Risk factors for the development of post-traumatic cerebral vasospasm.

BACKGROUND: Post-traumatic vasospasm is a well-recognized sequela of head injury. The risk factors associated with post-traumatic vasospasm have not been well defined. We studied 119 consecutive patients with head injury to determine the risk factors for post-traumatic vasospasm. METHODS: Twenty-nine (27.1%) patients were excluded from the study because of poor insonation (n = 12) or a hospital stay of less than 72 hours (n = 17). Seventy (77.8%) of 90 patients suffered severe head injury. Sixteen (17.8%) patients sustained moderate head injury and four (4.4%) patients sustained mild head injury. All patients were monitored with transcranial Doppler (TCD) ultrasonography daily. RESULTS: Post-traumatic vasospasm was detected in 32 (35.6%) of 90 patients. Among these patients, 29 (90.6%) had severe head injury, and three (9.4%) had moderate head injury. None of the patients with mild head injury suffered post-traumatic vasospasm. In most cases, the onset of post-traumatic vasospasm began on the fifth day and lasted 1 to 9 days. In 8 (25%) patients, post-traumatic vasospasm began within the first three days of the head injury. Among 32 patients with post-traumatic vasospasm, 10 (31.2%) patients had mild vasospasm, 20 (65.5%) had moderate vasospasm, and 2 (6.3%) had severe post-traumatic vasospasm. Clinical deterioration was documented in two (2.5%) patients. CONCLUSIONS: Development of post-traumatic vasospasm correlated only with severe subarachnoid hemorrhage on initial computed tomographic scan. There was an increased incidence of post-traumatic vasospasm in patients with epidural hematomas, subdural hematomas, and intracerebral hemorrhages. The Glasgow Coma Scale (GCS) score on admission was inversely related to the development of post-traumatic vasospasm. In most cases, the period of vasospasm was short and clinical deterioration was rare. Probably, two varieties of post-traumatic vasospasm exist, one that lasts a shorter time and does not correlate with the presence of SAH, and a second that correlates with the presence of SAH, lasts longer, and resembles aneurysmal vasospasm.

Sequential imaging and volumetric analysis of an intracerebral C6 glioma by means of a clinical MRI system.

In this study, using high resolution coils; implanted growing rat brain tumors were imaged sequentially with 3-D volume measurements generated by means of a clinical magnetic resonance imaging system (CMRI) and commercially available wrist coil. Ten female Sprague-Dawley rats were used, eight were implanted with C6 rat glioma cells and two served as controls. The images that were used for the three-dimensional (3-D) measurements were obtained from T1 weighted post contrast sequences. A commercially available computer work station with 3-D image analysis software was used to generate the tumor volumes. In addition to the rat studies a mouse was included to see if the resolution would be adequate for imaging very small brains. Six rats had brain tumor growth after transplantation and two rats did not have any tumor growth, however, their images were similar to the controls animals. Tumor volumes varied widely among the implanted rats. The number of implanted tumor cells had no direct relationship to developing tumor volumes. This study demonstrates that high resolution images of a rat brain tumor can be obtained from a CMRI system using a commercially available wrist coil which is capable of imaging two rats at the same time or even a mouse brain. A commercially available computer work station was able to generate the tumor volumes. The ability to image brain tumor and generate volume measurements over time has potential for animal research.

Hemangioblastoma of the filum terminale: case report.

OBJECTIVE AND IMPORTANCE: Tumors of the cauda equina and specifically the filum terminale are uncommon. We report the fourth case of a hemangioblastoma occurring in the filum terminale. CLINICAL PRESENTATION: This 35-year-old man presented with a 4-year history of low back pain that had been previously diagnosed as a bulging disc and exhibited severe pain in response to percussion of his lower back but was neurologically intact. He was found to have a large, enhancing mass filling the thecal sac at L2-L3. INTERVENTION: The tumor was found to be attached to the filum terminale and was cleanly dissected off en toto. Microscopically, the mass consisted of endothelial cells in addition to abundant fat-laden stromal cells and reticulum. CONCLUSION: We present a case report and a review of the literature. Our patient was the first to exhibit no radicular complaints. The diagnosis was delayed in all four cases and was not determined until the time of surgery. Complete excision offers the best chance for cure, and spinal angiography can aid in diagnosis. However, a high index of suspicion is needed for preoperative detection.

Solitary choroid plexus metastasis from a renal cell carcinoma.

