Reversible paraparesis due to extramedullary hematopoiesis.

Extramedullary hematopoiesis should be considered in the differential diagnosis of spastic paraplegia in a patient with thalassemia. Radiotherapy remains the treatment of choice, and regain of motor power is expected.

Posterior Reversible Encephalopathy Syndrome in a Patient with Hemorrhagic Fever with Renal Syndrome.

We presently report the case of hantavirus infection in a 45-year-old male who was hospitalized to our clinic of infectious diseases, with fever, myalgia, vomiting, nausea, headache, and abdominal pain. The physical findings included hepatomegaly, splenomegaly, rash, and conjunctival injection. Eight days before the start of complaints, the patient has cut trees in the mountain. An acute renal failure was observed with an oliguria and an increase of serum creatinine and blood urea nitrogen. Urinalysis shows albuminuria and hematuria. Elevations of amylase, lipase, and liver enzymes levels, low serum albumin level, and thrombocytopenia were observed. A positive ELISA test for hantavirus IgM/IgG antibodies confirmed hemorrhagic fever with renal syndrome. On the third day of hospitalization, the patient had seizures. The unenhanced head computed tomography (CT) performed after seizures showed subcortical bilateral hypodensities within frontal, parietal, and occipital regions corresponding to areas of increased signal intensity in magnetic resonance imaging (MRI) associated with cerebral edema in posterior reversible encephalopathy syndrome (PRES). The treatment consisted of supportive therapy. The patient underwent another head MRI with contrast enhancement after 2 months, which resulted normal.

Early reappearance of disappeared ruptured small aneurysm with concomitant vertebral artery dissection.

Thrombosis of a previously ruptured intracranial aneurysm is a frequent event and it most commonly occurs in large or giant aneurysms. We present a dynamic short-term follow-up and management of thrombosis in a ruptured small posterior inferior cerebellar artery aneurysm with concomitant vertebral artery dissection (VAD). Clinical and radiological follow-up findings and reviewed literature on thrombosis of small ruptured aneurysms are the focus of this presentation. Early reappearance of a disappeared ruptured small cerebral aneurysm with a concomitant VAD may be attributed to the controlled ovarian hyperstimulation phase of in vitro fertilization and prolonged use of oral contraceptive pills.

Right Hemispheric Leukoencephalopathy as an Incidental Finding Following a Lightning Strike.

BACKGROUND: Lightning injuries may produce a variety of medical conditions, and specific neurological complications have been identified, with the character of immediate aftershock effects or even long-term consequences. AIM: The authors describe the incidental finding following a routine unenhanced brain MRI performed to a young female patient, suffering from a headache. CASE REPORT: Diffuse white matter changes with the character of a leukoencephalopathy were seen, which strictly interested only the right cerebral hemisphere. The parents referred that she suffered from an indoor lightning strike at age of seven months, although she survived with almost no external burns or signs, and recovered uneventfully at that time. A discussion over the effects of electrocution and lightning strike on the human body in general, and over the nervous system, is made. Particular attention must be shown when making the differential diagnosis of leukoencephalopathies with a strictly one-hemisphere extension since several other conditions might resemble each other under the radiological aspect, here including brain viral infections, genetic disorders, and so on. CONCLUSION: The particularity of the long-term aftershock effects of the lightning strike on the central nervous system raise again the necessity of collecting data and duly reporting every electrical accident, lightning events included.

Cerebral proliferative angiopathy with tumor-like hemorrhage: A case report and literature review.

Cerebral proliferative angiopathy (CPA) is defined as a rare vascular disorder, characterized by diffuse arterial proliferation and distinctive angiogenetic features. Complication with hemorrhage is exceedingly rare, but once the bleeding occurs, the chance of re-bleeding is increased. Here we report a case of a patient with CPA complicated with bleeding and re-bleeding, and imaging findings mimicking a brain tumor, which has not been reported in the literature so far.

Kinetic evaluation of low-grade gliomas in adults before and after treatment with CCNU alone.

