An adult case of cerebral malakoplakia successfully cured by treatment with antibiotics, bethanechol and ascorbic acid.

Cerebral malakoplakia is a very rare chronic inflammatory disease. We herein report the case of a 49-year-old female who presented with a slowly progressive speech disturbance and right hemiparesis. Computed tomography and magnetic resonance imaging showed irregular enhanced mass lesions with numerous scattered areas of calcification in the left insula, thalamus and basal ganglia. Histopathologically, the biopsy specimen showed basophilic laminated inclusion bodies and intracellular and extracellular calculospherules, usually with a typical targetoid appearance (Michaelis-Gutmann bodies). Treatment with antibiotics, bethanechol and ascorbic acid improved her symptoms in association with a decrease in the abnormal calcification and enhancement. The cerebral malakoplakia mimicked a brain tumor in terms of the patient's clinical course and neuroradiological image findings; however, it was successfully cured with medical treatment. This case provides evidence that the pathogenesis of cerebral malakoplakia is deeply tied to bacterial infection and that medical treatment is effective in cases of this disease.

[Effect of Gorei-san with tranexamic acid for preventing recurrence of chronic subdural hematoma].

OBJECT: Chronic subdural hematoma is often seen in elderly patients. One burr hole surgery with subdural drainage has been performed and prognosis is good, but the recurrence rate is still about 10%. To prevent the recurrence, we used Kampo-medicine Gorei-san with tranexamic acid after surgery. The purpose of this study is to investigate if the recurrence is able to prevent by using these drugs. METHODS: From January 2008 to December 2010, 199 consecutive cases with chronic subdural hematoma were examined at Nagatomi Neurosurgical Hospital. Patients were divided into four groups according to the administered drugs; Gorei-san, tranexamic acid, Gorei-san with tranexamic acid and no drug groups. The recurrence rate was compared between each group. The chi-square test was performed as a statistical analysis. RESULTS: In all patients, the mean age was 77.7±10.5 years. There were 140 males and 59 females. Overall recurrence rate was 7.0%. Each recurrence rate was 8.3% in the Gorei-san administration group, and 10.9% in the tranexamic acid group, and 2.9% in Gorei-san with tranexamic acid group, and 5.7% in the no-drug group. There was no significant difference between the four groups in statistical analysis. CONCLUSIONS: Gorei-san with the tranexamic acid administration group had the minimum recurrence. There was no significant difference but these drugs would be preventable recurrence of chronic subdural hematoma. We need to accumulate more cases as a prospective study in the future.

Acute calcific prevertebral tendonitis mimicking tension-type headache.

A 74-year-old woman was admitted to our hospital due to severe nuchal pain and occipitalgia. Neurological examination found neck stiffness but no throat pain or dysphagia. Blood examination showed slight elevation of white blood cell count, but C-reactive protein level was normal. Cerebrospinal fluid examination found no abnormalities. Computed tomography (CT) and magnetic resonance (MR) imaging demonstrated no abnormalities in the brain. Cervical CT showed a small calcification in front of the C1 body. Cervical T(2)-weighted MR imaging showed a high intensity area in front of the upper cervical vertebral body from C1 to C4, suggesting inflammation of the longus colli muscles. We diagnosed acute calcific prevertebral tendonitis. She was administered nonsteroidal anti-inflammatory drugs. Her symptoms gradually improved and she was discharged without neurological deficit 8 days after admission. It is important to be aware of the possibility of this rare disease in a patient with severe occipitalgia but no sign of intracerebral lesion.

Ruptured anterior cerebral artery aneurysm at the origin of the accessory middle cerebral artery.

A 36-year-old female patient was admitted to our hospital with a rare case of aneurysm at the origin of the accessory middle cerebral artery (MCA) manifesting as severe headache and vomiting. Neurological examination did not detect any abnormalities or consciousness disturbance. Computed tomography demonstrated diffuse subarachnoid hemorrhage. Magnetic resonance angiography showed an aneurysm in the horizontal portion of the left anterior cerebral artery (A(1)). Digital subtraction angiography and three-dimensional digital subtraction angiography demonstrated a saccular aneurysm originating at the junction of the left A(1) and accessory MCA. Another accessory MCA originated at the proximal portion of the left A(2) without an aneurysm. Two accessory MCAs were found on the left. Neck clipping was performed via a left pterional approach. One month after admission, she was discharged without neurological deficits.

Severe postoperative vasculitis of the central nervous system in a child with arteriovenous malformation: case report.