Metastatic tumors to the choroid plexus are rare. We report a case of renal cell carcinoma metastasizing to the choroid plexus of the lateral ventricular atrium. This tumor was shown by magnetic resonance imaging, followed by craniotomy and histologic confirmation. Computed tomography of the abdomen showed the primary tumor. We also reviewed 40 years of the literature and found 14 cases of metastasis to the choroid plexus. We discuss the clinical features of this intraventricular metastasis.

Should endolymphatic sac tumors be considered part of the von Hippel-Lindau complex? Pathology case report.

OBJECTIVE: Von Hippel-Lindau (vHL) disease is an inherited disorder characterized by numerous cystic and solid neoplasms. Because of the recent identification of the vHL gene, other investigators have demonstrated genetic mutations in this gene in several of the neoplasms associated with the disease. We describe a patient with an endolymphatic sac (ELS) tumor and vHL disease. The purpose of this study was to identify a similar genetic mutation within the vHL gene of the ELS tumor. METHODS: Using the patient's archival pathological slides, neoplastic cells were microdissected to yield a purely neoplastic cell population. The deoxyribonucleic acid of these cells was then extracted and amplified via polymerase chain reaction. After sufficient amplification, the specimen was analyzed on a single-strand conformation polymorphism gel system to detect putative changes in the base sequence. RESULTS: Single-strand conformation polymorphism gel system analysis yielded two bands representing the two single strands of deoxyribonucleic acid that were amplified. The upper band of the specimen was shifted down (compared with controls), representing a conformational change as a result of genetic mutation. CONCLUSION: ELS tumors are uncommon, and, to our knowledge, only seven cases associated with vHL disease have been reported in the literature. Although this association has been previously mentioned, no definitive studies have linked the two together. We report the eighth case of ELS tumor and vHL disease. We have demonstrated through molecular biological techniques, that, in our patient's tumor, a genetic mutation occurred, and that this mutation is similar to mutations previously reported in other neoplasms associated with vHL. We therefore suggest that ELS tumors be considered among the neoplasms associated with vHL.

Three-dimensional reconstruction of melanotic neuroectodermal tumor of infancy involving the occipital bone and dura.

A rare case of melanotic neuroectodermal tumor of infancy involving the right occipital bone in an 11-month-old infant is described. The bone tumor and its dural extension were surgically removed. Three-dimensional reconstruction of the tumor and brain from neuroimaging data added worthwhile information for preoperative planning. Microscopic examination revealed melanotic and neuroblastic tissue in a fibrillary matrix involving the expanded bone and superficial dura. A focal osteoblastic cranial mass in an infant should alert the clinician to consider this tumor.

Successful surgical removal of an asymptomatic optic nerve hemangioblastoma in von Hippel-Lindau disease.

An asymptomatic patient with a family history of von Hippel-Lindau disease carried the abnormal gene for this disease. An imaging survey that consisted of computed tomography, magnetic resonance imaging, and cerebral angiography revealed an optic nerve hemangioblastoma. The potential for visual loss in the future was the indication for microsurgical intervention. This was the first asymptomatic optic nerve hemangioblastoma to be imaged and the first to be successfully removed without any permanent neurological deficits or vision loss.

Maffucci's Syndrome and Intracranial Chondrosarcoma.

Maffucci's syndrome is a rare, congenital mesenchymal dysplasia characterized by multiple enchondromata and hemangimata, both of which may undergo malignant degeneration. Intracranial involvement is uncommon. A literature review yielded only six cases of Maffucci's syndrome with intracranial chondrosarcoma and two cases of Ollier's disease (enchondromata alone) with intracranial chondrosarcoma. We report the seventh case of Maffucci's syndrome in a patient with a very large and extensive skull base chondrosarcoma requiring staged operations for removal.

Expanding cyst of the septum pellucidum. Case report.

Expanding cysts of the septum pellucidum, although rare, may be a cause of significant neurological dysfunction. Most become symptomatic as a result of obstruction of the interventricular foramina and produce headaches, papilledema, emesis, and loss of consciousness. Behavioral, autonomic, and sensorimotor symptoms occur when an expanding cyst impinges on the structures of the hypothalamoseptal triangle or impairs the deep cerebral venous drainage. Neuroophthalmological symptoms may develop as a consequence of hydrocephalus or direct compression of visual structures. The authors describe the case of a young boy with an expanding septum pellucidum cyst who presented with a sudden, severe headache and loss of consciousness. In addition, he had a history of hyperactivity and progressively declining school performance. All symptoms resolved following decompression of the cyst. Seventeen cases from the literature are reviewed. The pathophysiological mechanisms underlying the development of symptoms secondary to expanding septum pellucidum cysts are outlined, and the related clinical neuroanatomy is described. A model is proposed for the natural history of expanding septum pellucidum cysts that provides a rational basis for understanding their clinical behavior and response to intervention. In most cases, fenestration or shunting will relieve the obstructive hydrocephalus and mass effect caused by the cyst and will produce rapid symptomatic improvement.

