Cerebral Vasospasm after Posterior Fossa Tumor Surgery: A Case Report and Literature Review.

INTRODUCTION: This report presents an unusual case of symptomatic vasospasm following resection of posterior fossa tumor in a 9-year-old female patient. To the best of our knowledge, only 6 pediatric cases of vasospasms as a complication of brain tumor surgery have been reported in the literature previously. CASE PRESENTATION: After an uneventful 12 days postoperatively, the patient suddenly presented with acute neurological deterioration on the 13th day and MR angiography showed bilateral narrowing of the supraclinoid segments of the internal carotid artery and the proximal parts of the A1 and M1 segments. Hypervolemia and vasospasm treatments were administered, and the patient exhibited no neurological deficit at the time of discharge, confirmed via normal MRI. CONCLUSION: Early diagnosis and intervention in case of suspected symptomatic cerebral vasospasm after pediatric posterior fossa tumor surgery are essential in order to achieve favorable outcomes.

Double challenge: cochlear implantation in the only hearing ear with progressive hearing loss following meningitis and vestibular dysfunction after implantation.

OBJECTIVE: Vestibular dysfunction associated with cochlear implantation is rare. It is usually seen in patients with otosclerosis due to spread of electrical activity throughout the demineralized bone. A 17-year old female with progressive hearing loss 2 years after meningitis and vestibular dysfunction in the implanted ear is presented in this study. FINDINGS: The patient had mild hearing loss in the right ear and total hearing loss on the left side because of complete ossification of the cochlea following meningitis. She had to have cochlear implantation in the right ear because of progression of hearing loss. She had successful implantation but she experienced vestibular dysfunction following activation of cochlear electrodes. Closure of two electrodes caused disruption of auditory programming. Then the patient was subjected to long term vestibular rehabilitation program. CONCLUSION: Timing for implantation before the completion of cochlear ossification is crucial not to miss the chance for hearing restoration. However, difficulties in hearing rehabilitation due to extensive ossification can be doubled by vestibular problems triggered by stimulation of the vestibular nerve by cochlear electrodes. Attempts to reduce the balance problem will complicate auditory programming. Vestibular rehabilitation for long term helps to carry on hearing progress.

An Interesting Unknown Combined Pathology in a Patient with Acute Balance Problem.

A 54-year-old woman with acute-onset nausea and vomiting presented to outpatient clinic. She had headache for 3 weeks. She had difficulty during tandem gait and was falling to the right. Otherwise, her neurological examination was normal. She had normal hearing. VNG analysis revealed spontaneous nystagmus beating to the left with optical fixation. However, she had horizontal and slightly down-beating gaze-evoked nystagmus at primary gaze position. Temporal bone CT and MRI showed widespread encephalitis of the right side of the brain and isolated destruction of the right superior semicircular canal. The patient was treated with high-dose combined antibiotics. She had remarkable recovery within 3 weeks.

The New Double-Layer Micromesh Stent (Roadsaver®): Use in Endovascular Treatment of Supraaortic and Visceral Artery Aneurysms and Pseudoaneurysms.

PURPOSE: This study was designed to present our preliminary experience with the Roadsaver® double-layer micromesh (DLM) stent in the endovascular treatment of supra-aortic and visceral aneurysms and to utilize the flow-diverting effect of this new design in the treatment of these aneurysms. METHODS: DLM stent (Roadsaver®, Terumo, Tokyo, Japan) was used in five patients (median age 61.8 years; three men) for treating arterial aneurysms (one common carotid artery, one vertebral artery V1 segment, one superior mesenteric artery, and two renal artery aneurysms). RESULTS: All stents were successfully deployed. Follow-up imaging with conventional catheter angiography or computed tomography showed successful treatment of all aneurysms. CONCLUSIONS: The new DLM stent appears to be promising for the treatment of supra-aortic and visceral aneurysms.

Intravascular Placement of Metallic Coils as Lung Tumor Markers for CyberKnife Stereotactic Radiation Therapy.

