Intracranial Involvement of Systemic Hodgkin Lymphoma: A Case Report and Literature Review.

A 27-year-old male patient, previously diagnosed with Hodgkin lymphoma (HL), presented with gait disturbance. Brain MRI showed a 4.5 cm mass lesion in the right occipital lobe, suggesting either intracranial involvement of HL or a potential meningioma. Despite high-dose methotrexate and steroid treatment, the patient's symptoms persisted, and imaging showed an enlarging mass, leading to surgical intervention. Histopathological examination confirmed central nervous system (CNS) involvement of HL. Postoperatively, the patient underwent whole-brain radiotherapy and demonstrated marked clinical improvement. Our literature review from 1980 to 2023 identified only 46 cases of intracranial HL (IC-HL), underscoring its rarity. Lymphomas represent 2.2% of brain tumors, with 90%-95% being diffuse large B-cell lymphoma (DLBCL). In contrast, the incidence of CNS-HL patients is a mere 0.02%. Notably, IC-HL and intracranial DLBCL have differences in their typical locations and treatment strategies. Unlike DLBCL, which predominantly appears in the supratentorial region (87%), IC-HL is found there in 61.5% of cases. Additionally, 33.3% of IC-HL cases occur in the cerebellum, with 43.5% associated with posterior circulation regions. Furthermore, while biopsy followed by chemotherapy induction is a common strategy for DLBCL, 81.8% of IC-HL cases underwent surgical resection, and only 18.1% had a biopsy alone. The distinct characteristics of IC-HL tumors, including their larger size, attachment to the dura, and fibrotic nature with clear boundaries, might account for the preference for surgical intervention. The unique features of IC-HL compared to DLBCL highlight the need for distinct considerations in diagnosis and management.

Saturated Fatty Acid Emulsions Open the Blood-Brain Barrier and Promote Drug Delivery in Rat Brains.

We performed this study to evaluate whether saturated fatty acid (SFA) emulsions affect the BBB and determine the duration of BBB opening, thereby promoting drug delivery to the brain. Butyric, valeric, caproic, enanthic, and caprylic acid emulsions were infused into the carotid artery of the rat model. We evaluated the BBB opening and drug delivery over time. The trypan blue and doxorubicin delivery studies were repeated from 30 min to 6 h. In the 1 h rats in each group, transmission electron microscopy (TEM) was performed to morphologically evaluate tight junctions, and the delivery of temozolomide was assessed by desorption electrospray ionization mass spectrometry. The ipsilateral hemisphere was positive for trypan blue staining in all the five SFA emulsion groups. In the valeric, enanthic, and caprylic acid emulsion groups, RGB ratios were significantly higher at 30 min and decreased thereafter. Doxorubicin delivery increased in all emulsion groups at all time points. Tight junctions were observed to be open in all groups. TMZ delivery was significantly higher in the ipsilateral hemisphere. In conclusion, intra-arterially infused SFA emulsions opened the BBB and promoted drug delivery within 30 min, which decreased thereafter. Therefore, SFA emulsions may aid BBB research and promote drug delivery to the brain.

Posterior reversible encephalopathy syndrome following uneventful clipping of an unruptured intracranial aneurysm: A case report.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is characterized mainly by occipital and parietal lobe involvement, which can be reversible within a few days. Herein, we report a rare case of PRES that developed after craniotomy for an unruptured intracranial aneurysm (UIA). CASE SUMMARY: A 59-year-old man underwent clipping surgery for the treatment of UIA arising from the left middle cerebral artery. Clipping surgery was performed uneventfully, and he regained consciousness quickly immediately after the surgery. At the 4th hour after surgery, he developed a disorder of consciousness and aphasia. Magnetic resonance imaging revealed cortical and subcortical T2/FLAIR hyperintensities in the parietal, occipital, and frontal lobes ipsilaterally, without restricted diffusion, consistent with unilateral PRES. With conservative treatment, his symptoms and radiological findings almost completely disappeared within weeks. In our case, the important causative factor of PRES was suspected to be a sudden increase in cerebral perfusion pressure associated with temporary M1 occlusion. CONCLUSION: Our unique case highlights that, to our knowledge, this is the second report of PRES developing after craniotomy for the treatment of UIA. Surgeons must keep PRES in mind as one of the causes of perioperative neurological abnormality following clipping of an UIA.

