Extremely delayed renal cell carcinoma metastasis mimicking convexity meningioma.

Cerebral extra-axial metastasis mimicking meningioma which satisfy several criteria for a diagnosis of meningioma, but which have proved instead to be metastatic carcinoma and extremely delayed cerebral metastasis from renal cell carcinoma, form the focus of the presentation. 68-year-old-woman who had been operated for renal cell carcinoma 20 years previously is presented with new symptoms of intracranial mass. A large extra-axial mass of the convexity which destroyed calvarium and dura was excised with Simpson Grade I removal, revealed metastatic carcinoma. Imaging characteristics can not always discern between meningioma and metastatic tumours. A meticulous clinical evaluation and histopathological diagnosis is essential in patients with intracranial mass even when they resemble both primary and metastatic tumours.

Extremely delayed renal cell carcinoma metastasis mimicking convexitymeningioma

Cerebral extra-axial metastasis mimicking meningiomawhich satisfy several criteria for a diagnosisof meningioma, but which have proved instead to bemetastatic carcinoma and extremely delayed cerebralmetastasis from renal cell carcinoma form the focus ofthe presentation.68-year-old-woman who had been operated forrenal cell carcinoma 20 years previously is presentedwith new symptoms of intracranial mass. A large extraaxialmass of the convexity which destroyed calvariumand dura was excised with Simpson Grade I removal,revealed metastatic carcinoma.Imaging characteristics can not always discern betweenmeningioma and metastatic tumours. A meticulousclinical evaluation and histopathological diagnosisis essential in patients with intracranial mass even theyresemble both primary and metastatic tumours (AU)

Se presenta un caso de metástasis craneal extra-axial,que satisface varios criterios para el diagnóstico de meningioma,en el cual se demostró que se trataba de lametástasis tardía de un carcinoma renal.Una paciente de 61 años, que había sido operada deun carcinoma renal 20 años antes, se presentó con síntomasde un tumor cerebral. Se extirpó un gran tumorextra-axial de la convexidad, que destruía la bóvedacraneal y la duramadre, (Simpson grado I), pero quereveló se trataba de una metástasis.Las imágenes de estas característica no siempre pueden discernir entre un meningioma y una metástasis.Es esencial realizar una meticulosa valoraciónclínica y un diagnóstico histopatológico en pacientescon tumores intracraneales, aunque parezcan tumoresmetastáticos (AU)

Can facet joint infiltrative analgesia reduce postoperative pain in degenerative lumbar disc surgery?

OBJECTIVE: Perioperative analgesia effects the postoperative course of pain. The purpose of this study was to evaluate its possible relation with the consumption of dolantine and analgesics and the facet-induced pain and postoperative pain score in degenerative disc surgery. METHODS: We employed perioperative intra- and perifacet bupivacaine infiltration technique to reduce the postoperative pain after lumbar disc surgery. The study was randomized and observer blinded enrolling 40 American Society of Anesthesiologists physical status class I-II patients scheduled for elective degenerative lumbar disc surgery. The patients were divided into two groups of 20 of which Group 1 underwent injection of bupivacaine into the subcutaneous and muscular layers around the incision site, while Group 2 underwent additional intra- and perifacetal joint infiltration. Postoperatively, the patients were provided with a programmed patient-controlled pump which was only activated on demand to infuse dolantine for the next 24 hours. In the postanesthesia care unit the delay for analgesia and the dose of dolantine used were recorded. RESULTS: There was no statistical significance between these two groups regarding postoperative visual analoque scale scores. The time before the first analgesic request was significantly longer in facet group (p= 0,006). The cumulative dolantine dose was also significantly lower in the facet group (p= 0,001). CONCLUSION: The results indicate that facet joint infiltrative analgesia may have an effect on the postoperative analgesic requirement and reduce the dolantine consumption.

Can facet joint infiltrative analgesia reduce postoperative pain in degenerative lumbar disc surgery?