Case report: CT and MRI of intracranial dermoid causing headache.

This case shows an unusual intracranial cause of chronic headache in a 30-year-old female. Computerized tomography and magnetic resonance imaging were used to demonstrate an intracranial, dermoid cyst located in the left middle cranial fossa. Droplets of fat-like material, which leaked from this cyst, were present in the basilar subarachnoid spaces and left sylvian fissure. Since the surgical excision of the cyst, the patient has not had any severe headaches.

Magnetic resonance imaging of massive intracranial invasion by an ethmoidal adenoid cystic carcinoma (cylindroma).

Magnetic resonance imaging showed a massive intracranial invasion by an adenoid cystic carcinoma (cylindroma) originating from an ethmoid sinus. The tumor was excised and follow-up radiation therapy was planned because of bone involvement and superficial invasion of the right olfactory tract area.

Moyamoya disease in an adult with Down syndrome: comparison of magnetic resonance angiography and conventional angiography.

Moyamoya disease, or idiopathic progressive arteriopathy, is a vascular occlusive disease that results in stenosis of the internal carotid arteries, stimulating the development of collaterals and telangiectatic vasculature from basilar and leptomeningeal arteries. Within the past several years, several reports have suggested that children with Down syndrome can develop moyamoya vasculopathy. We present the first reported magnetic resonance angiographic diagnosis of moyamoya disease in an adult with Down syndrome. This was also confirmed by conventional cerebral angiography.

Rhinocerebral mucormycosis in IDDM. Sequential magnetic resonance imaging of long-term survival with intensive therapy.

OBJECTIVE: To describe the clinical course and the utility of computerized tomography (CT) and magnetic resonance imaging (MRI) in the successful management of an often fatal fungal infection in a 12-year-old patient with insulin-dependent diabetes mellitus (IDDM). CASE: The patient was admitted to The University of Mississippi Medical Center (UMC) for the purpose of diabetic ketoacidosis (DKA) management and subsequent intensive therapy for mucormycosis according to nationally accepted standards of care. Strict diabetic control was instituted with frequent monitoring of blood glucose levels and interval assessment of HbA1c. Sequential MRI studies were obtained according to approved patient standards; the clinical and MRI course of the infection was charted. RESULTS: The patient's DKA resolved within 12 h on intravenous fluid repletion and insulin therapy. His sinusitis/rhinitis noted on admission did not respond to intravenous antibiotic therapy and progressed with obvious left orbital involvement and left cranial nerve palsies by 72 h of hospitalization. CT and MRI were invaluable aids to the early diagnosis and design of appropriate surgical and antifungal management of this patient, who survived with minimal left cranial nerve palsies. CONCLUSIONS: Our patient is among the youngest of IDDM patients reported to have survived rhinocerebral mucormycosis. His survival is attributed to early recognition of possible mucormycosis with diagnostic support of CT and MRI, surgical debridement and antifungal therapy, and intensive blood glucose control. Sequential MRI is invaluable to the design of therapy for this type of patient and shows the nearly 3-year recovery from mucormycosis.

Computed tomography and three-dimensional reconstruction in the evaluation of occipital condyle fracture.

Two cases of a rare Anderson type III occipital condyle fracture are presented. In any patient sustaining craniovertebral injury an occipital condyle fracture may be missed because plain films can be unremarkable. It is important to include computed tomography or coronal hypocycloidal tomography for all suspect cases of craniovertebral junction injury. Although three-dimensional reconstruction did not alter therapy for this injury, spatial localization of the fracture fragment was enhanced by this method. Serious neurological deficits are possible if this unusual injury is not treated.

Colonic filiform polyposis and a malignant adenomatous polyp.

We have reported a case of pseudopolyposis in the unusual form of filiform polyps in the transverse colon with an adenomatous polyp in the sigmoid colon that had a focus of malignant degeneration. The patient did not have any significant past history of inflammatory bowel disease.