Third whole-brain radiation therapy for multiple brain metastases. Should it be considered in selected patients?

Whole brain reirradiation for the treatment of multiple brain metastases has shown promising results. However, concerns remain over the possible neurotoxic effects of the cumulative dose as well as the questionable radiosensitivity of recurrent metastases. A second reirradiation of the whole brain is ordinarily performed in our department for palliative purposes in patients presenting with multiple metastatic brain progression. For this study, an investigational third whole brain reirradiation has been administered to highly selected patients to obtain disease control and delay progression. Clinical outcomes and neurological toxicity were also evaluated.

Spontaneous carotid-cavernous fistula supplied by the contralateral meningohypophyseal trunk: case report and literature review.

Carotid-cavernous sinus fistulas (CCF) are abnormal communications between the carotid artery and the cavernous sinus. Most spontaneous CCFs are low-flow fistulas, supplied by branches of the omolateral internal carotid artery or the external carotid artery. A 64-year-old man, with increasing diplopia, mild exophthalmos on the left side, blurred left vision and omolateral red eye, was admitted to our institution. The patient underwent a bilateral cerebral angiography that showed a left CCF fed by meningo-hypophyseal branches of the right internal carotid artery and draining from the cavernous sinus into a parahippocampal vein. A transarterial embolization of the carotid-cavernous fistula was performed, with complete obliteration of the fistula. Although anecdotal reports exist, there is a scarcity of well-documented cases of exclusively contralateral flow in the carotid-cavernous fistula. Most of the reported cases referred to contralateral flow into the carotid-cavernous fistula by the external carotid artery branches. To the best of our knowledge, there are no previous cases of a spontaneous CCF supplied by contralateral meningo-hypophyseal branches. A discussion of treatment options and a literature review are also performed.

Acute subdural intracranial hematoma after combined spinal-epidural analgesia in labor.

Intracranial subdural hematoma is a rare, but well-described complication of epidural and spinal anesthesia, as documented by more than a decade of publications. Non-postural headache and vomiting are warning signs. A headache lasting more than 5 days should arouse suspicion of intracranial hemorrhage, whether or not it is associated with the appearance of neurological signs or the deterioration of neurological status. Urgent cranial computed tomography can confirm the diagnosis of subdural hematoma, which has the potential to cause a dramatic cerebral herniation syndrome. A combination of spinal epidural (CSE) anesthesia and analgesia is commonly used to obtain pain relief during caesarean sections and labor. We report the case of a patient who suffered from severe neurological deterioration and manifested signs of brain herniation due to the development of an acute intracranial subdural hematoma after CSE analgesia for labor. An emergency craniotomy was performed to remove the subdural hematoma and the patient recovered well. Close observation of patients undergoing CSE analgesia or anesthesia complaining of prolonged non-postural headaches, with or without neurological symptoms, is recommended.

[Oncocytic meningioma. Case report]. / Meningioma oncocitario. Descrizione di un caso.

Among the histological variants of meningiomas the oncocytic subtype is rarely observed. Up-today, only six cases of oncocytic meningioma are described. This subtype of meningiomas shows an aggressive behavior and recurrences are more frequent. We describe a case of oncocytic meningioma in a 78-years-old woman. The patient had a history of breast cancer diagnosed 9 years before the brain biopsy; bilateral mastectomy and adjuvant chemotherapy was performed. She had a right frontal tumour measuring 3 cm in diameter. The patient is alive and well eleven months after surgery. The tumour was composed by large polygonal neoplastic cells with finely granular eosinophilic cytoplasm. Neoplastic cells were arranged in sheets and nests delimited by thin fibrous septa rich in vessels. Psammomatous bodies were also present. Mitoses were rare and necrosis was absent. Oncocytic differentiation was demonstrated by conventional histology and immunohistochemistry. Immunohistochemistry revealed a strong and diffuse positivity for antimitochondrial antiserum, vimentin and EMA; a focal reactivity for cytokeratin was observed. The rarity of oncocytic meningiomas is underlined with only six cases described in the world literature. The immunophenotypic profile and the differential diagnosis of the neoplasm is discussed and the concept of oncocytic meningioma as a distinct entity of tumour is emphasized.

Surgical decompression and radiation therapy in epidural metastasis from cervical cancer.

Spinal cord compression by epidural metastasis is considered an exceptional complication in patients with cervical carcinoma. We report three patients treated for a cervical carcinoma who developed epidural metastasis with spinal cord compression at 9, 25 and 48 months after primary treatment of the uterine malignancy. All patients had poorly-differentiated adenocarcinomas with lymphovascular space invasion, and two had lymph node metastasis. All patients underwent emergency decompressive laminectomy followed by radiotherapy and a partial recovery of the neurological function was achieved. In two patients the spinal cord was the only site of recurrent disease, whereas the other had lung and brain metastasis at the time of epidural involvement diagnosis. All three patients, however, died of disseminated disease. Surgical decompression followed by radiation therapy may result in a complete preservation of the neurologic functions in patients with spinal cord compression secondary to metastatic carcinoma of the uterine cervix. Considering the propensity for disseminated disease, long term survival might be achieved only with the use of effective chemotherapy.

Laparoscopic removal of two dislocated ventriculoperitoneal catheters: case report.

In a child two previously migrated abdominal catheters from ventriculoperitoneal shunts were removed from the abdominal cavity by use of laparoscopy. Avoiding the usually longitudinal laparatomy, two small incisions were necessary to insert the laparoscope (sub-umbilical incision) and grasping forceps (left iliac pit incision). Laparoscopy allowed for identification of a working ventriculoperitoneal shunt, that was correctly in place, and for removal of two old migrated catheters. The child was mobilized the same day and the post-operative course was uneventful.

Surgical resection of a cerebral metastasis from cervical cancer: case report and review of the literature.

AIMS AND BACKGROUND: Central nervous system metastasis from cervical carcinoma is uncommon. CASE REPORT: We report the case of a 51-year-old woman who developed a solitary cerebral metastasis 29 months after radical hysterectomy with pelvic lymphadenectomy for a stage IB, grade III cervical cancer. The patient suddenly complained of headache, confusion and dizziness; she was submitted to emergency surgical resection of a 2 x 3 cm metastasis in the right frontal lobe. The postoperative course was uneventful and she completely recovered from her neurological deficit. Following surgery the patient underwent careful restaging. Massive bilateral involvement of the pelvic wall was diagnosed, and the patient received three courses of cisplatin-based chemotherapy. She developed liver and lung metastases and died 10 months later of progressive disseminated disease, without, however, any sign of recurrent or persistent cerebral involvement. CONCLUSION: Neurosurgical resection should be considered in cervical cancer patients with solitary brain metastasis in the absence of systemic disease.

Central nervous system involvement secondary to metastatic mixed müllerian tumor of the uterus.

The central nervous system is traditionally considered an uncommon site for metastatic disease from female genital tract tumors. We report the case of a 48-year-old woman with malignant mixed müllerian tumor of the uterus, who developed spinal cord compression by epidural metastasis a few days after the diagnosis of the uterine malignancy. Emergency decompressive laminectomy was performed and a good recovery of the neurological function was achieved. In the following days, while submitted to extensive staging for the uterine malignancy, the patient complained of headache, confusion and visual disturbance. CT scan revealed multiple brain metastases. No other site of metastatic disease could be detected. The patient refused any further treatment and died 1 month later from progressive cerebral disease. Attention should be paid to the possibility of unusual distant metastases associated to uterine sarcoma in order to treat these patients promptly.