[A case of ganglioglioma extended to the lateral ventricle and associated with neurofibromatosis type 1].

We encountered a rare case of intraventricular ganglioglioma associated with neurofibromatosis type 1. A 42-year-old woman presented with a feeling of heaviness of the head and dizziness. She was diagnosed with neurofibromatosis type 1 because she had multiple subcutaneous neurofibromas and café au lait spots. On admission, she deteriorated slightly(Japan Coma Scale 1)and suffered from cognitive dysfunction and right hemiparesis. A computed tomography(CT)scan showed that she had an obstructed hydrocephalus with a long and circular mass lesion, 2cm in diameter, in the anterior horn of the left lateral ventricle. The mass showed low signal intensity(SI)on the T1-weighted image(WI), heterogeneous high SI on the T2-WI, and dense enhancement on a Gd-DTPA contrast MRI, extending from the head of the left caudate nucleus to the lateral ventricle. The patient underwent an urgent operation via an anterior transcallosal approach because of an obstructed hydrocephalus. The tumor was removed in its entirety, including its origin at the caudate head. The pathological diagnosis was a ganglioglioma grade 1 according with the classification of the World Health Organization. Here we describe this case and discuss the rare association between gangliogliomas and neurofibromatosis type 1.

Clinicopathological characteristics in patients presenting with acute onset of symptoms caused by Rathke's cleft cysts.

BACKGROUND: Symptomatic Rathke's cleft cyst is usually accompanied by a long history of headache, visual disturbance, and hypopituitarism; however, rare cases present with acute onset and the clinical features in such cases remain uncertain. We report herein the clinical features of Rathke's cleft cyst with acute onset and discuss the clinical significance. METHOD: In this study, we defined acute onset as the clinical course with clinical symptoms within a 7-day history. From among 35 cases of symptomatic Rathke's cleft cyst that were pathologically diagnosed at Fukuoka University Hospital between 1990 and 2009, five cases presented with acute onset. The symptoms, endocrinological findings, MR image findings, and pathological findings of these cases were analyzed retrospectively. FINDINGS: Mean age was 56.8 years. Initial symptoms included headache (n = 3), general malaise (n = 2), polyuria (n = 2), and fever (n = 1). MR imaging revealed an intrasellar cystic lesion with suprasellar extension in all cases and showed rim enhancement in three cases. All cases were treated by transsphenoidal surgery. Pathological findings included hemorrhage (n = 2), hypophysitis (n = 2), and abscess formation in the cyst (n = 1). Postoperatively, all symptoms, except for hypopituitarism, improved in all cases. CONCLUSIONS: Rathke's cleft cysts sometimes present with acute onset, and the presentation is consistent with the features of pituitary apoplexy caused by pituitary adenoma. Although pituitary apoplexy due to hemorrhage, inflammation, or infection due to an underlying Rathke's cleft cyst is difficult to diagnose pre-operatively, Rathke's cleft cyst should be included in the differential diagnosis, and early surgical treatment is needed, as for pituitary apoplexy caused by pituitary adenoma.

[A case of herpetic meningoencephalitis associated with massive intracerebral hemorrhage during acyclovir treatment: a rare complication].

We report a case of a 35-year-old female with herpetic meningoencephalitis confirmed by polymerase chain reaction and immunohistochemical study for herpes simplex virus-1 accompanied with a massive intracerebral hematoma as a complication. A hematoma localized at the medial temporal lobe and the medial frontal lobe occurred on the 11th day after initiation of acyclovir treatment. She subsequently required emergency surgery for temporal lobectomy, as well as hematoma and external decompression. Intracerebral hematoma with MR imaging showed gyral pattern along the cortex of the medial temporal lobe and the base of the medial frontal lobe. We speculate that the hemorrhage occurred by rupture of small vessels affected by vasculitis in addition to hypertension caused by increased intracranial pressure. We therefore emphasize the risk of intracerebral hemorrhage at an early stage or during acyclovir treatment, especially during one or two weeks after initiation of the treatment, and the necessity of careful observation during these periods.

Mechanism of photofrin-enhanced ultrasound-induced human glioma cell death.

