[Multiple cerebral tuberculomas presenting with paradoxical expansion: a case report].

A 24-year-old male presented with headache. He had been treated with antituberculous drugs for 19 months. MRI revealed 4 intracranial Gd-DTPA enhanced lesions surrounded by massive edema in the right frontal, both occipital and left basal ganglionic regions. Digital subtraction angiography showed no tumor stain. Two procedures for tumor resection were performed for the right frontal and left occipital regions, the latter of which definitively diagnosed by the polymerase chain reaction method. The tumors were well demarcated, showed a rough surface, and were elastically hard. The two residual lesions responded differently to chemotherapy. The lesion in the right occipital region decreased in size, while the other in the left basal ganglionic region continued to grow gradually 26 months after the antituberculous chemotherapy was started. According to previous reports, treatment should be continued for as long as 12-30 months in cases showing paradoxical expansion. In this case, the left basal ganglionic lesion began to decrease in size after 28 months of administration of anti-tuberculous drugs. We report successful treatment of a case of multiple tuberculomas presenting with paradoxical expansion managed by a combination of surgery and continuous chemotherapy.

Ganglion cyst in the ligamentum flavum of the cervical spine causing myelopathy: report of two cases.

BACKGROUND: Ganglion cyst in the ligamentum flavum is commonly found in the lower lumbar region; occurrence in the cervical region is extremely rare. We report two cases of ganglion cyst in the cervical region and the clinical, pathological, and radiological findings. METHODS: The first patient was an 81-year-old man who was admitted to our hospital with gradually progressive gait disturbance and radiating pain in both arms and legs, which was dominant on the left side. The second patient was a 65-year-old man with progressive muscle weakness of the extremities who was admitted with radiating pain in the right arm. In both cases, the cervical spinal cord had been compressed by the cystic mass with degeneration of the ligamentum flavum (the former left, the latter right) at the level of C3-4. RESULTS: The extradural-intraspinal cystic masses, which were revealed by computed tomography (CT) and magnetic resonance imaging (MRI) to be situated antero-laterally to the cervical laminae, were removed surgically without difficulty. After surgery, the symptoms and neurologic signs improved in both cases. CONCLUSIONS: Ganglion cyst in the ligamentum flavum of the cervical spine is a very rare lesion causing radiculo-myelopathy. In both our cases, a correct diagnosis could be established preoperatively based on CT myelogram and MRI findings, and the results of surgery were excellent.

Surgical approach to ossification of the thoracic yellow ligament.

BACKGROUND: Symptomatic ossification of the yellow ligament (OYL) at the lower thoracic level is uncommon. Although wide laminectomy has, until now, been the primary treatment for this disease, we propose a less invasive technique based on a new method of three-dimensional computed tomography (CT). METHODS: The clinical features and radiologic imaging findings of 37 patients with OYL (mean age, 54 years) were analyzed. The surgical approach was selected based on the position of the depicted OYL on 3D CT scan in each patient. RESULTS: The male-to-female ratio was 3:1. Involvement of the upper thoracic region was seen 11 times; of the middle region 8 times, and of the lower region 40 times (several patients had involvement in more than one region). About half of the patients complained of gait disturbance on admission caused by the markedly enlarged OYL. No postoperative complications were found. Neurologic deterioration was observed in only one patient. CONCLUSIONS: OYL should be treated as early as possible, using the least invasive technique available. By using 3D CT, we were able to perform limited surgery consisting of foraminotomy or extended partial laminectomy at the affected level after confirming the anatomic location of the OYL. In laterally extended OYL, it is necessary to decompress the radicular artery in order to prevent ischemic damage to the spinal cord.

Cervical intramedullary sarcoidosis.

Spinal cord involvement by sarcoid is quite rare. Only fourteen cases of histologically proven sarcoid without meningeal infiltration have been reported. We present the first CT scan description and the second description of the findings on MR imaging of intramedullary sarcoidosis. We also report successful surgical intervention in this case. In a review of surgical reports, we could find only 2 cases of improvement in symptoms after surgical intervention. Additionally, we stress the importance of early diagnosis using the various neuroradiological methods described. We feel that if surgery is performed at an early stage, it may be possible to obtain successful resection of the mass and a good clinical outcome.

Fibrous dysplasia of the cervical spine with atlanto-axial dislocation.

We report on a case of fibrous dysplasia of the cervical spine accompanied by atlanto-axial dislocation, a rare condition first reported by Stirrat. A 37-year-old man who had shown cervical myelopathy for about 6 months was diagnosed as having cervical fibrous dysplasia on the basis of plain x-ray and CT film findings. In addition, atlanto-axial dislocation, which was the apparent main cause of his symptoms, was also detected. We performed a successful two-stage operation from first the posterior and then the anterior approach. The possibility that grafted cancellous bone for anterior fusion may be replaced by dysraphic tissue in the presence of fibrous dysplasia was a complicating factor in this case.