Objetivo. La analgesia peroperatoria influye en el curso del dolor postquirúrgico. El propósito del estudio reside en la evaluación de la posible relación entre el consumo de dolantina y otros analgésicos en el control del dolor postquirúrgico de origen facetario lumbar en la enfermedad discal degenerativa. Métodos. Empleamos peroperatoriamente infiltraciones percutáneas de bupivacaína intra y perifacetariapara reducir el dolor postoperartorio tras cirugía discal lumbar. El estudio fue randomizado y oculto al observador y se realizó sobre 40 pacientes operados de cirugía electiva por enfermedad degenerativa lumbar, con una situación general Clase I-II de la clasificación de la American Society of Anesthesiologist. Los pacientes se dividieron en dos grupos de 20 .El Grupo1 se le administró bupivacaína en el tejido subcutáneoy capas musculares. El grupo 2 recibió una inyección adicional de bupivacaína intra y perifacetaria. Durante el postoperatorio, los pacientes, dispusieron de una bomba programable de analgesia controlada, que se activó exclusivamente a demanda para infundir dolantina en las 24 horas siguientes a la operación. En la Unidad de Reanimación postquirúrgicas se recogieron las necesidades de dolantina de los distintos pacientes. Resultados. No se encontraron diferencias estadísticamente significativas entre ambos grupos en relación a los valores de la escala analógica visual. El tiempo de demanda del primer bolo analgésico fue significativamente mayor en el grupo de facetas infiltradas (p=0,006). La acumulación de las dosis de dolantina fue también significativamente inferior en el grupo de facetas infiltradas (p=0.001) Conclusión. Los resultados indican que la infiltración de la faceta articular con anestésico local puede tener un efecto positivo reduciendo las necesidades analgésicas postoperatorias de dolantina

Objective. Perioperative analgesia effects the postoperative course of pain. The purpose of this study was to evaluate its possible relation with the consumption of dolantine and analgesics and the facet-induced pain and postoperative pain score in degenerative disc surgery. Methods. We employed perioperative intra- and perifacet bupivacaine infiltration technique to reduce the postoperative pain after lumbar disc surgery. The study was randomized and observer blinded enrolling40 American Society of Anesthesiologists physical status class I-II patients scheduled for elective degenerative lumbar disc surgery. The patients were divided into two groups of 20 of which Group 1 underwent injection of bupivacaine into the subcutaneous and muscular layers around the incision site, while Group 2 underwent additional intra- and perifacetal joint infiltration. Postoperatively, the patients were provided with a programmed patient-controlled pump which was only activated on demand to infuse dolantine for the next 24 hours. In the postanesthesia care unit the delay for analgesia and the dose of dolantine used were recorded. Results. There was no statistical significance between these two groups regarding postoperative visual analoque scale scores. The time before the first analgesic request was significantly longer in facet group (p=0,006). The cumulative dolantine dose was also significantly lower in the facet group (p= 0,001). Conclusion. The results indicate that facet joint infiltrative analgesia may have an effect on the postoperative analgesic requirement and reduce the dolantine consumption

Late dissemination of ependymoma: case report.

Spinal cord dissemination over 10 years after surgical removal of the fourth ventricle ependymoma without local recurrence is extremely rare. A 49-year-old male underwent a macroscopically gross total removal of the fourth ventricle ependymoma and postoperative radiotherapy to the posterior fossa. Twelve years after the initial operation, the patient complained from uncontrolled fever attacks, low back pain and numbness of the legs. Spinal Magnetic Resonance Imaging revealed intradural extramedullary mass lesions located at the thoracic 2-3 and lumbar 5 vertebrae levels. Cerebrospinal fluid examination showed no tumour cells. He underwent total excision of these spinal lesions. Although the majority of the recurrences take place within a few years after surgery, we experienced a case with multiple spinal disseminations 12 years after the resection of the fourth ventricle ependymoma and administration of the radiation therapy to the posterior fossa. Up to our knowledge, this case represents the second unusual late recurrence reported in the literature. We conclude that low grade ependymomas should be followed neurologically and radiologically for more than 10 years after the initial treatment.