Spheno-Orbital Plasmacytoma as an Initial Presentation of Multiple Myeloma.

Intracranial plasmacytoma is a rare neoplasm and a subtype of malignant plasma cell tumor. Most patients with plasma cell tumors are diagnosed with multiple myeloma, but 5%-10% of patients are not. This report includes descriptions of radiologic and clinical findings in a patient with intracranial plasmacytoma. Intracranial extra-axial plasmacytomas can be easily misdiagnosed as meningioma in radiologic and clinical findings. A 69-year-old woman presented with exophthalmos and diplopia, and MRI indicated meningioma. Thus, she underwent gross total resection, and her pathologic diagnosis was plasmacytoma. Exophthalmos and diplopia were fully recovered. She was finally diagnosed with multiple myeloma based on systemic evaluation and treated with targeted chemotherapy. MRI conducted at 3 months after surgery showed no local recurrence or remnant tumor. Although intracranial plasmacytomas are difficult to distinguish from meningiomas in preoperative evaluation, gross total resection is recommended for the same purposes as meningiomas. If the pathologic diagnosis is a plasmacytoma, it is essential to have a systemic evaluation for multiple myeloma.

Wire perforation of the missed tiny aneurysm originating from the fenestrated A1 segment during the endovascular approach.

Vascular anomaly and aneurysmal formation of an anterior communicating artery (ACOM) complex has often been reported. Because of such a complicated relationship between the vascular structure and aneurysms, ACOM aneurysm is one of the most difficult aneurysms to treat among other common anterior circulation aneurysms. We herein report a case of wire perforation of a missed tiny aneurysm arising from the fenestrated A1 segment during the endovascular approach to ACOM aneurysm. Although the fenestration of A1 segment is a rare vascular anomaly, it is likely to accompany saccular type aneurysms in the vicinity of the vascular anomaly. Endovascular treatment for ACOM aneurysm requires more detailed evaluations of the accompanying vascular anomaly and hemodynamics around ACOM to avoid complications.

Triolein emulsion enhances temozolomide brain delivery: an experimental study in rats.

PURPOSE: To evaluate the enhancement of temozolomide (TMZ) delivery in the rat brain using a triolein emulsion. MATERIALS AND METHODS: Rats were divided into the five groups as following: group 1 (negative control), group 2 (treated with triolein emulsion and TMZ 20 mg/kg), and group 3 (TMZ 20 mg/kg treatment without triolein), group 4 (treated with triolein emulsion and TMZ 10 mg/kg), and group 5 (TMZ 10 mg/kg treatment without triolein). Triolein emulsion was infused into the right common carotid artery. One hour later, the TMZ concentration was evaluated quantitatively and qualitatively using high-performance liquid chromatography (HPLC-MS) and desorption electrospray ionization mass spectrometry (DESI-MS) imaging, respectively. The concentration ratios of the ipsilateral to contralateral hemisphere in each group were determined and the statistical analysis was conducted using an unpaired t-test. RESULTS: Quantitatively, the TMZ concentration ratio of the ipsilateral to the control hemisphere was 2.41 and 1.13 in groups 2 and 3, and were 2.49 and 1.14 in groups 4 and 5, respectively. Thus, the TMZ signal intensities of TMZ in group 2 and 4 were statistically high in the ipsilateral hemispheres. Qualitatively, the signal intensity of TMZ was remarkably high in the ipsilateral hemisphere in group 2 and 4. CONCLUSIONS: The triolein emulsion efficiently opened the blood-brain barrier and could provide a potential new strategy to enhance the therapeutic effect of TMZ. HPLC-MS and DESI-MS imaging were shown to be suitable for analyses of enhancement of brain TMZ concentrations.

Contralateral Interhemispheric Transcallosal Approach for Thalamic Cystic Cavernous Malformation.

A 42-year-old man presented with a headache and right hemiparesis and was found to have a cystic mass with a calcified mural nodule in the left thalamus. Because the thalamus is surrounded by vital neurovascular structures, the surgical approach to thalamic lesions can be challenging. We decided to remove the mass for decompression and pathological diagnosis. The mass was removed through a contralateral interhemispheric transcallosal transchoroidal approach with less retraction and parenchymal injury than other approaches to avoid brain retraction and cortical injury. The pathological diagnosis was cavernous malformation. Temporary worsening of the preoperative hemiparesis was recovered over two months following surgery. Tolerable thalamic pain syndrome remained. Here, we report a rare case of thalamic cavernous malformation with a favorable outcome through a contralateral surgical approach.