Primary intracranial epidermoid carcinoma--case report.

A 38-year-old male who presented with trigeminal nerve paresis was found to have a cerebellopontine angle tumor. The tumor was subtotally removed. Multiple histological sections showed no malignant changes, and the diagnosis was typical epidermoid cyst. Tumor growth recurred twice and the diagnosis after the third operation was epidermoid carcinoma. A review of the available literature yielded only 22 reported cases of malignant intracranial epidermoid cyst.

[Spinal subarachnoid hemorrhage due to neurinoma of the cauda equina].

A case of neurinoma of the cauda equina which showed spinal subarachnoid hemorrhage was reported. A 39-year-old man was admitted to our hospital because of left lumboischialgia, on August 7, 1987. Myelography disclosed a round mass at L2, and cerebrospinal fluid was slightly xanthochromic. MRI demonstrated a round isointensity mass by T1 weighted image, and slightly high intensity by T2 weighted image. On August 26, 1987, the patient developed sudden onset of headache, but his headache disappeared under medication. On August 27, 1987, laminectomy L1-3 and total removal of the tumor were carried out. At operation, marked subarachnoid hemorrhage was discovered. He was discharged with slight hypesthesia of the dermatome of left S2.

The occurrence of different types of spinal tumours in one patient. A case report and review of the literature.

Three histologically different types of spinal tumours were found in a 16-year old girl. Each tumour was detected independently at a distant region. They were two intramedullary ependymomas at C3 and T2, two schwannomas at the C6 and C7 root, and one intradural meningioma at T7. All tumours were successfully removed by a two-stage operation without adding neurological deficits. In this paper the findings of metrizamide myelography, metrizamide CT, intravenous enhanced CT and MRI are presented. The application of these various neuroradiological methods made it possible to confirm the precise location and the nature of the tumour in order to operate safely.

[An extramedullary spinal cord tumor associated with syringomyelia: a case report].

A 53-year-old woman presenting weakness in the left hand for ten years was diagnosed seven years ago as having juvenile muscular atrophy of the unilateral upper extremity. Afterwards, her left forearm and hand gradually became weaker. A neurologist pointed out syringomyelia in the film of MR imaging. However, the cause of syringomyelia was not demonstrated until gadolinium-DTPA-enhanced MR imaging disclosed a spinal tumor. Through an operation it was found that it was an intradural extramedullary tumor at C7 level. Histological diagnosis of the tumor was meningioma. Only 12 reports of syringomyelia associated with extramedullary intraspinal tumors were found. Among them each tumor in three cases was diagnosed by delayed metrizamide computed tomography, only one case by MR imaging. Though in our case myelography, postmyelographic CT, intravenous enhanced CT and MR imaging were performed, gadolinium-DTPA-enhanced MR imaging was eventually most useful in diagnosing this tumor. The pathophysiologic mechanism by which the syrinx fills, and the differentiation in MR imaging between syrinx and tumor cyst were reviewed.

Idiopathic cervical arachnoid cyst. 3 case reports.

Three cases of cervical intradural arachnoid cysts of different forms are described in detail from the viewpoint of neuroradiological findings. In two patients the symptoms simulated juvenile muscle atrophy of unilateral upper extremity; the other case showed findings as in a tumour. It should be noted that in comparison with cysts at the thoracic level, cervical arachnoid cysts show various different neurological and neuroradiological findings. In this paper, some characteristics of cervical arachnoid cyst in myelography, CT and MRI are discussed, in addition to the neurological aspects.

[Spinal epidural meningioma--a case report with special reference to neuroradiological findings].

Spinal meningiomas are common as intradural-extramedullary neoplasm, but solitaly epidural spinal meningiomas are extremely rare. They may often be misdiagnosed as malignant neoplasms which are much more common in this location. Furthermore, at the time of operation, it is often difficult to distinguish the epidural meningioma from malignant tumors, even by the microscopic examination of the fresh frozen section. We present a case of spinal epidural meningioma, and emphasize the importance of preoperative neuroradiological examinations. A 26-year-old woman was referred to us from a neurologist of another hospital under the diagnosis of thoracic spinal tumor. She noticed sensory numbness in the lower extremities and thermal hypesthesia below the breasts about one year previously, and progressive gait disturbance about half a year prior to admission. Neurological examination revealed spastic paraparesis with hypesthesia of all modalities below T3. Plain films of the thoracic spine showed scalloping of the posterior margine of the T3 vertebral body. Metrizamide myelography showed a complete block at T3/4, and metrizamide CT revealed marked dural compression by an epidural mass which occupied the left side of the spinal canal from T2 to T4. The subarachnoid space all around the spinal cord was preserved comparatively well. The tumor was homogeneously enhanced by intravenous contrast enhanced CT scan, and the extracanalicular extension was not revealed. MRI [SE (400/25)] showed an iso-intensity signal tumor. Neither extracanalicular nor intrathecal extension of the tumor was showed. In addition to the possibility of the malignant tumors, we considered the possibility of spinal epidural meningioma. At operation, of highly vascularized, moderately firm epidural tumor was found invading the surrounding epidural fat.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical treatment of the herniated cervical disc--a consideration on the choice of operative method following our experience with 200 patients].

