Intracranial Undifferentiated Sarcoma Arising from a Low-Grade Glioma: A Case Report and Literature Review.

Undifferentiated sarcomas are rarely identified in the intracranial region. A 23-year-old man was admitted with a chief complaint of headache. Initial magnetic resonance images showed signs of low-grade glioma in the frontal lobe. Stereotactic biopsy was performed, and a diagnosis of diffuse astrocytoma was confirmed. Three months later, the patient presented with a high-grade tumor as seen on imaging studies. He underwent total resection of the tumor and histopathological tests identified an undifferentiated sarcoma. The patient died eight months later due to massive tumor bleeding. To the best of our knowledge, this is the first report of undifferentiated sarcoma arising from low-grade glioma without any chemotherapy or radiotherapy.

Radiological significance of ligamentum flavum hypertrophy in the occurrence of redundant nerve roots of central lumbar spinal stenosis.

OBJECTIVE: There were previous reports of redundant nerve roots (RNRs) focused on their clinical significance and pathogenesis. In this study, we investigated the significant radiologic findings that correlate with RNRs occurrence. These relations would provide an advanced clue for clinical significance and pathogenesis of RNRs. METHODS: Retrospective research was performed with data from 126 patients who underwent surgery for central lumbar spinal stenosis (LSS). Finally, 106 patients with common denominators (inter-observer accuracy : 84%) were included on this study. We divided the patients into two groups by MRI, patients with RNRs and those with no RNRs (NRNRs). Comparative analyses were performed with clinical and radiologic parameters. RESULTS: RNRs were found in 45 patients (42%) with central LSS. There were no statistically significant differences between the two groups in severity of symptoms. On the other hand, we found statistically significant differences in duration of symptom and number of level included (p<0.05). In the maximal stenotic level, ligamentum flavum (LF) thickness, LF cross-sectional area (CSA), dural sac CSA, and segmental angulation are significantly different in RNRs group compared to NRNRs group (p<0.05). CONCLUSION: RNRs patients showed clinically longer duration of symptoms and multiple levels included. We also confirmed that wide segmental angulation and LF hypertrophy play a major role of the development of RNRs in central LSS. Together, our results suggest that wide motion in long period contribute to LF hypertrophy, and it might be the key factor of RNRs formation in central LSS.

Brain abscess caused by Gemella morbillorum: case report and review of the literature.

We describe a rare case of cerebral abscess in an immunocompetent 67-year-old male with Gemella morbillorum as the causative agent. Gemella morbillorum is an aerobic gram positive coccus and is deemed to be a normal inhabitant of the oral cavity. The aim of this report is to introduce Gemella morbillorum as the emerging pathogen involved in brain abscesses. To the best of our knowledge only eight cases of Gemella morbillorum brain abscess have been reported in the literature. An exhaustive review of the literature is included with emphasis on the primary source of infection, clinical presentation, radiological diagnosis, and treatment modalities.

The angiogenic capacity from ligamentum flavum subsequent to inflammation: a critical component of the pathomechanism of hypertrophy.

STUDY DESIGN: In vitro study about angiogenic potentiality of ligamentum flavum (LF) cells using coculture of human lumbar LF cells and activated macropage-like THP-1 cells. OBJECTIVE: To test our hypothesis that activated LF, which was exposed to inflammation, induces angiogenesis, thus resulting in hypertrophy. SUMMARY OF BACKGROUND DATA: Inflammatory reactions after mechanical stress produce fibrosis and scarring of the LF that result in hypertrophy, a major pathological feature of spinal stenosis. This study evaluated the roles of LF cells in the pathomechanism of hypertrophy, focusing on angiogenesis. METHODS: To determine their response to the inflammatory reaction, human LF cells were cocultured with phorbol myristate acetate-stimulated macrophage-like THP-1 cells. The conditioned media were assayed for tumor necrosis factor (TNF)-α, interleukin (IL)-1ß, IL-6, IL-8, vascular endothelial growth factor (VEGF), and transforming growth factor (TGF)-ß1. Naïve and macrophage-exposed LF cells that responded to TNF-α/IL-1ß were compared using the same outcome measures. Hypertrophied LF tissue was stained by TGF-ß1 primary antibody using immunohistochemical method. RESULTS: Larger quantities of IL-6, IL-8, and VEGF were secreted by cocultured cells than by macrophages alone and LF cells alone combined. Prior macrophage exposure increased the secretion of IL-8 and VEGF in response to TNF-α/IL-1ß stimulation whereas IL-6 production was increased in response to IL-1ß. The coculture appeared to increase TGF-ß1 secretion but the level was lower than that for macrophage-like cells alone and LF cells alone combined. CONCLUSION: LF cells interact with macrophage-like cells to produce angiogenesis-related factors except TGF-ß1. Activated LF cells that have been exposed to macrophage, can impact the inducement of angiogenesis-related factors, suggesting that fibrosis and scarring during inflammatory reaction is the major pathomechanism of LF hypertrophy.