Late dissemination of ependymoma: case report

Spinal cord dissemination over 10 years after surgical removal of the fourth ventricle ependymoma without local recurrence is extremely rare. A 49-year-old maleunderwent a macroscopically gross total removal of the fourth ventricle ependymoma and postoperative radiotherapy to the posterior fossa. Twelve years after the initial operation, the patient complained from uncontrolled fever attacks, low back pain and numbness of the legs. Spinal Magnetic Resonance Imaging revealed intradural extramedullary mass lesions located at the thoracic 2-3 and lumbar 5 vertebrae levels. Cerebrospinal fluid examination showed no tumour cells. He underwent total excision of these spinal lesions. Although the majority of there currences take place within a few years after surgery, we experienced a case with multiple spinal disseminations12 years after the resection of the fourth ventricle ependymoma and administration of the radiation therapy to the posterior fossa. Up to our knowledge, this case represents the second unusual late recurrence reported in the literature. We conclude that low grade ependymomas should be followed neurologically and radiologically for more than10 years after the initial treatment

La diseminación raquídea, después de la extirpaciónquirúrgica de un ependimoma del cuarto ventrículo, sin recurrencia local, es muy rara. Un varón de 49 años fue intervenido de un ependimoma del IV ventrículo, con resección total y radioterapia postoperatoria de la fosa posterior. Doce años después de esta intervención, el paciente comenzó a quejarse de episodios febriles incontrolables, dolor lumbar y adormecimiento en las piernas. La resonancia magnética mostraba lesiones localizadas a la altura de la 2-3ª vértebra dorsal y de la L5. El líquido cefalorraquídeo no mostraba células tumorales. Fue operado de ambos tumores raquídeos, con resección total. Aunque la mayoría de las recurrencias tienen lugar en los primeros años después de la operación, hemos observado un caso con diseminación raquídea múltiple, después de la resección de un ependimoma del IV ventrículo y radioterapia de la fosa posterior. Que sepamos, este caso es el segundo de recurrencia tardía, publicado en la literatura. En conclusión, los ependimomas de bajo grado deben ser vigilados neurológica y radiológicamente durante más de diez años después del tratamiento inicial

Primary cranial vault lymphoma presenting as a traumatic subdural hematoma.

OBJECTIVE AND IMPORTANCE: The authors present a rare case of a primary cranial vault lymphoma, mimicking a subacute subdural hematoma after head trauma. CLINICAL PRESENTATION: A 78-year-old woman was admitted to the hospital with progressive left hemiparesis, headache and a gradually increasing soft lump over the right parietal region 1 week after head trauma due to falling from a high place. A computed tomography (CT) scan demonstrated a hyperdense parieto-occipital subdural and subgaleal lesion together with marked midline shift and white matter edema. INTERVENTION: Considering her trauma story and clinical progression, the patient underwent an emergency operation with the diagnosis of subdural hematoma. However, the lesion was found to be of a tumors nature and the histopathological diagnosis was high-grade malignant non-Hodgkin's lymphoma. CONCLUSION: The authors emphasize the rarity of primary cranial vault lymphoma and its importance in the differential diagnosis of cranial vault mass lesions extending either intra- or extracranially. This case may be considered as another example where magnetic resonance imaging (MRI) is the ultimate definitive test in the emergency ward whenever CT demonstrates any findings which are unclear.

Ceftriaxone-induced symptomatic pseudolithiasis mimicking ICP elevation.

In neurosurgery, ceftriaxone is a widely used, third generation cephalosporin for the treatment of CNS infections and perioperational prophylaxis. Recent studies have demonstrated that ceftriaxone induces reversible precipitates in the gallbladder. This complication is referred to as "biliary pseudolithiasis", and it has symptoms similar to the raised intracranial pressure (ICP) symptoms of the perioperative period. Symptomatic biliary pseudolithiasis should be kept in mind in all pediatric neurosurgery cases under ceftriaxone therapy in order to prevent unnecessary postoperative investigations and surgery.

Pott's puffy tumor of the vertex years after trauma in a diabetic patient: case report.