There is a controversy on the surgical treatment for the so-called cervical herniated disc. Recently operators choosing the anterior approach have increased in more and more. However, considering the historical view of the treatment of disc disease, it is obvious that the posterior approach is also an important method, especially in the cases combined with the stenotic cervical spinal canal. During the past five years 200 patients of cervical herniated disc disease were operated in our clinic by using our newly devised instruments and new materials. We studied the relation between the operative approach, the extent of interbody fusion and the surgical results. The social adaptation of the operated patients was also examined especially by comparing the short follow-up with the long one. Regardless of surgical approach, the percentage of the good recovery is higher (10% at the most) in the short follow-up than that in the long observation. The consequence is thought to show that the social adaptation deteriorates as the time goes on. Based on these results, the historical aspects and the technical problems of anterior and posterior approach were reviewed, focusing especially the controversial points. On the other hand, presenting our opinion on the surgical approach, we showed how the surgical problems have been solved and other complications lowered by introducing our new technique. Consequently, we stress that it is insignificant to discuss whether we should choose the anterior approach or the posterior approach. Finally, in case of criticizing the surgical results, it is reemphasized that we should think over not only the simple operative results, but also the aspect of social adaptation.

[Arachnoiditis ossificans after repeated myelographies and spinal operations--a case report and review of the literature].

A 58-year-old female was admitted because of lumbago and dysesthesia on the lateral aspect of the left leg. She had myelographies and spinal operations 4 years ago. Metrizamide myelogram on admission revealed the findings of adhesive arachnoiditis. During operation, four plaques involving the cauda equina were found, removed and histologically proved to be osseous tissue. In reviewing the previously published cases of arachnoiditis ossificans, it is divided into two forms. One is incidentally found in the arachnoid membrane at the time of an autopsy or spinal operation. The other is a progressive form causing impairment of the spinal cord and cauda equina. Compared with the former, the latter is extremely rare. At present, there appears to be a general agreement about the pathological process to ossification in the latter. The ossified plaque has its origin in meningothelial cell clumps located at the junction of the arachnoid sheet and the trabecula. The ossification occurs secondarily as a result of degenerative change in these clumps after myelography, spinal operation, subarachnoid hemorrhage, spinal trauma and spinal anesthesia. In our case, it is presumed that repeated spinal operations or myelographies played a role as a trigger toward ossification.

Extradural multiple spinal meningioma. Literature review a case report.

A case is reported of recurring or multiple spinal meningioma and focuses again on the incomplete information at present available regarding this class of meningioma. Repeated operations were performed earlier in the extradural space at C2 and an intradural tumour at the same level was completely removed. After a six year interval, we diagnosed an intramedullary meningioma once again at C2, which was subtotally removed. Histological examination indicated an angioblastic tumour, the same type of meningioma as was previously found. Postoperative recovery was satisfactory. Two years later, an intradural extramedullary tumour at T2-3 level was totally removed. Again postoperative recovery went well. In view of the rare occurrence of this meningioma, and the reports on it, we envisaged the pathogenesis of our case as an invasion from the extradural into the intradural space and into the spinal cord. Its appearance in the thoracic region might have been by dissemination via the cerebrospinal fluid pathways or it may have occurred independently.

[Spinal epidural malignant lymphoma--report of two cases and review of the literature].

Spinal epidural lymphoma is rarely found in Japan, comparing with Europe and America. We experienced two cases, who were suffered from intractable pain and gait disturbance. In both cases, a wide laminectomy and partial removal of the epidural tumor were performed because of the deteriorated paraparesis. After that, they were able to walk without support. These epidural tumors were supposed to be primary spinal epidural lymphomas, judging from the clinical course and some other examinations, that is, Gallium scintigram and CT scan, etc. There were few reports that mentioned CT findings of spinal lymphomas. In our two cases, we got the characteristic CT findings of spinal lymphomas. In case 1, plain CT demonstrated a high density mass at epidural space extending into the intra- and extra-foraminal region. CT scan following intravenous injection showed the tumor enhancement remarkably and homogeneously. Bone erosion was not found even on plain CT, in both cases. These findings were thought to be different from those of metastatic tumors. It may be possible to diagnose and decide the therapeutic planning preoperatively, when we get these characteristic CT findings of spinal lymphomas.