The effects of anterior cervical discectomy and fusion with stand-alone cages at two contiguous levels on cervical alignment and outcomes.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) using stand-alone cages is an effective method of treating degenerative disease. However, stand-alone cages are reported to have a relatively high incidence of implant subsidence with secondary kyphotic deformity particularly after multilevel ACDF. The purpose of our article was to investigate clinical and radiological outcomes after ACDF using stand-alone cages, at two contiguous levels, with a particular focus on changes in regional alignment and the correlation between alignment of the operated cervical levels and the entire cervical spine. METHODS: Twenty-seven patients with 54 levels and a mean age of 50.8 years were enrolled between January 2005 and August 2006. They underwent ACDF using polyetheretherketone cages packed with demineralized bone matrix without plate fixation at two contiguous levels. Mean follow-up period was 25.5 months (range, 13-60). Clinical outcome was evaluated using two Visual Analog Scales and the Neck Disability Index (NDI). We assessed fusion, regional alignment (RA) of the operated levels and cervical global alignment (GA) preoperatively in the immediate 1-week postoperative period and at the final follow-up. An interspinous distance ≥2 mm was used as an indicator of pseudoarthrosis at each level. FINDINGS: All patients showed improvements in clinical outcome, with 96% of patients showing mild NDI scores (<14). Radiological solid fusion was obtained at 48 of 54 levels (88.9%) and in 21 of 27 patients (77.8%). Lower cervical levels were significantly more vulnerable to pseudoarthrosis (100%). Fusion rate had no significant correlation with outcome (p > 0.05). RA of the operated levels was improved at the final follow-up compared with preoperatively in 76% of patients, although it had decreased compared with the immediate postoperative period due to subsidence in 84% of patients. In total, 80.8% of patients showed improvements in GA. Furthermore, improvements in RA showed a significant positive correlation with those in GA (p = 0.001), although improvement in RA and GA did not correlate significantly with clinical outcome (p > 0.05). CONCLUSIONS: Though some degree of subsidence occurred in most cases, RA had improved at the last follow-up compared with preoperatively, which contributed to the significant improvement in GA. However, improvement of RA and GA was not correlated with outcomes.

Adult cervical intramedullary teratoma: first reported immature case.

Intramedullary teratomas, particularly adult cervicothoracic lesions, are extremely rare. Up to now only 6 cases of intramedullary cervical teratomas have been reported in adults, and all of these were histologically mature. The authors present the case of a 35-year-old man with progressive myelopathic symptoms who was admitted through an outpatient clinic and was surgically treated. The characteristics, diagnosis, epidemiology, and treatment of cervical intramedullary teratomas in adults are also reviewed. Postoperative MR imaging showed that the tumor had been near totally removed, and severely adherent tissue remained ventrocranially with tiny focal enhancement on follow-up MR imaging. Pathological examinations revealed immature teratoma without any malignant component. Adjuvant therapy was not performed. Although no change in neurological findings and symptoms was apparent postoperatively, lesion regrowth was demonstrated on MR imaging 4 months after surgery. At 8 months postoperatively, myelopathic symptoms had developed and a huge intramedullary tumor recurred according to MR imaging. This case is the seventh reported instance of intramedullary cervical teratoma in an adult, and the first case report of the immature type with malignant features.

Cervical juxtafacet cyst with myelopathy due to postoperative instability. Case report.