Pott's puffy tumor is a rare clinical entity characterized by subperiosteal abscess associated with osteomyelitis. It is usually seen as a complication of frontal sinusitis or trauma. This is the unique report of a Pott's puffy tumor located over the vertex of a type 1 diabetic patient with an unusual latency of 14 years following injury. A 27-year old man presented with pain and a soft swelling on his vertex. Magnetic resonance imaging demonstrated subperiosteal abscess in the vertex region associated with dural thickening and perisinusal irregularities of epidural space. Further history revealed that he had a trauma to the same location when he was 13 years old. Considering possible complications due to proximity of the lesion to the sagittal sinus, we retrained from aggressive surgical interventions. We treated our patient with a simple surgical abscess drainage followed by prolonged use of antibiotics and achieved complete therapy. The cellular and humoral elements of the immune system may be disrupted in diabetic patients resulting in such atypical courses and complications of infections. We want to emphasize both importance of the prompt diagnosis of Pott's puffy tumor as intracranial invasion may cause severe neurologic problems, and importance of a surgical intervention tailored for the individual lesion.

Pott’s puffy tumor of the vertex years after trauma in a diabetic patient: case report

El tumor “hinchado” de Pott es una entidad rara, caracterizada por un absceso subperióstico asociado a una osteomielitis. Se ve habitualmente como una complicación de sinusitis frontal o de un traumatismo. Esta es la única comunicación de un tumor hinchado de Pott localizado en el vértex craneal de un paciente diabético con una latencia, poco habitual, de 14 años. Se presenta el caso de un varón de 27 años con dolor e hinchazón en el vértex. La resonancia magnética demostró un absceso subperióstico en la región del vértex, asociado a un engrosamiento de la duramadre e irregularidades en torno al seno longitudinal superior, en el espacio epidural. En la historia posterior se recogió que había sufrido un traumatismo en la misma localización cuando tenía 13 años. Al considerar las posibles complicaciones, debido a la proximidad de la lesión al seno sagital, nos abstuvimos de un tratamiento quirúrgico muy agresivo. Tratamos al paciente con un drenaje simple del absceso, seguido de un tratamiento prolongado con antibióticos y se consiguió la curación completa. Los elementos celulares y humorales del sistema inmunológico pueden estar alterados en los pacientes diabéticos, lo cual da lugar a evoluciones atípicas y a complicaciones infecciosas. Queremos poner de relieve la importancia de un diagnóstico precoz de un absceso de Pott, puesto que la invasión intracraneal puede dar lugar a graves problemas neurológicos, y la importancia de una intervención quirúrgica adecuada a cada tipo de lesión

Pott’s puffy tumor is a rare clinical entity characterized by subperiosteal abscess associated with osteomyelitis. It is usually seen as a complication of frontal sinusitis or trauma. This is the unique report of a Pott’s puffy tumor located over the vertex of a type 1 diabetic patient with an unusual latency of 14 years following injury.A 27-year old man presented with pain and a soft swelling on his vertex. Magnetic resonance imaging demonstrated subperiosteal abscess in the vertex region associated with dural thickening and perisinusal irregularities of epidural space. Further history revealed that he had a trauma to the same location when he was 13 years old. Considering possible complications due to proximity of the lesion to the sagittal sinus, we retrained from aggressive surgical interventions. We treated our patient with a simple surgical abscess drainage followed by prolonged use of antibiotics and achieved complete therapy. The cellular and humoral elements of the immune system may be disrupted in diabetic patients resulting in such atypical courses and complications of infections. We want to emphasize both importance of the prompt diagnosis of Pott’s puffy tumor as intracranial invasion may cause severe neurologic problems, and importance of a surgical intervention tailored for the individual lesion

Spontaneous resolution of "protruded" lumbar discs.

Decreasing size of disc material that has herniated, whether "contained" or "protruded" has previously been described and sometimes this can be so complete that residual material is barely visible. In a retrospective clinical survey, from among almost 2180 consecutive patients admitted during 1994 - 2002 with low back pain; due to our low follow-up ratios and high price of the magnetic resonance imaging (MRI), only 42 patients with a lumbar disc protrusion could be found who had two MRI scans obtained at least five weeks apart. Among these, 4 patients were spotted with a totally resolved disc protrusion. T (2)-weighted MRI images were suggesting shrinkage due to dehydration and regression within the annulus of protruded disc fragments that had not fully migrated. Our patients are further examples for total resolution of the large "protruded" disc without any treatment; and since concomitant disc protrusions at other levels persisted, the resolution of these discs is supposed to be spontaneous.

Meningioma presenting with only urinary symptoms which is diagnosed by magnetic resonance imaging followed by urodynamic study.