BACKGROUND: Cerebral vasculitis is very rare complication after craniotomy. We report a case and discuss the etiology, diagnosis, and treatment of this complication. CASE DESCRIPTION: A 12-year-old boy was admitted because of a consciousness disturbance due to a ruptured AVM. Computed tomography revealed a left parietal subcortical hematoma. No apparent nidus was detected on the angiography findings, but AVM was suspected. After resection of the hematoma, the patient did not recover consciousness, and his high fever continued. Despite postoperative induced hypothermia, progressive multiple cerebral infarctions occurred. Postoperative angiography showed multiple arterial narrowing, and a "string of beads" phenomenon was observed in the anterior and posterior circulation in addition to the residual AVM. After administering steroid therapy, he recovered consciousness, but had a severe disability. After angiography, which was performed 1 year after onset, an improvement of the vasculitis and the complete occlusion of AVM were observed. CONCLUSION: We should therefore include cerebral vasculitis in the differential diagnosis when encountering a case with an unusual progressive stroke because a timely diagnosis and aggressive treatment are of critical importance for a successful recovery in such patients.

Unique infiltrating morphology of a meningioma-a case report.

BACKGROUND: We report on the case of a patient with meningioma that was correctly identified through biopsy. CASE DESCRIPTION: A 69-year-old woman presented with slight headache and was then examined at our hospital. Neurologic and physical examinations found no abnormality. Magnetic resonance imaging demonstrated a well-enhanced huge, dural-based, and plaque-like mass extending throughout the parietooccipital convexity and the posterior fossa. Tumors pressed the adjacent brain cortex while extending along the Virchow-Robin space. A CT scan also showed hyperostosis on the parietooccipital bone. Angiography demonstrated a vascular blush that appeared to be of a tumor-like shape. A biopsy was performed to confirm the diagnosis. The histologic findings demonstrated meningothelial meningioma with infiltration into the Virchow-Robin space. CONCLUSIONS: Many radiographic patterns of meningioma have been reported, but the present case is quite rare. The radiographic and pathologic findings in our patient are discussed.

Difficulty in diagnosing a case with apparent sequel cerebral sparganosis.

BACKGROUND: We report on a case of cerebral sparganosis that was correctly identified by a biopsy 10 years after the initial infection. CASE DESCRIPTION: A 62-year-old man presented with an unusual case of cerebral sparganosis mansoni. He was admitted to our hospital for removal of a right frontal meningioma. Computed tomographic scan and MRI of the brain showed atrophy of the left cerebral hemisphere, enlargement of the lateral ventricle, and several small ring-enhanced lesions in the left frontal lobe. The patient had suffered from motor aphasia and right hemiparesis for 10 years; in addition, he had been treated for cerebral infarction. We performed a left frontal biopsy, during which we also removed the meningioma. The histologic diagnosis was cerebral sparganosis mansoni. CONCLUSIONS: The follow-up CT findings after the patient's first attack were thought to be characteristic of cerebral sparganosis mansoni. However, the radiographic findings were difficult to differentiate from those of neoplasias.

Stereotactic radiosurgery for aggressive papillary tumor of the temporal bone: case report.

BACKGROUND: Papillary tumors of the temporal bone are very rare neoplasms that show locally aggressive behavior though they have low-grade histologic features. The best treatment for these tumors is a radical resection. However, if the tumor is very large, local invasiveness and hypervascularity can prevent surgeons from achieving a complete resection. As an additional treatment for the residual tumor, it remains controversial whether radiation therapy has any role. CASE DESCRIPTION: The authors describe a 53-year-old woman who suffered from left-sided tinnitus, hearing loss, and diplopia due to a large aggressive papillary tumor of the temporal bone. Radiosurgery was very effective for the tumor, which had regrown a few years after conventional radiation therapy and chemotherapy. CONCLUSIONS: The authors conclude that radiosurgery should be considered as an option for the treatment of aggressive papillary tumor of the temporal bone.

Sleep cycle in patients in a state of permanent unconsciousness.

Since the recent diagnostic criteria for persistent vegetative state (PVS) require the presence of a sleep-wake cycle, certain patients in similar conditions should be excluded from PVS. Since the diagnosis of PVS might correlate with legal issues, an accurate definition is necessary. To clarify the clinical significance of a sleep-wake cycle, 12 patients in a state of permanent unconsciousness after brain damage were clinically and electrophysiologically reviewed. In addition to routine EEG, evoked potentials and MRI, the simultaneous recordings of EEG and patients by videotape were performed for 24 hours. Four patients who showed severe brain stem damage did not show a sleep-wake cycle. In the other eight patients, a sleep-wake cycle was observed. However, among these patients there was no obvious difference in their clinical status. Although these data suggest that the presence of a sleep-wake cycle might reflect the brain stem damage, it is considered that the presence of a sleep-wake cycle might be unnecessary for the diagnostic criteria for PVS. Further study of various forms of brain damage will provide better understanding of the significance of the presence of a sleep-wake cycle.