A 74-year-old man presented with a cervical juxtafacet cyst on the right side of C5-6 and prominent myelopathy. He had been treated with anterior cervical discectomy and fusion at C4-5 as well as anterior foraminotomy of the right C5-6 lesion 20 months previously. The patient underwent complete surgical excision of the lesion. The patient recovered uneventfully, and the myelopathy resolved. Reexamination of the images revealed that we failed to investigate a suspicious minimal cervical juxtafacet cyst on the initial preoperative images and that the degree of subluxation at C5-6 on flexion radiography had increased postoperatively. Therefore, the surgeon should be aware that juxtafacet cyst can be progressive in planning of cervical spinal surgery which can cause or aggravate instability in the presence of an incidental, suspicious juxtafacet cyst on preoperative imaging at the same level, even if the lesion is very small and subclinical.

Spontaneous spinal epidural hematoma: an urgent complication of adding clopidogrel to aspirin therapy.

We report a 56-year-old patient who had been taking antihypertensive medication in combination with prophylactic aspirin for 19 years who was diagnosed with stable angina with significant coronary artery stenosis on angiography. He was treated with drug-eluting coronary stent placement. Clopidogrel was added to the previous treatment regimen after stent placement. He visited the emergency room with complaints of severe back pain accompanied by radiculopathy and left leg weakness. The patient had an excellent outcome after immediate diagnosis by MRI and emergent evacuation of spontaneous spinal epidural hematoma (SSEH). The present case is interesting because it is the first case in spine which corresponds to the findings of MATCH study that bleeding tendency would be raised by dual antiplatelet treatment (aspirin+clopidogrel). With the popularity of antiplatelet medications, physicians should be aware of this critical side effect and provide urgent treatment. Furthermore, we should be cautious when we prescribe clopidogrel in addition to aspirin because it could cause bleeding complications like SSEH.

Traumatic retroclival epidural hematoma in a child: case report.

An 11-year-old girl presented with a very rare traumatic retroclival epidural hematoma manifesting as bilateral abducens nerve palsy, deviation of the uvula to the left, and weakened movement of tongue, which developed after a motor vehicle accident. The patient was treated conservatively and showed good outcome. Retroclival hematoma is a mainly pediatric entity usually associated with ligamentous injury at the craniocervical junction, and can be treated conservatively with good outcome.

Surgical consideration of the intraspinal component in extradural dumbbell tumors.

BACKGROUND: The dumbbell tumor is considered a distinct group of tumors of the spinal nerve sheath owing to its intriguing clinical and radiological characteristics. More than half of dumbbell tumors are completely restricted to the extradural space, although preoperative MRI in some cases suggests the presence of intradural/extradural tumors. The aim of this retrospective investigation is to elucidate the clinical features and to suggest the surgical strategy to reduce the operating time and prevent additional complications in extradural type. METHODS: The medical records and radiological studies of 7 consecutive cases (4 male, 3 female, mean age 40.4 years) who underwent removal of the intraspinal component of their extradural dumbbell tumors between January 1996 and December 2005 were analyzed. Diagnosis and preoperative evaluation were performed with MRI and myelogram/CTs. RESULTS: The relationship of the tumor mass to dural sac in preoperative MRIs was so indistinct as to suggest an intradural mass in 5 cases. We found that extradural portion was covered with an attenuated dura and that the dural ring was invaginated into the intradural portion in these cases. Therefore, the author began with the epidural removal of the intraspinal and extraspinal component, followed by carefully extracting the intradural-like mass. CONCLUSIONS: In conclusion, we suggest that invagination of the dural ring is the anatomical feature that may be confused with an intradural/extradural tumor during operations for extradural dumbbell tumors. Initial epidural mass removal, extraction of intradural/extradural tumors subsequent to dural opening, and affirmation of presence of intradural tumor remnant could save time during dumbbell tumor surgery.

Intracranial recurrence of the scalp dermatofibrosarcoma.