OBJECT: The aim of this study was to evaluate the impact of CCNU chemotherapy alone on low-grade glioma (LGG) growth dynamics. METHODS: The authors measured the evolution of the mean tumor diameter (MTD) in adult patients with LGG before (n=28 patients) and after (n=38 patients) CCNU administration. RESULTS: Natural (spontaneous) growth of LGG in the present study was 4.3 mm/year (range 2.1-6.6 mm/year). The median MTD decrease after CCNU was 5.1 mm/year (range 1-8.9 mm/year). MTD decrease was noted in 30 patients (late decrease in 4 patients, and ongoing decrease in 24 patients with oligodendroglial tumors and 2 with astrocytic tumors). The median duration it took for the MTD to decrease after initiation of CCNU treatment was 619 days (1038 days for oligodendroglial tumors vs 377 days for astrocytic tumors; p=0.003). CONCLUSIONS: These results show that CCNU as a single agent has a significant impact on LGG tumor growth. The impact of CCNU seems to be comparable to the previously reported impact of temozolomide therapy and of combined procarbazine, CCNU, and vincristine chemotherapy.

An unusual complication of atrial fibrillation ablation: case report.

The authors report a complication of catheter ablation that, to their knowledge, has never been previously reported. A 63-year-old man had undergone successful transvenous catheter thermoablation for atrial fibrillation. The patient remained well until 3 days prior to further admission when he noticed itching in the right frontal area of his scalp. On palpating his scalp, he discovered a metallic body projecting out of it and he proceeded to extract 20 cm of wire from his head. The following day a progressive left hemiplegia developed, and the patient experienced a deteriorating level of consciousness. A CT scan of the brain showed a right frontotemporal intraparenchymal hemorrhage and revealed a metallic structure in the middle of the hematoma. The hematoma was evacuated and a decompressive craniotomy was performed. The guidewire was identified, but it was only possible to extract part of it. It was covered by fibrous tissue, secondary to inflammatory reaction. To the authors' knowledge, this is the first report of guidewire-induced brain hemorrhage. The guidewire apparently had not been removed and had spontaneously migrated from the heart to the brain and beyond to the scalp where it then exited the patient's head. The patient had been well before he attempted to pull out the wire. Earlier identification of the iatrogenic complication of a retained guidewire might have prevented the fatal outcome in this case.

Bathing epilepsy: report of three caucasian cases.

INTRODUCTION: Bathing epilepsy is a specific type of reflex epilepsy triggered by domestic bathing in water. It is a geographically specific epilepsy syndrome that is more prevalent in India Cases in Caucasian population are very rarely reported. These cases share many similar clinical features and a similar prognosis to the Indian cases. CASE REPORT: We describe three cases of bathing epilepsy in Albanian population; two cases with well controlled seizures and one with drug-resistant seizures.

Saccular trilobed aneurysm of azygos anterior cerebral artery.

Multiple saccular or giant aneurysms of azygos anterior cerebral artery (AACA) at the distal segments A2-A5 are very rarely reported. Distal anterior cerebral artery (DACA) aneurysms represent approximately 2%-7% of all cerebral aneurysms. We present the case of an Albanian 62-year-old male, admitted at our service after sudden onset of severe headache and vomiting. Computerized tomography (CT) of the head showed hemorrhage in the front of corpus callosum. CT angiography followed by digitally subtracted angiography (DSA) documented a large necked aneurysm with three lobes at the origin of calloso-marginal artery and a single DACA, also known as AACA. A frontal parasagittal craniotomy was performed. Obliteration of the aneurysm was done only by separate clipping of each three lobes at the respective neck. Postoperative DSA demonstrated complete exclusion of the aneurysm and a regular flow of AACA. The patient recovered uneventfully. Despite it is a rare occurrence, an aneurysm of distal segments of anterior cerebral artery A2-A5, concomitant to AACA should be studied with DSA. In the era of embolization, conserving good microsurgical skills is fundamental for dealing with multilobar cerebral aneurysms, associated with rare anatomical variations.

Glioblastoma after AVM radiosurgery. Case report and review of the literature.

BACKGROUND: Stereotactic radiosurgery (SRS) is considered to be a relatively safe procedure in cerebral arteriovenous malformation management. There are very few reported cases of SRS-associated/induced malignancies. METHODS: We show the case of a 21-year-old female who presented with a 21-mm(3) ruptured AVM in the right mesial frontocallosal region. Embolization and/or radiosurgery was proposed. She preferred radiosurgery. The AVM was treated with CyberKnife(®) SRS. RESULTS: She presented behavior changes 6 years after SRS. MRI showed a right subcortical frontal lesion with increased perfusion, more consistent with high-grade glioma. The lesion's center was within the irradiated region of the previous SRS, having received an estimated radiation dose of 4 Gy. Pathological examination noted a hypercellular tumor showing astrocytic tumor cells with moderate pleomorphism in a fibrillary background, endothelial proliferation, and tumor necrosis surrounded by perinecrotic pseudopalisades. Numerous mitotic figures were seen. The appearances were those of glioblastoma, WHO grade IV, with neuronal differentiation. SRS-associated/-induced GBM after treatment of a large AM is exceptional. SRS-associated/-induced malignancies are mostly GBMs and occur on average after a latency of 9.4 years, within very low-dose peripheral regions as well as the full-dose regions; 33.3 % of patients were under 20 years at the time of SRS, and in 66 % the lesion treated was a vascular pathology. CONCLUSION: Although it is unlikely that the risk of radiation-induced cancer will change the current standard of practice, patients must be warned of this potential possibility before treatment.