OBJECTIVE: To present our experience with placing endovascular coils in pulmonary arteries used as a fiducial marker for CyberKnife therapy and to describe the technical details and complications of the procedure. MATERIALS AND METHODS: Between June 2005 and September 2013, 163 patients with primary or secondary lung malignancies, referred for fiducial placement for stereotactic radiosurgery, were retrospectively reviewed. Fourteen patients (9 men, 5 women; mean age, 70 years) with a history of pneumonectomy (n = 3), lobectomy (n = 3) or with severe cardiopulmonary co-morbidity (n = 8) underwent coil (fiducial marker) placement. Pushable or detachable platinum micro coils (n = 49) 2-3 mm in size were inserted through coaxial microcatheters into a small distal pulmonary artery in the vicinity of the tumor under biplane angiography/fluoroscopy guidance. RESULTS: Forty nine coils with a median number of 3 coils per tumor were placed with a mean tumor-coil distance of 2.7 cm. Forty three (87.7%) of 49 coils were successfully used as fiducial markers. Two coils could not be used due to a larger tumor-coil distance (> 50 mm). Four coils were in an acceptable position but their non-coiling shape precluded tumor tracking for CyberKnife treatment. No major complications needing further medication other than nominal therapy, hospitalization more than one night or permanent adverse sequale were observed. CONCLUSION: Endovascular placement of coil as a fiducial marker is safe and feasible during CyberKnife therapy, and might be an option for the patients in which percutaneous transthoracic fiducial placement might be risky.

CT- and Fluoroscopy-Guided Percutaneous Transabdominal Embolization of Type II Endoleak.

We report a case of a 79-year-old male patient who was treated 3 years previously at another hospital for an abdominal aortic aneurysm with a maximal diameter of 80 mm. After the treatment control period, computed tomography imaging revealed a type II endoleak and no progression in the size of the aneurysm sac. Selective injection of the superior mesenteric artery revealed that the endoleak was filled by the inferior mesenteric artery via the marginal artery. However, it was not possible to access using retrograde catheterization. We decided to treat the type II endoleak percutaneously. Embolization was performed at the tomography table using fluoroscopy with a mobile C-arm, and the puncture was performed transabdominally because there was no access to the sac via a translumbar approach. Under fluoroscopic guidance, various diameter/length coils were deployed. Follow-up computed tomography scans confirmed the collapsed aneurysm sac. When other conventional endovascular methods have failed, percutaneous transabdominal treatment of a type II endoleak with sac enlargement offers an alternative treatment method.

Tumor-Cut: segmentation of brain tumors on contrast enhanced MR images for radiosurgery applications.

In this paper, we present a fast and robust practical tool for segmentation of solid tumors with minimal user interaction to assist clinicians and researchers in radiosurgery planning and assessment of the response to the therapy. Particularly, a cellular automata (CA) based seeded tumor segmentation method on contrast enhanced T1 weighted magnetic resonance (MR) images, which standardizes the volume of interest (VOI) and seed selection, is proposed. First, we establish the connection of the CA-based segmentation to the graph-theoretic methods to show that the iterative CA framework solves the shortest path problem. In that regard, we modify the state transition function of the CA to calculate the exact shortest path solution. Furthermore, a sensitivity parameter is introduced to adapt to the heterogeneous tumor segmentation problem, and an implicit level set surface is evolved on a tumor probability map constructed from CA states to impose spatial smoothness. Sufficient information to initialize the algorithm is gathered from the user simply by a line drawn on the maximum diameter of the tumor, in line with the clinical practice. Furthermore, an algorithm based on CA is presented to differentiate necrotic and enhancing tumor tissue content, which gains importance for a detailed assessment of radiation therapy response. Validation studies on both clinical and synthetic brain tumor datasets demonstrate 80%-90% overlap performance of the proposed algorithm with an emphasis on less sensitivity to seed initialization, robustness with respect to different and heterogeneous tumor types, and its efficiency in terms of computation time.

Emergence of a high-grade sarcoma in a recurrent meningioma: malignant progression or collision tumor?

Anaplastic meningiomas that resemble sarcomas often reveal clues to their meningothelial differentiation or develop in a plausible setting that confirms their meningothelial origin. Malignant mesenchymal neoplasms without obvious evidence of meningothelial differentiation or origin are more likely to be true primary or metastatic sarcomas. Because of their clinical and biological differences, it is important to distinguish anaplastic meningioma from a sarcoma. We present a 67-year-old woman with multiple meningiomas, who developed a high-grade spindle cell tumor 6 months after the resection of a World Health Organization grade I meningioma. It was not clear whether this tumor represented a malignant transformation of meningioma or a primary sarcoma. Malignant transformation of a meningioma is exceptional within this short period and a coexisting sarcoma and meningioma are equally uncommon. Even though these malignant neoplasms are rare in general, they appear to be more prevalent in patients with multiple meningiomas including those with neurofibromatosis type 2.

Treatment of lymphangioma of the face with intralesional bleomycin: case discussion and literature review.