We report a case of recurrent scalp dermatofibrosarcoma in a 30-year-old woman who underwent surgical intervention on three separate occasions during a 60-month period, and who received post-operative radiotherapy. A small, hard, elastic mass on the right parieto-occipital scalp was initially treated by simple resection in another clinic. Despite surgical intervention and radiotherapy, a recurrent tumor associated with infiltration to the calvarium was detected. The patient was then referred to our institution and a wide resection performed. Two years later, however, the patient was readmitted to our institution as a result of tumor recurrence with intracranial involvement. Scalp dermatofibrosarcoma is an uncommon but aggressive scalp tumor; therefore, wide local excision with good margins is essential to decrease the risk of regional recurrence. Close surveillance in these cases is necessary due to late tumor recurrences.

Internal carotid artery dorsal wall aneurysm with configurational change: Are they all false aneurysms?

BACKGROUND: Aneurysms arising from nonbranching sites of the ICA, so-called dorsal wall aneurysm, are rare entity, and present as blister type or saccular type. Occasionally configurational changes have been observed on serial cerebral angiography: a small blister-like bulge on ICA wall on initial angiography progressing to a saccular appearance within a few weeks. Such aneurysm showing configurational change has been regarded as a false aneurysm with fragile wall just like blister-type aneurysm, and direct surgical approach has been considered highly risky. CASE DESCRIPTION: A 42-year-old woman with a subarachnoid hemorrhage revealed small "blister-like" aneurysm at the medial wall of the ICA on initial angiography. After 12 days, the following angiograms demonstrated increased aneurysmal size and change of shape into a saccular configuration. Direct surgical approach was performed. The aneurysm had a relatively firm neck, and was successfully clipped without intraoperative rupture. The dome of aneurysm was resected after clipping and the histologic examination revealed it as a true aneurysm. CONCLUSIONS: This case suggests that all dorsal wall aneurysms with configurational change are not false aneurysms, and that angiographic findings do not always correlate with the nature of the aneurysmal wall; therefore, we should give more credence to direct surgical observation rather than preoperative angiographic findings when considering the most suitable surgical option.

Giant neurocysticercosis cyst in the cerebellar hemisphere.

A 67-year-old man presented with dizziness, nausea, and ataxia. Magnetic resonance imaging showed a large (5.5 x 4 x 4 cm) cystic lesion in the left cerebellar hemisphere with internal septation, a mural nodule, and thin rim enhancement. Cystic cerebellar tumor such as hemangioblastoma was initially suspected. Following surgery, the cyst was identified as cerebellar neurocysticercosis. Neurocysticercosis is the most common parasitic disease of the central nervous system but is occasionally misdiagnosed as tumor because of the varying neuroimaging presentation. This case shows that neurocysticercosis should be considered in the differential diagnosis of giant cystic lesions in the cerebellum as surgical intervention may be unnecessary.

DPCPX-resistant hypoxic synaptic depression in the CA1 region of hippocampal slices: possible role of intracellular accumulation of monocarboxylates.

Adenosine plays the principal role in synaptic depression during various energy-depleted conditions. However, additional inhibitory factors not associated with A1 adenosine receptors appear to be involved in hypoxic insults. Monocarboxylate accumulation and consequent acidic changes during hypoxia may be responsible for this remaining depression in synaptic activity. Field evoked potentials were recorded in the CA1 region of rat hippocampal slices. Preincubation with 8-cyclopentyl-1,3-dipropylxanthine (DPCPX) disclosed 43% of DPCPX-resistant synaptic depression (DRSD) during oxygen deprivation (OD). In contrast, no DRSD was detected in various conditions with limited glucose utilization, such as glucose deprivation and oxygen-glucose deprivation. Inhibition of anaerobic glycolysis (iodoacetate, sodium fluoride) abolished DRSD during OD, whereas blockade of monocarboxylate utilization with alpha-cyano-4-hydroxycinnamic acid (4-CIN) provoked DRSD in normoxic medium. These observations suggest that an intracellular accumulation of monocarboxylates is responsible for DRSD during hypoxia.

Transient recovery of synaptic transmission is related to rapid energy depletion during hypoxia.