The Effect of Pain Reduction during Headframe Fixation for Stereotactic Radiosurgery by the Preceded Local Anesthesia under the Needle Cap Guidance.

BACKGROUND: Gamma knife radiosurgery (GKRS) has become a major alternative in the neurosurgical field. However, many patients complained of considerable discomfort during the fixation of rigid headframe. This study investigated whether our modified procedure could reduce fixation-related pain. METHODS: Sixty-six patients who underwent GKRS were enrolled in this study. Thirty-one patients (Group A) underwent the conventional subcutaneous infiltration technique, and 35 patients (Group B) did the modified procedure. In group A, the headframe was held in position by an assistant, and local anesthetics were injected subcutaneously using a 23-gauge spinal needle at pinning sites. Subsequently, pins were applied according to measurements based on spinal needle depth. In group B, with the frame held in position by an assistant, pin sites were marked with a surgical pen under the guidance of needle cap placed on the pin holes. The head frame was then removed, and local anesthetics were injected subcutaneously and periosteally at each marked pin site using a 26-gauge needle. The headframe was then repositioned 5 minutes after local infiltration, and pins were applied according to measurements based on spinal needle depth. To evaluate pain severity during procedures, visual analogue scale (VAS) scores were recorded during local infiltration and frame placement with pins. The pain scores of the two groups were analyzed statistically. RESULTS: Group B had a significantly lower VAS score during frame placement than group A (7.26 vs. 3.61; p<0.001), and mean VAS score at local infiltration was also significantly lower in group B (4.74 vs. 3.74; p=0.008). CONCLUSION: Patients in group B experienced significantly less pain than those in group A during pin placement. Pre-fixation time advanced local anesthesia might reduce pain during stereotactic procedures, and the use of a 26-gauge needle appeared in less pain during local infiltration.

Lateral Ventricular Meningioma Presenting with Intraventricular Hemorrhage.

A 35-year-old female visited emergency department for a sudden onset of headache with vomiting after management for abortion at local department. Neurological examination revealed drowsy mentality without focal neurological deficits. CT showed 3.2×3.4 cm hyperdense intraventricular mass with intraventricular hemorrhage. The intraventricular hemorrhage was found in lateral, 3rd, and 4th ventricles. MRI showed well enhancing intraventricular mass abutting choroid plexus in the trigone of the right lateral ventricle. CT angiography showed tortuous prominent arteries from choroidal artery in tumor. Her neurological status deteriorated to stupor and contralateral hemiparesis during planned preoperative workup. Urgent transtemporal and transcortical approach with decompressive craniectomy for removal of intraventricular meningioma with hemorrhage was done. Grossly total removal of ventricular mass was achieved. Pathological finding was meningotheliomatous meningioma of World Health Organization (WHO) grade I. The patient recovered to alert mentality and no motor deficit after intensive care for increased intracranial pressure. However, visual field defect was developed due to posterior cerebral artery territory infarction. The visual deficit did not resolve during follow up period. Lateral ventricular meningioma with spontaneous intraventricular hemorrhage in pregnant woman is very uncommon. We report a surgical case of lateral ventricular meningioma with rapid neurological deterioration for intraventricular hemorrhage.

Bone Flap Changes after Cranioplasty Using Frozen Autologous Bone Flaps: A Three-Dimensional Volumetric Reconstruction Study.