[Conjoined lumbosacral nerve roots--diagnosis by metrizamide myelography and metrizamide CT].

Several kinds of the lumbosacral nerve root anomalies have already been recognized, and the conjoined nerve roots is the most common among them. It does not make symptoms by itself, but if there is a causation of neural entrapment, for example, disc herniation, lateral recessus stenosis, spondylolisthesis, etc., so called "biradicular syndrome" should occur. Anomalies of the lumbosacral nerve roots, if not properly recognized, may lead to injury of these nerves during operation of the lumbar spine. Recently, the chance of finding these anomalous roots has been increased more and more with the use of metrizamide myelography and metrizamide CT, because of the improvement of the opacification of nerve roots. We describe the findings of the anomalous roots as revealed by these two methods. They demonstrate two nerve roots running parallel and the asymmetrical wide root sleeve. Under such circumstances, it is important to distinguish the anomalous roots from the normal ventral and dorsal roots.

[Neuroradiological evaluation of benign extramedullary tumors in the high cervical region and at the foramen magnum].

Twelve cases of benign extramedullary tumors in the high cervical region and at the foramen magnum were experienced during past five years among eighty all spinal and paraspinal tumors. The diagnosis of masses in this region is very difficult because of the variety of clinical course, symptoms and neurological findings as pointed out by many reporters. Also in our cases, 70% of the patients complained of the deteriorated motor weakness of the upper or lower extremities on admission, though they had noticed the onset of slight neck or occipital pain a few years ago. Neurological examination on admission clearly showed the symptom of myelopathy except in two cases with a tumor at the foramen magnum and C1 level. The percentage of positive findings of plain X-rays was 50%, that of metrizamide myelography was 92% and that of IV. e. CT and met. e. CT was 100%. NMR-CT was performed in 2 cases, and in one of them it was useful in confirming the tumor configuration and extension. Five interesting cases were described mainly from the neuroradiological aspects. Finally the differentiation between meningioma and neurinoma was discussed from the aspects of myelogram, CT and NMR-CT. As already pointed out, it is most important not to forget the existence of tumors in this region when one comes across the confused symptoms, afterwards not to overlook the slight positive neurological and neuroradiological findings.

Spinal haemangiolipoma. Three case reports.

Three cases of haemangiolipoma are described. Two of them were in the thoracic region and one in the lumbar region. All of them were subtotally removed, positively diagnosed histologically and good recovery was obtained. In reviewing 16 previous cases, the clinical characteristics, neurological features and neuroradiological findings were noted. Spinal extradural haemangiolipomas show a high incidence in middle-aged people and at the mid-thoracic level. Usually they show the signs of an extradural space-occupying lesion. Sometimes, worsening and improving are found particularly in female cases. Reviewing the existing literature, our diagnosis and procedures stress the importance of technical aspects in performing myelography and the findings of CT scanning.

Intrasacral perineurial cyst.

A rare case of intrasacral perineurial cyst is presented. Findings on metrizamide myelography and computed tomography scan are described, and their usefulness in the diagnosis of this rare condition is emphasized. The literature is reviewed, and the clinical and pathological features of the 17 reported cases including our own are summarized. Indication for operation and surgical approach are briefly discussed.

[Spinal intradural arachnoid cyst. Report of five cases and a review of the literature].

Five cases of intradural arachnoid cysts were reported. Two rare cases were in cervical region, other three cases in thoracic region. Clinical and radiological findings were discussed in 67 cases including ours. All our cases with chronic clinical course except one showing spastic para- or tetraparese, sensory disturbance and gait disturbances were not much different to other reported cases in neurological findings. Plain radiography, tomography and intravenous enhanced CT were not effective. In all of the cases spinal CT was performed following metrizamide myelography. Only one cyst failed to detect during metrizamide myelography, but a metrizamide CT revealed the intradural arachnoid cyst even in this case. Vonofakos says that metrizamide myelogram failed to found the arachnoid cysts, however, we could confirm them by performing metrizamide CT about 3 hours after conventional myelography. Moreover reconstruction technique was very effective in ascertaining the shape and the extention of the tumors. Especially it is recommended to do delayed metrizamide CT with ReView technique in order to show the detailed relation between the cyst and the spinal cord. In conclusion, we emphasize the accurate neurological examination, the importance of total myelography and the improvement of fluoroscopic technique in myelography and CT scanning.