Transient recovery (TR) of evoked synaptic potential during the late stage of hypoxic hypoglycemia (HH) insult was investigated in rat hippocampal slices using extracellular recording methods. TR was observed in association with a rapid deterioration of antidromic population spikes (aPSs) following HH insult. TR was not elicited in normoglycemic hypoxia (NH), in which a gradual and delayed deterioration of aPSs was noted. TR was not modulated by either Ca(2+)- or PKC-dependent processes. When a glycolytic inhibitor was added, NH resulted in a rapid deterioration of aPSs and prompted appearance of TR. TR was also seen in slices using lactate to generate energy via oxidative phosphorylation, when hypoxic conditions were subsequently created. Other pharmacological interventions that aimed to cause rapid deterioration of aPSs without depleting energy stores failed to reproduce TR. The evidence thus suggests that the underlying mechanisms of TR appearance during HH insult are highly correlated with rapid energy depletion.

C-1 root schwannoma with aggressive lateral mass invasion.

Schwannomas are relatively common, benign tumors that are thought to arise from the nerve sheath cell. Schwannomas of the C1 root are extremely rare and seldom invade lateral masses because they gradually increase in size and can extend through the wide space behind the lateral mass instead of the intervertebral foramen. We present here an unusual case of a benign schwannoma that aggressively invaded the lateral mass of C-1.

Microsurgical midline approach for the decompression of extraforaminal stenosis in L5-S1.

OBJECT: When performing surgery, the extraforaminal window is very narrow at the L5-S1 level. The authors describe a microsurgical method for decompression of the L-5 nerve root trapped between a marginal osteophyte of the vertebral body and the transverse process. The procedure was performed in 16 patients with extraforaminal stenosis. METHODS: The cranial part of the L5-S1 facet joint and the caudal portion of the pedicle and transverse process of L-5 were removed via a midline skin incision and partial resection of the pars interarticularis; a high-speed drill was used as was a surgical microscope. The affected nerve root was decompressed and mobilized cranially. Postoperatively all patients reported excellent relief of their sciatic pain, and there were no technique-associated complications. There was no recurrence during the follow-up period, that ranged from 14 to 70 months. CONCLUSIONS: The authors recommend this technique for the effective decompression of symptomatic extraforaminal L5-S1 stenosis. The need for a dangerous and tedious removal of the vertebral osteophyte together with spinal fusion is avoided.

Facet fusion in the lumbosacral spine: a 2-year follow-up study.

OBJECTIVE: A clinical and radiological follow-up study was undertaken to assess the safety, efficacy, and complication rate associated with instrumented facet fusion of the lumbar and lumbosacral spine. METHODS: This study involved 99 patients with degenerative lumbar disorders who were treated surgically at the authors' neurosurgical department and followed for more than 2 years. Eighty-two patients underwent one-level fusion for the treatment of Grade I or II degenerative spondylolisthesis and accompanying spinal canal stenosis (44 patients) or recurrent disc herniation (38 patients). Seventeen patients underwent two-level fusion for the treatment of either double instances of the above indications (seven patients) or concurrent stenosis at the adjacent level (10 patients). RESULTS: There were no technique-related complications. The overall 2-year success rate of fusion was 96%; the success rates by fusion type were 99% in one-level fusions and 88% in two-level fusions. Degenerative spondylolisthesis had the highest success rate at 100%, whereas the success rate in patients who had not responded to previous discectomy was 93%. Patients with concurrent stenosis experienced the lowest success rate: 80%. Excellent or good clinical results were obtained for 85% of patients with one-level fusions and for 65% of patients with two-level fusions. CONCLUSION: Instrumented facet fusion alone is a simple, safe, and effective surgical option for the treatment of patients with single-level disorders, especially patients with degenerative spondylolisthesis.

Oncocytic paraganglioma of the cauda equina in a child. Case report and review of the literature.

The authors report a case of oncocytic paraganglioma of the cauda equina in a 12-year-old girl who presented with lower back and leg pain on the right side of 6 months' duration. Magnetic resonance imaging revealed an ellipsoidal, intradural, extramedullary mass causing cord compression at the level of L1. Total laminectomy was performed on T12 and L1, and the tumor was excised completely without difficulty despite adherence of the tumor to the spinal cord. Postoperatively, the leg pain and motor weakness were much improved. The use of electron microscopy, and the immunohistochemical demonstration of synaptophysin in this tumor, allowed a confident diagnosis of an oncocytic paraganglioma to be made. To the authors' knowledge, this patient represents the first definite case of an oncocytic paraganglioma of the cauda equina in a child.