PURPOSE: Bone flap resorption (BFR) after cranioplasty with an autologous bone flap (ABF) is well known. However, the prevalences and degrees of BFR remain unclear. This study aimed to evaluate changes in ABFs following cranioplasty and to investigate factors related with BFR. MATERIALS AND METHODS: We retrospectively reviewed 97 patients who underwent cranioplasty with frozen ABF between January 2007 and December 2016. Brain CT images of these patients were reconstructed to form three-dimensional (3D) images, and 3D images of ABF were separated using medical image editing software. ABF volumes on images were measured using 3D image editing software and were compared between images in the immediate postoperative period and at postoperative 12 months. Risk factors related with BFR were also analyzed. RESULTS: The volumes of bone flaps calculated from CT images immediately after cranioplasty ranged from 55.3 cm³ to 175 cm³. Remnant bone flap volumes at postoperative 12 months ranged from 14.2% to 102.5% of the original volume. Seventy-five patients (77.3%) had a BFR rate exceeding 10% at 12 months after cranioplasty, and 26 patients (26.8%) presented severe BFR over 40%. Ten patients (10.3%) underwent repeated cranioplasty due to severe BFR. The use of a 5-mm burr for central tack-up sutures was significantly associated with BFR (p<0.001). CONCLUSION: Most ABFs after cranioplasty are absorbed. Thus, when using frozen ABF, patients should be adequately informed. To prevent BFR, making holes must be kept to a minimum during ABF grafting.

Synergistic combination of chemo­phototherapy based on temozolomide/ICG­loaded iron oxide nanoparticles for brain cancer treatment.

Chemo­photothermal therapy for cancer treatment has received increasing attention due to its selective therapeutic effects. In the present study, the anticancer effects of drug­loaded Fe3O4 magnetic nanoparticles (MNPs) by chemo­photothermal therapy on U­87 MG human glioblastoma cells was investigated. Anticancer drug­loaded Fe3O4 MNPs were prepared by loading temozolomide (TMZ) and indocyanine green (ICG), and were characterized by X­ray diffraction, UV­vis spectroscopy, thermal gravimetric analysis, transmission electron microscope, as well as drug­loading capacity. Following treatment with near­infrared (NIR) light irradiation, the administration of Fe3O4­TMZ­ICG MNPs resulted in the apoptosis of U­87 MG glioblastoma cells through the generation of reactive oxygen species. Western blot analysis and reverse transcription­quantitative polymerase chain reaction revealed that Fe3O4­TMZ­ICG MNPs with NIR laser irradiation lead to significantly enhanced anticancer effects on U­87 MG glioblastoma cells through the modulation of intrinsic and extrinsic apoptosis genes, including Bcl­2­associated X protein, Bcl­2, cytochrome c, caspase­3, Fas associated via death domain and caspase­8. These results suggest that Fe3O4­TMZ­ICG MNPs may be potential candidates when administered as chemo­phototherapy for the treatment of brain cancer.

Pituicytoma with Significant Tumor Vascularity Mimicking Pituitary Macroadenoma.

A 19-year-old man presented with bitemporal hemianopsia and was found to have a large sellar and suprasellar tumor, resembling a pituitary macroadenoma. Emergency transsphenoidal approach was attempted because of rapid visual deterioration with headache. However, the approach was complicated and stopped by uncontrolled hemorrhage from the tumor. After conventional cerebral angiography and recognition of an unusual pathology, transcranial approach was achieved to prevent permanent visual loss. The final pathological diagnosis was pituicytoma with epithelioid features. Pituicytoma is a rare low-grade tumor (WHO Grade I) of pituicytes involving the sellar and suprasellar region, and originating from special glial cells of the neurohypophysis. Because of the high vascularity, the firm consistency, and invasion to surrounding neurovascular structures, a pituicytoma should be included in the differential diagnosis of a mass in the sellar and suprasellar area if the tumor shows high enhancement with vascular components. We report a case of rare pituicytoma mimicking a pituitary macroadenoma with massive hemorrhage to disturb surgery.

Semi-Jailing Technique Using a Neuroform3 Stent for Coiling of Wide-Necked Intracranial Aneurysms.