Neurological tumour processes when involving bladder organs or innervations may give rise to urological symptoms. Depending on the organ or nerve tract affected, and emptying capacity of the bladder, the clinical signs manifested may be extremely varied, simulating different pathological entities that may lead to unnecessary treatment.

Abnormal bony protuberance of anterior atlas causing dysphagia. A rare congenital anomaly.

STUDY DESIGN: A Case report. OBJECTIVE: To report an exceedingly rare case of dysphagia caused by abnormal bony protuberance of anterior atlas. SETTING: Kocaeli University Faculty of Medicine, Departments of Neurosurgery and Otorhinolaryngology. METHOD: Radiological examinations revealed a large anterior abnormal bony tuberance of atlas in an 11-year-old boy who complained of dysphagia of 5 years donation. RESULT: The anterior bony tuberance of the atlas was resected by a transoral approach. Histopathological examination of the surgical specimens showed normal bone tissue. Resection resulted in complete resolution of the dysphagia. CONCLUSIONS: Dysphagia can be caused by disorders of the cervical spine. These disorders are usually seen in elderly adults. In the pediatric population, spinal abnormality is an exceedingly rare cause of dysphagia. Abnormal inductive signals from the adjacent notocord and ventral neural tube may play role in the pathogenesis of this abnormal bony protuberance.

Diagnostic value of bed-side ultrasonographic evaluation by anterior approach in spine disorders? A preliminary report.

A preliminary investigation was planned so as to evaluate the effectiveness of ultrasonography for bed- side evaluation of patients with suspected spinal pathology. Its application by anterior approach in 37 cases showed that herniated disc material, bone, epidural fat, scar tissue, tumoral masses and their relation to the interspace and dural sac could be visualized. A short description of the sonographic appearance of normal and pathological structures was also given in comparison to Computed Tomography or Magnetic Resonance images. Ultrasonographic examination was inadequate in five of the patients due to obesity, meteorism or diminution of the intervertebral disc space. Advantages of this technique are the availability almost in every hospital, the ease of obtaining images at various angles, avoiding the use of x-rays and the low price. The disadvantages are its relatively poor definition as compared to Computed Tomography or Magnetic Resonance Imaging and its inability to see through bone.

Utilidad diagnóstica de la ultrasonografía empleada en la cabecera del enfermo para evaluar la patología raquimedular por vía anterior / Diagnostic value of bed-side ultrasonographic evaluation by anterior approach in spine disorders? A preliminary report

Se propuso hacer una investigación para valorar la efectividad de la exploración de la patología espinal con ultrasonografía, en la propia cama del paciente. En una exploración por vía anterior, se estudiaron 37 pacientes y se pudo observar la hernia de disco, el hueso, la grasa epidural, tejido cicatricial, tumores y su relación con el saco dural y con el interespacio. Se hace una descripción somera del aspecto ecográfico, tanto de la imagen normal como de la patológica, comparándola con estudios de TAC o RM. El examen con ultrasonografía no fue fiable en cinco casos, debido a obesidad, meteorismo o disminución del espacio distal. Entre las ventajas de esta técnica destaca su disponibilidad en casi todos los hospitales, la posibilidad de obtener imágenes en cualquier ángulo, la ausencia de radiaciones y el bajo precio. Las desventajas son la definición pobre, en relación con la TAC y RM y la imposibilidad de obtener imágenes a través del hueso (AU)

Epipteric bones in the pterion may be a surgical pitfall.

BACKGROUND: The pterion, the most commonly used neurosurgical landmark, is defined as the junction of frontal, parietal, and greater wing of the sphenoid and the squamous part of temporal bones. Our aim was to identify the variations of the pterion which may be a potential surgical pitfall. METHODS: Both sides of 300 adult skulls were examined but 110 sides were eliminated since their pterion could not be identified owing to a damage. The shortest distance between the lateral orbital rim and the most anterior junction of the four bones forming the pterion was measured on all sides. RESULTS: Out of 490 sides the pterion was found to contain epipteric bones in 44 (9 %), and in these skulls the most anterior junction of the bones may be as close as 16 mm to the lateral orbital rim. CONCLUSION: In skulls with an epipteric bone variation, particularly the anterius and proprium types; the pterion can mistakenly be assessed to be at the most anterior junction of bones and a burr hole placed over there may cause inadvertent penetration into the orbit.

