerebral blood flow (CBF), cerebral blood volume (CBV) and time to peak (TTP) were measured in the edema, peritumoral edema and in the normal areas of brain. RESULTS: The peritumoral edema measured a mean CBF of 17.36 ml/min/100 ml (median=15.8) and the mean CBF value in the whole edema was 93.86 ml/min/100 ml (median=79.9). The mean CBV measured in the peritumoral edema was 2.7 (median=2.3) and the measured mean CBV of edema was 15 (median=13.2). In the region of the peritumoral edema, the mean CBF and CBV were lower than in the edema bed. Normal brain remote from the edema measured less CBF (mean=28.36 ml/min/100 ml, median=29.7) and CBV (mean=4.1, median=3.8) than the edema. Six patients were noted to have CBF of less than 15 ml/min/100 ml in the perilesional edema. The measured mean CBF and CBV in the normal area of brain were higher than in the peritumoral edema, while the TTP was greater in the perilesional edema (mean=11, median=10.4) when compared with areas of normal brain (mean=9.9, median=9.5) with statistically significant p values. CONCLUSION: The values obtained elucidate the fact that perilesional edematous areas are ischemic. By subset analysis, it may be possible to identify those areas with recoverable tissue from non-recoverable tissue.

Rupture of brainstem cyst with clinical benefit after head injury. Case report.

The authors report an interesting case of the rupture of a brainstem cyst following blunt head trauma. They discuss the case, review reports of similar events, and suggest a possible mechanism by which the cyst could have resolved without surgery.