OBJECTIVE: The semi-jailing technique (SJT) provides stent-assisted remodeling of the aneurysm neck during coil embolization without grasping the coil delivery microcatheter. We retrospectively evaluated the efficacy and safety of SJT using a Neuroform3 stent for coiling of wide-necked intracranial aneurysms. METHODS: We collected the clinical and radiological data between January 2009 and June 2015 of the wide-necked aneurysms treated with SJT using a Neuroform3 stent. RESULTS: SJT using a Neuroform3 stent was attempted in 70 wide-necked aneurysms (68 patients). There were 56 unruptured and 14 ruptured aneurysms. The size of aneurysm ranged from 1.7 to 28.1 mm (mean 6.1 mm). The immediate angiographic results were complete occlusion in 55 aneurysms (78.6%), neck remnant in 7 (10.0%), and aneurysm remnant in 8 (11.4%). Overall, periprocedural complications occurred in 13 patients (19.1%), including asymptomatic thromboembolism in 7 (10.3%), symptomatic thromboembolism in 4 (5.9%), and symptomatic hemorrhagic complications in 2 (2.9%). Conventional angiography follow-up was obtained in 55 (78.6%) of 70 aneurysms (mean, 10.9 months). The result showed progressive occlusion in 7 aneurysms (12.7%) and recanalization in 1 aneurysm (1.8%). At the end of the observation period (mean, 17.5 months), all 54 patients without subarachnoid hemorrhage showed excellent clinical outcomes (modified Rankin Scale [mRS] 0), except two (mRS 1 or 2) and seven of 14 patients with subarachnoid hemorrhage remained symptom-free (mRS 0). CONCLUSION: In this report of 70 aneurysms, SJT using a Neuroform3 stent for coiling of wide-necked intracranial aneurysms showed good technical safety, as well as favorable clinical and angiographic outcomes.

Retro-Odontoid Pseudotumor without Atlantoaxial Subluxation or Rheumatic Arthritis.

We present a case of retro-odontoid pseudotumor (ROP) without rheumatoid arthritis (RA) or atlantoaxial subluxation (AAS). A 76-year-old woman presented with paresthesia and weakness of both lower and upper extremities. She had no laboratory or physical findings of RA. Dynamic X-ray showed no AAS and magnetic resonance imaging (MRI) showed a retro-odontoid mass compressing the spinal cord. Transdural mass debulking and biopsy were performed via minimal left suboccipital craniectomy and C1 hemilaminectomy. Two months after surgery, her symptoms were aggravated. Follow-up MRI visualized mass re-growth and spinal cord compression due to the mass and AAS. Posterior C1-2 fixation was performed without further decompression. Twelve months after posterior fixation, no symptoms were apparent and follow-up MRI showed complete resolution of the ROP with C1-2 bony fusion. The ROP with C1-2 instability might be completely resolved only C1-2 fusion without decompression. Furthermore, we speculated that osteoarthritis of C1-2 itself causes a partial tear or degradation of the transverse ligament, that induced formation of ROP.

The Efficacy of Single Barrel Superficial Temporal Artery-middle Cerebral Artery Bypass in Treatment of Adult Patients with Ischemic-type Moyamoya Disease.

OBJECTIVE: So far, there is no study answering the question of which type of surgical technique is practically the most useful in the treatment of adult patients with ischemic type moyamoya disease (MMD). We evaluated the efficacy of single barrel superficial temporal artery (STA)-middle cerebral artery (MCA) bypass in the treatment of adult patients with ischemic type MMD by retrospectively collecting clinical and radiological data. MATERIALS AND METHODS: A retrospective review identified 31 adult patients who underwent 43 single barrel STA-MCA bypass procedures performed for treatment of ischemic-type MMD between 2006 and 2014. The male to female ratio was 17:14 and the mean age was 41 years (range, 21-65 years). Peri-operative complications, angiographic and clinical outcomes were analyzed retrospectively. RESULTS: The permanent neurological morbidity and mortality rates were 2.3% and 0%, respectively. During the observation period of a mean of 35 months (range, 12-73 months), 29 patients (93.5%) had no further cerebrovascular events and transient ischemic attack occurred in two patients (6.5%), resulting in an annual stroke risk of 2.2%. Follow-up computed tomography perfusion (CTP) (mean, 18.4 months after surgery) documented improved cerebral hemodynamics in the revascularized hemispheres (p < 0.001). Post-operative patency was clearly verified in 38 bypasses (88.4%) of 43 bypasses on follow-up imaging (mean, 16.5 months). CONCLUSION: Our results suggest that single barrel STA-MCA bypass with wide dural opening is safe and durable method of cerebral revascularization in adult patients with ischemic type MMD and can be considered as a potential treatment option for adult patients with ischemic type MMD.

Eleven Year's Single Center Experience of Endovascular Treatment of Anterior Communicating Artery Aneurysms: Focused on Digital Subtraction Angiography Follow-Up Results.

