Prognostic factors following resection of intracranial metastases.

Background: The aim of this study was to identify prognostic factors associated with resection of intracranial metastases. Methods: A retrospective case series including patients who underwent resection of cranial metastases from March 2014 to April 2021 at a single center. This identified 112 patients who underwent 124 resections. The median age was 65 years old (24-84) and the most frequent primary cancers were nonsmall cell lung cancer (56%), breast adenocarcinoma (13%), melanoma (6%), and colorectal adenocarcinoma (6%). Postoperative MRI with contrast was performed within 48 hours in 56% of patients and radiation treatment was administered in 41%. GraphPad Prism 9.2.0 was used for the survival analysis. Results: At the time of data collection, 23% were still alive with a median follow-up of 1070 days (68-2484). The 30- and 90-day, and 1- and 5-year overall survival rates were 93%, 83%, 35%, and 17%, respectively. The most common causes of death within 90 days were as follows: unknown (32%), systemic or intracranial disease progression (26%), and pneumonia (21%). Age and extent of neurosurgical resection were associated with overall survival (P < 0.05). Patients aged >70 had a median survival of 5.4 months compared with 9.7, 11.4, and 11.4 for patients <50, 50-59, and 60-69, respectively. Gross-total resection achieved an overall survival of 11.8 months whereas sub-total, debulking, and unclear extent of resection led to a median survival of 5.7, 7.0, and 9.0 months, respectively. Conclusion: Age and extent of resection are potential predictors of long-term survival.

A Rare Case of Spinal Mastocytosis Presenting as an Extradural Mass.

BACKGROUND: Systemic mastocytosis is a hematopoietic disorder of mast cell deposits in various systemic tissues that can include skin, spleen, liver, and bone marrow. When accumulation occurs within bone it has been reported to cause osteoporosis, osteosclerosis, or sometimes a mixed pattern. In exceptionally rare circumstances, it has been reported to present as an exophytic mass causing neural compression. CASE DESCRIPTION: A 72-year-old man was admitted with progressive worsening in his mobility and heavy and numb sensation in his bilateral lower limbs that worsened on walking. His weakness subsequently progressed such that he was no longer able to mobilize for 48 hours prior to admission. On examination he was found to be myelopathic with a sensory level noted at approximately the T10/11 area. Whole spine magnetic resonance imaging was conducted, which revealed a heterogeneous lesion involving the vertebral body and posterior elements of T10. The patient underwent T9-T11 laminecetomy with intralesional debulking of metastatic spinal column tumor. Postoperatively, the patient was noted to have improved anti-gravity power in the lower limbs. Intraoperative biopsy samples revealed focal paratrabecular infiltrates of abnormal mast cells with collagen fibrosis and focal bone destruction, along with cytogenetic features in keeping with systemic mastocytosis. CONCLUSIONS: We describe a rare case of systemic mastocytosis presenting as an extradural lesion causing compressive myelopathy and paraparesis. To our knowledge, this has only been described once before in literature. The patient underwent decompression surgery with improvement in neurology postoperatively. He was subsequently referred to the hematology team for further investigation and management.

Management of Concomitant Moyamoya Disease, Arterial Venous Malformation, and Intracranial Aneurysm: Case Illustration, Literature Review, and Management Algorithm.

BACKGROUND: Moyamoya disease (MMD), arterial venous malformations (AVMs), and intracranial aneurysms are distinct cerebrovascular disease processes that most commonly occur in isolation. The literature on the treatment algorithm of each individual condition is well established. An association between MMD and intracranial aneurysms is also known, but MMD in association with AVM is rare. CASE DESCRIPTIONS: The authors discuss various dilemmas in the multimodality management of these conditions when they coexist with an illustrative case of a 46-year-old woman who presented following a stroke, with 1) left-sided MMD, 2) left-sided frontal AVM, and 3) an aneurysm arising from the A1 segment of the right anterior cerebral artery. These were managed respectively by 1) the left external carotid artery to M2 segment of middle cerebral artery bypass using an autologous radial artery graft and left indirect superior temporal artery-encephaloduroarteriosynangiosis, 2) stereotactic radiosurgery, and 3) endovascular coiling of the aneurysm. Three years following intervention, cerebral angiography showed a patent bypass, complete obliteration of the AVM, and no residual filling of the coiled aneurysm. CONCLUSIONS: Our strategy of surgical revascularization for MMD, radiosurgery for AVM, and endovascular coiling for aneurysm resulted in a positive long-term clinical outcome. In view of the rarity of the condition, the authors propose a management algorithm for such patients.