Parathyroid hormone-related protein and its receptor in human glial tumors.

OBJECTIVE: Parathyroid hormone-related protein (PTHrP) and its mRNA have been found to be expressed in a variety of human tumors including breast, prostate, colon, lung, renal and ovarian cancers. The purpose of this study is to evaluate the expression of PTH/PTHrP receptor and ligand in human glial tumors. METHODS: We examined the coexpression of PTH/PTHrP receptor and ligand in 73 glial tumors of different histological grades and 4 nonneoplastic human brain specimens and three glioblastoma cell lines, by using Western Blot analysis and immunohistochemical analysis. RESULTS: PTHrP and PTH/PTHrP receptors were shown in the neurons, reactive astrocytes and the endothelial cells of normal brain tissue as well as tumor cells, reactive astrocytes and vasculature of nonneoplastic tissue. They were expressed at higher levels in pure astrocytic tumors as compared to tumors with oligodendroglial components. CONCLUSION: PTH/PTHrP receptor and PTHrP ligand are co-expressed in human glial tumors. There increased expression suggests an autocrine and/or paracrine loop may exist.

Regulation of secretion of PTHrP by Ca(2+)-sensing receptor in human astrocytes, astrocytomas, and meningiomas.

Parathyroid hormone-related protein (PTHrP) is the major mediator of the humoral hypercalcemia of malignancy and of malignant osteolysis associated with skeletal metastases of common epithelial cancers. PTHrP secretion is regulated by the extracellular calcium concentration ([Ca(2+)](o)) in several types of normal and malignant cells. Because the [Ca(2+)](o)-sensing receptor (CaR) is a key mediator of [Ca(2+)](o)-regulated hormone secretion [e.g., of parathyroid hormone (PTH) by parathyroid chief cells], we investigated the expression of the CaR and PTHrP in normal and neoplastic glial cells and studied the effects of [Ca(2+)](o) on PTHrP secretion. Our results show that primary embryonic human astrocytes (HPA) express CaR mRNA and protein as detected by RT-PCR and Western analysis, respectively. Furthermore, astrocytomas and meningiomas also express the CaR at similar levels as assessed by RT-PCR and Northern and Western blot analyses. HPA and astrocytomas express transcripts encoding all three known isoforms of PTHrP [PTHrP(139), PTHrP(141), and PTHrP(173), comprising 139, 141, and 173 predicted amino acid residues, respectively] as assessed by RT-PCR, whereas meningiomas express only the first two of these. Finally, elevated levels of [Ca(2+)](o) and other polycationic CaR agonists dose dependently stimulate PTHrP secretion from HPA, astrocytomas, and meningiomas, although both basal and high [Ca(2+)](o)-stimulated rates of PTHrP secretion are approximately 2. 5-fold higher in HPA than in the glial tumors studied here. Therefore, our results show that HPA, astrocytomas, and meningiomas express both the CaR and PTHrP and that CaR agonists stimulate PTHrP secretion.

Growth rate of multiple intracranial hydatid cysts assessed by CT from the time of embolisation.

We report the case of a 25-year-old man with multiple bilateral hydatid cysts of the brain in whom we were able to assess the growth rate of the cysts on repeated examination. On average, the cysts increased in diameter by 1 cm per month.

Orbital hydatid cysts: report of four cases.

Hydatid cysts of central nervous system are rare and comprise only 2% to 3% of all hydatid cysts reported. Orbital localization is very uncommon and has been reported less than 1% of all hydatid diseases. The primary treatment of hydatid disease is surgical. The most important complication of the surgical treatment is secondary hydatidosis due to spillage of the cyst contents. Because of the difficulties of the orbital localization, total extirpation of the cysts without rupture is almost impossible. Preventing spontaneous rupture of the cysts during surgery and postoperative antihelmintic treatment should be taken into consideration in these cases. This study includes four cases who underwent surgery for orbital hydatid cysts. Radiological characteristics, operative technique and postoperative medical therapy are discussed.