OBJECTIVE: Anterior communicating artery (AcomA) aneurysms represent the most common intracranial aneurysms and challenging to treat due to complex vascularity. The purpose of this study was to report our experience of endovascular treatment of AcomA aneurysms. METHODS: Between January 2003 and December 2013, we retrospectively reviewed the medical records of 134 AcomA aneurysm patients available more than 6 months conventional angiographic and clinical follow-up results. We focused on aneurismal or AcomA vascular characters, angiographic and clinical follow-up results, and retreatment. RESULTS: The rate of ruptured cases was 75.4%, and the small (<10 mm) aneurysms were 96.3%. Based on the subtypes defined by dominance of A1, 79 patients (59%) had contralateral A1 hypoplasia or agenesis. The immediate post-procedural angiography confirmed complete occlusion in 75.4%, partial occlusion in 24.6%. Procedure related complications were observed in 25 (18.6%) patients. Most of the adverse events were asymptomatic. Follow-up conventional angiography at ≥6 months was performed in all patients (mean 16.3 months) and major recanalization was noted in 6.7% and regrowth in one case. The aneurysm size (p=0.016), and initial treatment results (p=0.00) were statistically significant risk factors related to aneurysm recurrence. An overall improvement in mRS was observed during the clinical follow-up period and no rebleeding episode occurred. CONCLUSION: This study demonstrated that endovascular treatment is an effective treatment modality for AcomA aneurysms with low morbidity. Patients should take long term clinical and angiographic follow-up in order to assess the recurrence and warrant retreatment, especially ruptured, large, and initially incomplete occluded aneurysms.

Percutaneous transluminal angioplasty and stenting for severe stenosis of the intracranial extradural internal carotid artery causing transient ischemic attack or minor stroke.

The purpose of this study is to assess the technical feasibility and clinical efficacy of percutaneous transluminal angioplasty and stenting (PTAS) for symptomatic stenosis of the intracranial extradural (petrous and cavernous) internal carotid artery (ICA).Review of medical records identified 26 consecutive patients who underwent PTAS using a balloon-expandable coronary stent (n = 15, 57.7%) or a Wingspan self-expandable stent (n = 11, 42.3%) for treatment of severe stenosis (>70%) involving the intracranial extradural ICA. The inclusion criteria were transient ischemic attack with an ABCD(2) score of ≥3 (n = 12, 46.2%) or minor stroke with an NIHSS score of ≤4 (n = 14, 53.8%). Technical success rates, complications, and angiographic and clinical outcomes were analyzed retrospectively.PTAS was technically successful in all patients. The mean stenosis ratio decreased from 77.1% to 10.0% immediately after PTAS. The overall incidence of procedural complications was 23.1%, and the postoperative permanent morbidity/mortality rate was 7.7%. A total of 22 patients were tracked over an average period of 29.9 months. During the observation period, 20 patients (90.9%) had no further cerebrovascular events and stroke recurrence occurred in two patients (9.1%), resulting in an annual stroke risk of 3.7%. Two cases (11.1%) of significant in-stent restenosis (>50%) were found on follow-up angiography (n = 18).PTAS for severe stenosis (>70%) involving the intracranial extradural ICA showed a good technical feasibility and favorable clinical outcome in patients with transient ischemic attack or minor stroke.

Pituitary apoplexy following mitral valvuloplasty.

Pituitary apoplexy is a rare but potentially life-threatening clinical syndrome caused by the sudden enlargement of a pituitary adenoma secondary to hemorrhage or infarction. Pituitary apoplexy after cardiac surgery is a very rare perioperative complication. Factors associated with open heart surgery that may lead to pituitary apoplexy include hemodynamic instability during cardiopulmonary bypass and systemic heparinization. We report a case of pituitary apoplexy after mitral valvuloplasty with cardiopulmonary bypass. After early pituitary tumor resection and hormonal replacement therapy, the patient made a full recovery.

Globus pallidus interna deep brain stimulation for chorea-acanthocytosis.

Chorea-acanthocytosis (ChAc) is a rare hereditary disorder characterized by involuntary choreiform movements and erythrocytic acanthocytosis. Pharmacotherapy for control of involuntary movements has generally been of limited benefit. Deep brain stimulation (DBS) has recently been used for treatment of some refractory cases of ChAc. We report here on the effect of bilateral high-frequency DBS of globus pallidus interna in a patient with ChAc.