Microsurgical Resection of Giant Radio-Induced Cavernous Malformation: 2- Dimensional Video.

Radioinduced cavernous malformations (RICMs) are low-flow, angiographically occult vascular lesions. Giant radioinduced cavernous malformations (GRICMs) are a subtype of RICMs that are characterized by their large size. GRICMs are defined as RICMs that are larger than 3 cm in diameter.1 They are uncommon conditions accounting for 0.1% to 0.5% among patients who have received radiation therapy for head and neck cancer or brain tumors.2,3 The risk of developing GRICMs increases with the dose of radiation received and the length of time since radiation exposure.4 Other factors that may increase the risk of developing GRICMs include age, genetic predisposition, and underlying medical conditions.5 Due to the relatively low incidence of GRICMs and the limited number of studies on this condition, there are limited data about the management of this condition. This case report describes a 12-year-old female who was previously treated for a pilocytic astrocytoma in 2012. After undergoing stereotactic biopsy and whole-brain radiotherapy (50 gray in 28 sections), she was diagnosed with a radioinduced cavernous malformation in 2016 during follow-up imaging. The RICM was managed conservatively with imaging follow-up, which showed no increase in size between 2016 and 2019. However, in 2020, the patient experienced a seizure episode associated with left-sided hemiplegia. Further investigation with cranial magnetic resonance imaging and digital subtraction angiography showed a mixed-intensity image and surrounded by a low signal intensity rim on T2-weighted images, representing hemosiderin in the right central lobe, with intense perilesional edema, with no enhancement. Given the size and location of the mass, the patient underwent microsurgical resection of the RICM (Video 1). The surgery was successful, and the lesion was successfully resected. This case highlights the importance of careful monitoring for RICMs in patients who have received radiation therapy, as well as the potential for these lesions to cause significant symptoms and disability. The case also demonstrates that surgical intervention may be necessary in some cases to manage RICMs and that microsurgical resection can be an effective treatment option. The patient gave informed consent for surgery and video recording.

Immunomodulatory response in an experimental model of brain death.

Liver transplantation has come a long way and is now regarded as the gold standard treatment for end-stage liver failure. The great majority of livers utilized in transplantation come from brain-dead donors. A broad inflammatory response characterizes BD, resulting in multiorgan damage. This process is primarily mediated by cytokines, which increase the immunogenicity of the graft. In male Lewis rats, we evaluated the immune response in a BD liver donor and compared it to that of a control group. We studied two groups: Control and BD (rats subjected to BD by increasing intracranial pressure). After the induction of BD, there was an intense rise in blood pressure followed by a fall. There were no significant differences observed between the groups. Blood tissue and hepatic tissue analyzes showed an increase in plasma concentrations of liver enzymes (AST, ALT, LDH and ALP), in addition to pro-inflammatory cytokines and macrophages in liver tissue in animals submitted to BD. The current study found that BD is a multifaceted process that elicits both a systemic immune response and a local inflammatory response in liver tissue. Our findings strongly suggested that the immunogenicity of plasma and liver increased with time following BD.

Morphologic Variations in the Circle of Willis as a Risk Factor for Aneurysm Rupture in the Anterior and Posterior Communicating Arteries.

BACKGROUND: Intracranial aneurysms are acquired abnormal vascular dilations. The most dangerous complication of a cerebral aneurysm is its rupture, with a high rate of mortality. This study aimed to determine whether there is an association between anatomic variations in the circle of Willis and ruptured aneurysms in the anterior and posterior communicating arteries. METHODS: A cross-sectional study of adult patients with a diagnosis of intracranial aneurysm was carried out between March 2015 and March 2019. The patients were divided into groups of ruptured or unruptured aneurysm in the anterior and posterior communicating arteries. RESULTS: A total of 132 patients with anterior and posterior communicating artery aneurysms were included. The presence of anatomic variation in the circle of Willis presented a statistically significant association with ruptured aneurysms (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.11-4.65; P = 0.024). There was a statistically significant difference between the presence of nonspherical aneurysm and rupture (OR, 6.9; 95% CI, 3.12-15.48; P < 0.0001). Multivariate logistic regression observed smoking (OR, 2.4; 95% CI, 1.01-5.9; P = 0.4), anterior complex variations (OR, 2.68; 95% CI, 1.01-7.18; P < 0.04), and nonspherical morphology (OR, 4.7; 95% CI, 1.93-11.45; P = 0.001) presented a statistically significant association with the rupture. CONCLUSIONS: Our results suggest that the studied variations of the circle of Willis and nonspherical morphology, in addition to playing a role in the development of cerebral aneurysms, may contribute to their rupture.