The added value of bevacizumab concomitantly administered with carboplatin versus carboplatin alone in patients with recurrent glioblastomas.

AIMS AND BACKGROUND: Carboplatin (CBDCA) and bevacizumab (BEV) are active in glioblastoma (GBM) with different profiles of toxicity. To date, no study has compared the value of the addition of BEV to historical or traditional cytotoxic chemotherapy. We sought to determine the relative value of BEV in combination with CBDCA versus CBDCA alone in patients with recurrent GBM. METHODS AND STUDY DESIGN: Eligible patients with progressive GBM following surgery, radiotherapy and temozolomide received CBDCA either alone (group 1, n = 25) or in combination with BEV (group 2, n = 23) at 5 mg/kg once every 3 weeks between June 2010 and December 2013. Baseline characteristics and outcomes after treatment were recorded. The primary end points of this retrospective analysis were progression-free survival (PFS) and objective response rate. Secondary end points included safety and overall survival (OS). RESULTS: Forty-eight patients were enrolled. The median number of cycles was 4 in group 1 and 6 in group 2. No toxicities or intracerebral bleeding were observed. The objective response rate was higher in group 2 than group 1, 66% vs 24% (p = 0.003). The estimated median PFS and OS were 3.1 vs 6.7 months (p<0.0001) and 6.1 vs 8.6 months (p = 0.09) in group 1 vs group 2, respectively. CONCLUSIONS: The combination of BEV and CBDCA is associated with improved response rates and survival compared with CBDCA alone. These results highlight the value of BEV in recurrent GBM. However, the clinical benefit of this interesting approach needs validation in a larger patient cohort.

Platinum-based chemotherapy in recurrent high-grade glioma patients: retrospective study.

INTRODUCTION: To investigate the efficacy of platinum-based chemotherapy in patients with recurrent high-grade glioma (HGG) who had received previous alkylating line of chemotherapy. MATERIAL AND METHODS: Case notes of patients who had received chemotherapy with carboplatin or cysplatin for recurrent HGG between June 2006 and July 2012 were reviewed. Baseline characteristics and outcomes after treatment were recorded. RESULTS: Forty-eight patients received carboplatin/cysplatin as second line chemotherapy for recurrent HGG (grade III n = 6; grade IV n = 42). The median number of cycles completed was 4. Fifteen patients (28%) had at least minor response, 22 (49%) had stable disease and 11 (23%) had progressive disease. Six month progression-free survival was 30% (52% in patients with grade III glioma and 18% in patients with grade IV glioma). The median time to disease progression from the first treatment with platinum drug was 3.2 months. The median survival was 8 months (10 months for patients with grade III glioma and 7 months for patients with grade IV glioma). Among patients with either stable disease or a partial response, the median survival was 12 months compared with 3 months in patients with progressive disease. No survival or response rate differences were noted regarding the type of previous chemotherapy, nitrosoureas or temozolomide. CONCLUSIONS: Single-agent carboplatin/cysplatin has modest activity in patients with recurrent HGG previously treated with one line of chemotherapy, nitrosoureas or temozolomide. Despite the improvement of median survival of patients achieving stable disease or a partial response to treatment, more effective regimens are required for this patient population.

The role of computed tomography in detecting splenic arteriovenous fistula and concomitant atrial myxoma.