Surgical treatment of lymphangioma of the face is a difficult task to achieve due to close vicinity of the lesion to the facial nerve and possibility of scar tissue formation. Inefficient surgical removals generally will give rise to high recurrence rates because of infiltrative and diffuse extension of the lesion. However, complete cure has been described by non-surgical methods. A 5-year-old girl with extensive lymphangioma of the left cervicofacial area was treated with intralesional bleomycin injection under ultrasonographic guidance. Case discussion and related literature review was presented.

[Early and late outcomes of carotid artery stenting]. / Karotis arter stentlerinin erken ve geç sonuçlari.

OBJECTIVE: Carotid artery stenting is a new approach alternative to surgical carotid endarterectomy. Cerebral protection devices improved the applicability of this technique. In this study, we evaluated applicability, safety and late clinical outcomes of percutaneous interventions for carotid artery stenosis. METHODS: A prospective study included 26 patients (15 female, 11 male, mean age 70+/-16 years) undergoing percutaneous transluminal angioplasty and stenting with different sizes of balloons and stents for 28 internal carotid artery stenoses at Kadir Has University Department of Interventional Radiology between March 2002 and December 2004. Ten patients were asymptomatic, one had amaurosis fugax, four had transient ischemic attack within last four months, one had drop attacks, one had headache, seven had the findings of hemiparesis and three had hemiplegia. RESULTS: Stenosis rates were calculated according to North America Symptomatic Carotid Endarterectomy Trial. Median stenosis rate was 85% (range: 60%-95%). All of the 28 internal carotid artery stenoses were managed with balloon dilatation and stenting (technical success rate 100%). Median residual stenosis rate after procedure was 14% (range: 0%-30%). Asystole developed in five patients and bradycardia in eight patients. Ipsilateral middle cerebral artery infarction occurred in two patients. One patient had intracranial reperfusion bleeding four hours after the procedure. No procedural death was observed within one month of follow-up. One patient died of myocardial infarction four months after the procedure. Cranial computed tomography revealed multiple metastases in one patient complaining of intractable headache and primary source was found to be pulmonary carcinoma. No stent restenosis was defined at Doppler ultrasonographic examinations performed 6 and 12 months after procedures with normal flow patterns and velocities. Two patients underwent control angiography at 12th month and myointimal proliferations with insignificant obstruction (25% and 30%) were detected. CONCLUSION: Carotid artery stenting seems to be applicable and safe procedure but it is associated with infrequent major complications. Results of studies comparing surgery and angioplasty will be helpful in defining role of stenting in the treatment of carotid occlusive disease.

Recurrent tuberculous pseudoaneurysm of the descending thoracic aorta--a case report.

Tuberculous pseudoaneurysm of the aorta is a rare disease that is uniformly fatal if not treated properly. The authors present a case of a recurrent tuberculous false aneurysm of the descending thoracic aorta that was treated surgically with excision and primary repair of the lesion. To their knowledge, this is the first reported case of recurrent disease after a successful surgical treatment.

Endovascular stent graft treatment in a patient with splenic artery aneurysm.

Splenic artery aneurysms are rare but important vascular lesions that constitute approximately 60% of all visceral arterial aneurysms. Splenic artery is the third most common localization of intraabdominal aneurysm formation. Rupture is the main complication that occurs in 3%-10% of the cases. We describe a case with a proximal splenic artery aneurysm. To preserve splenic function and reduce the risk of aneurysmal rupture, we used stent-graft to embolize the aneurysm treated percutaneously. The follow up of patient was uneventful after embolization. Endovascular embolization of the splenic artery aneurysm may prevent the need for emergency surgery and also offer an effective alternative surgical treatment.

Intrahepatic arterioportal fistula: demonstration by dynamic 3D magnetic resonance angiography in under four seconds.

We report a case of a 35-year-old patient with clinical symptoms of portal hypertension that underwent dynamic contrast-enhanced 3D magnetic resonance angiography (MRA) of the abdomen. On breath-hold dynamic contrast-enhanced MRA in less than 4 seconds, contrast passage from the arterial to the portal system was successfully demonstrated. Patient was managed according to MRA findings.

Primary epiploic appendagitis: MRI findings.

Primary epiploic appendagitis (PEA) occurs secondary to inflammation of an epiploic appendage, and is considered to be a rare cause of acute abdomen. In this case report, we describe the magnetic resonance imaging (MRI) findings of PEA correlated with computed tomographic (CT) findings. MRI findings included an oval shaped fat intensity mass with a central dot on T1- and T2-weighted images, which possessed an enhancing rim on postgadolinium T1-weighted fat saturated images. The lesion was best visualized on postcontrast T1-weighted fat saturated images. MRI findings of PEA should be considered in the differential diagnosis with the other causes of acute abdominal pain.