Central Nervous System Vasculitis for Cryptococcosis in an Immunocompetent Patient.

Cryptococcal meningitis is a life-threatening condition caused by a fungal pathogen, Cryptococcus neoformans, that can infect both immunosuppressed and immunocompetent hosts. It is an important cause of morbidity and mortality in severely immunodeficient patients. However, in an immunocompetent patient it represents a diagnostic challenge, mainly because it is extremely rare, but also because of its nonspecific clinical manifestation. Neurovascular involvement in cryptococcal meningitis is rare and not well known and only few reports have described this association. We describe a cryptococcal meningitis in an immunocompetent patient associated with central nervous system vasculitis.

[Pachymeningitis associated with IgG4 disease]. / Paquimeningitis asociada a enfermedad por IgG4.

Hypertrophic pachymeningitis is an infrequent disorder. It can be idiopathic or secondary to infectious, autoimmune or neoplastic disease. The recently described 〈IgG4-related disease〉 could be the origin of many cases considered cryptogenic. We present the case of a 60-year-old man, with a history of headache and episcleritis in both eyes, with partial response to corticoid therapy. The brain MR study with gadolinium showed enhancement and thickening of the dura mater, extending from lateral wall of left temporal and occipital lobes to ipsilateral tentorium. Meningeal biopsy showed fibrosis and lymphoplasmacytic infiltrate, with more than 10 IgG4+ plasma cells per high power field. After treatment with rituximab there was clinical improvement accompanied by the virtual disappearance of the alterations detected in neuroimaging. Hypertrophic pachymeningitis as a manifestation of IgG4-related disease can be based on MRI findings if plasma IgG4 are elevated.

Paquimeningitis asociada a enfermedad por IgG4 / Pachymeningitis associated with IgG4 disease

La paquimeningitis hipertrófica es una enfermedad infrecuente. Puede ser idiopática, secundaria a infección o enfermedad oncológica. Recientemente se la describió asociada a la enfermedad por IgG4, pudiendo ser esta la causa de muchas clasificadas como idiopáticas. Se presenta el caso de un hombre de 60 años de edad con historia de cefalea y epiescleritis, con respuesta parcial a corticoides. La resonancia magnética con contraste evidenciaba refuerzo meníngeo a nivel temporal y occipital izquierdo con extensión a la tienda del cerebelo. La biopsia meníngea demostró fibrosis e infiltrado linfoplasmocitario con más de 10 células plasmáticas IgG4 positivas por campo de gran aumento. El tratamiento con rituximab provocó mejoría clínica y radiológica. La paquimeningitis hipertrófica es una manifestación de la enfermedad por IgG4 y debe ser sospechada con la resonancia magnética y niveles plasmáticos altos de IgG4.

Hypertrophic pachymeningitis is an infrequent disorder. It can be idiopathic or secondary to infectious, autoimmune or neoplastic disease. The recently described ‹IgG4-related disease› could be the origin of many cases considered cryptogenic. We present the case of a 60-year-old man, with a history of headache and episcleritis in both eyes, with partial response to corticoid therapy. The brain MR study with gadolinium showed enhancement and thickening of the dura mater, extending from lateral wall of left temporal and occipital lobes to ipsilateral tentorium. Meningeal biopsy showed fibrosis and lymphoplasmacytic infiltrate, with more than 10 IgG4+ plasma cells per high power field. After treatment with rituximab there was clinical improvement accompanied by the virtual disappearance of the alterations detected in neuroimaging. Hypertrophic pachymeningitis as a manifestation of IgG4-related disease can be based on MRI findings if plasma IgG4 are elevated.