PATIENT: Female, 45 FINAL DIAGNOSIS: Arterio-venous fistula of the splean Symptoms: Lef-side abdominal pain Medication: - Clinical Procedure: - Specialty: Surgery. OBJECTIVE: Rare disease. BACKGROUND: Splenic arterial-venous fistula and atrial myxoma are not rare cases but the co-existence of both lesions in the same patient is unpublished so far. CASE REPORT: A 45- year-old woman presented with vague left flank pain. She was initially scanned by B-dimensional echography, which revealed multiple enlarged hypo-echoic lesions in the splenic hilum. To further characterize the lesion, we performed computed tomography angiography (CTA). CTA showed dilatation of the splenic artery, and aneurismal dilatation of the splenic vein, associated with early opacification of the portal system. CTA showed also an intrasplenic venous aneurism, which was presumed to be the site of fistulous communication. Celiac arteriography confirmed the CTA findings. A left atrial mass was detected by cardiac echography, which was evaluated better by CTA, and was consistent with atrial myxoma. The patient underwent open surgery in different stage with resection of the atrial mass and spleen. The postoperative period was uneventful. CONCLUSIONS: This is a unique case in the literature, showing the coexistence of a dual-pathology splenic arterial venous fistula and atrial myxoma.

Bevacizumab alone at 5 mg/kg in an every-3-week schedule for patients with recurrent glioblastomas: a single center experience.

The use of bevacizumab is increasingly reported in neuro-oncology. The most common schedule is 10 mg/kg every 2 weeks. We retrospectively investigated the efficacy of a 3-week schedule of 5 mg/kg bevacizumab in patients with recurrent glioblastomas. Fourteen patients (median age, 46 years) were included in the study. The median number of bevacizumab cycles was 4 (range, 2-8). Five patients (36%) had a partial response, 7 (50%) had stable disease, and 2 (14%) had progressive disease. No grade III-IV toxicities were observed. The median progression-free and overall survival were 3.6 months and 6.4 months, respectively. Every-3-week low-dose single-agent bevacizumab showed substantial activity and a safe profile in patients with recurrent glioblastoma.

Burr hole evacuation for infratentorial subdural empyema.

Infratentorial empyema is a life threatening condition and constitutes a neurosurgical emergency. Purulent mastoiditis and medial otitis is the most common origin and a thorough eradication of the purulent foci is mandatory. Decompression craniectomy has been primarily advised in the literature as the gold standard of the surgical treatment but burr hole evacuation when there the lack of cerebellar edema is less invasive and deemed equally efficient in the few reported cases. This is the report of a seventeen year old female who presented in a comatose state due to infratentorial empyema with acute hydrocephalus and who improved immediately after burr hole evacuation. Details of the surgical procedures are given. Mastoidectomy was completed, with the patient under combined antibiotherapy. She leads a normal life now, more than six years after surgery.

Visual and auditory hallucinations revealing cerebellar extraventricular neurocytoma: uncommon presentation for uncommon tumor in uncommon location.

OBJECTIVE: Visual and auditory hallucinations in relation to a cerebellar tumor are rarely reported in children. Primary origin of extraventricular neurocytoma (EVN) in the cerebellum is very rare. CLINICAL PRESENTATION: We report on a case of a cerebellar EVN in a 13-year-old girl with the initial symptoms of psychiatric manifestations for more than 2 months. Magnetic resonance imaging of the brain revealed a patchy enhanced tumor in the paramedian left cerebellar region. No obstructive hydrocephalus was noted. INTERVENTION: Total surgical removal of the tumor was performed. The tumor was initially diagnosed as an oligodendroglioma. After special immunohistochemical studies, the final definitive diagnosis was an EVN without isocitrate dehydrogenase mutation. CONCLUSION: EVNs located in the cerebellum are extremely rare. We discuss the clinical symptoms and histological-immunohistochemical features of this rare tumor in that rare location.

Saphenous neuropathy due to large hydatid cyst within long adductor muscle: case report and literature review.

An unusual case of saphenous neuropathy secondary to compression by a large hydatid cyst within the adductor longus muscle is reported. Solitary hydatid cyst(s) localized in the skeletal muscles occur rarely and often mimic soft tissue tumours. Presentation with signs of peripheral nerve compression by a hydatid cyst in an extremity is exceedingly rare. Diagnosis can be established by ultrasound, computerized tomography or magnetic resonance if clinically suspected. Clinical suspicion of hydatid origin of a solitary muscle cyst should be high especially in patients hailing from areas endemic for echinococcosis. Laboratory tests are usually unhelpful in such cases and needle biopsy carries the risk of anaphylactic shock and should therefore be avoided. Surgical removal of the unruptured cyst is the treatment of choice in cases of intramuscular hydatid cyst. In the present case, excision of the hydatid cyst was followed by complete clinical recovery. In the absence of systemic involvement, treatment with albendazole may be avoided.