A Rare Case of Concurrent Herpes Simplex Encephalitis and Glioblastoma Multiforme.

Herpes encephalitis superimposed on an intracranial malignancy has previously been described mainly in the context of malignancy imitating infection or in the postoperative setting after neurosurgical intervention. We report a rare case of de novo presentation of concurrent herpes encephalitis and glioblastoma. A 63-year-old man presented with status epilepticus and subsequent magnetic resonance imaging (MRI) brain showed a right temporal enhancing lesion with mass effect. He underwent a craniotomy and debulking of this lesion, which on subsequent histology was positive for herpes simplex virus (HSV) antigens and HSV DNA was confirmed by polymerase chain reaction analysis. The sample however also had some hypercellular areas with atypical astrocytes. Our patient recovered well from surgery and was eventually commenced on acyclovir albeit with a delay of 3 weeks due to the initial diagnostic dilemma. However, he re-presented with lethargy and confusion a further 3 weeks later and an MRI scan showed recurrence of the temporal lesion with MR spectroscopy more suggestive of high-grade glioma. He, therefore, underwent a further debulking surgery and the histology revealed a WHO Grade 4 glioblastoma with some residual areas of inflammation. A diagnosis of 2 co-existing pathologies namely HSV encephalitis and glioblastoma was thus reached. Unfortunately, due to poor performance status, he could not undergo chemo-radiotherapy and died 8 months after presentation. Immuno-modulators, expressed locally and globally in glioma patients, are likely to render them susceptible to infections. There are an increasing number of reports of HSV encephalitis in the glioma setting postoperatively. However, we report a de novo presentation which has only been recognized once before in the 1970s. Recognition of HSV encephalitis in glioma patients in the de novo and also the postoperative context is important for commencing early treatment and preventing poor outcomes.

Syringomyelia secondary to "occult" dorsal arachnoid webs: Report of two cases with review of literature.

In a certain group of patients with syringomyelia, even with the advent of sophisticated magnetic resonance imaging (MRI), no associated abnormality or cerebrospinal fluid (CSF) block is easily identified. This type of syringomyelia is often termed idiopathic. Current literature has less than 10 reports of arachnoid webs to be the causative factor. We present our experience in the management of two cases of syringomyelia secondary to arachnoid webs. Both our patients presented with progressive neurological deterioration with MRI scans demonstrating cervical/thoracic syrinx without Chiari malformation or low-lying cord. There was no history of previous meningitis or trauma. Both patients underwent myelography that demonstrated dorsal flow block implying CSF obstruction. Cord displacement/change in caliber was also noted and this was not evident on MRI scans. Both patients underwent thoracic laminectomy. After opening the dura, thickened/abnormal arachnoid tissue was found that was resected thus widely communicating the dorsal subarachnoid space. Postoperatively at 6 months, both patients had significant symptomatic improvement with follow-up MRI scans demonstrating significant resolution of the syrinx. In patients with presumed idiopathic syringomyelia, imaging studies should be closely inspected for the presence of a transverse arachnoid web. We believe that all patients with idiopathic symptomatic syringomyelia should have MRI CSF flow studies and/or computed tomography (CT) myelography to identify such arachnoid abnormalities that are often underdiagnosed. Subsequent surgery should be directed at the establishment of normal CSF flow by laminectomy and excision of the offending arachnoid tissue.

"Bouveret's syndrome" presenting with acute pancreatitis a very rare and challenging variant of gallstone ileus.

INTRODUCTION: Bouveret's syndrome is a rare variant of gallstone ileus and describes gastric outlet obstruction secondary to an impacted stone in the duodenum. Its presentation is vague and clinical diagnosis is often difficult resulting in a delay in diagnosis. PRESENTATION OF CASE: We report a patient who presented initially with non-specific symptoms and subsequently with features in keeping with acute pancreatitis, but eventually was found to have Bouveret's syndrome. DISCUSSION: Different treatment strategies are discussed. Although endoscopic treatment combined with many newer modalities like lithotripsy have been tried, surgery remains the definitive management in the vast majority of cases. CONCLUSION: Bouveret's syndrome is a rare condition, can also present as pancreatitis and often difficult to diagnose initially, but with appropriate treatment has a good outcome.