BACKGROUND: Low-intensity ultrasound showed tumor cell killing by a non-thermal effect in human leukemia cells. The aim of our study was to investigate the efficacy of low-intensity ultrasound on malignant astrocytic tumor cells with the photosensitizer, Photofrin, which is taken up by the cell surface receptor, low density lipoprotein receptor-related protein/alpha2-macroglobulin receptor (LRP/alpha2MR). MATERIALS AND METHODS: Cells were sonicated with continuous wave ultrasound with or without the presence of Photofrin (75 mg/ml) at an intensity of 0.3 W/cm(2) for a duration of 5, 15, or 30 s. RESULTS: Ultrasound alone induced instant cell killing immediately after sonication in both U251MG and U105MG malignant gliomas cells. In U251MG cells, which expressed LRP/alpha2MR, significant enhancement of cell killing was observed following Photofrin pretreatment, 52.7+/-17.5%, 13.0+/-4.6% and 3.9+/-0.9% for 5, 15, and 30 s respectively (p<0.05). This enhancement of cell killing was abolished by preincubation with receptor-associated protein (RAP) which binds specifically to LRP/alpha2MR. This enhancement by Photofrin was not achieved in U105MG which did not express LRP/alpha2MR. U251MG cells accumulated 2.43+/-0.25 Photofrin mg/mg protein, which significantly decreased with RAP pretreatment (1.38+/-0.22 Photofrin mg/mg protein) (p<0.05). U105MG cells accumulated 1.31+/-0.16 Photofrin mg/mg protein, which was significantly less than in U251MG cells. Photofrin uptake was not altered by RAP pretreatment in U105MG cells. U251MG cells exposed to ultrasound in the presence of Photofrin showed multiple surface pores and dimple-like craters. CONCLUSION: This is the first report to demonstrate the usefulness of low-intensity ultrasound for the cell killing of malignant glioma cells. Antitumor activity might be enhanced by combination with photosensitizer, which is transported by cell surface LRP/alpha2-MR to some degree.

Sonodynamic therapy consisting of focused ultrasound and a photosensitizer causes a selective antitumor effect in a rat intracranial glioma model.

UNLABELLED: In this study we sought to determine the optimal focused ultrasound acoustic conditions with photosensitizers for the ablation of experimental intracranial glioma in rats. MATERIALS AND METHODS: Normal rat brains were sonicated via a transducer placed on the dural surface with or without a prior intravenous injection of the photosensitizer Rose Bengal (50 mg/kg of body weight). The ultrasound intensity was varied to 25, 110 or 150 W/cm(2), and the duration of irradiation was 10 s, or 1, 3, or 5 min. In experimental intracranial gliomas, one week after inoculation of C6 rat glioma cells in the rat brain, the rat brain was sonicated through a 10 mm-diameter craniotomy. RESULTS: A selective antitumor effect against cerebral glioma while sparing normal brain tissues was achieved by sonodynamic focused therapy consisting of focused ultrasound at 25 W/cm(2) at 1 MHz for 5 min and Rose Bengal (50 mg/kg of body weight). The areas of tumors in sham-operated rats and in rats that received sonodynamic therapy without and with Rose Bengal at an intensity of 25 W/cm(2) for 5 min were 19.53+/-3.89, 10.64+/-2.21 and 3.01+/-1.74 mm(2), respectively. The tumor area was significantly smaller in the ultrasound therapy groups than in control non-treated animals (p=0.002). There was no significant temperature change in tumor tissues during sonication with 25 W/cm(2) at 1 MHz. CONCLUSION: This is the first report to demonstrate the usefulness of sonodynamic therapy consisting of focused ultrasound and photosensitizer for the treatment of experimental malignant glioma.

Effects of focused ultrasound sonodynamic treatment on the rat blood-brain barrier.

BACKGROUND: Ultrasound has recently been applied to the treatment as well as the diagnosis of various pathologies, and its antitumor effects in the treatment of human cancer and experimental models of cancer have been demonstrated. In addition, it is possible that certain photosensitizers will enhance the antitumor effects of ultrasound. However, very few studies have been reported on how the blood-brain barrier is affected by sonodynamic therapy. The purpose of this study was to evaluate disruption of the blood-brain barrier with focused ultrasound with a photosensitizer, for clinical application of sonodynamic therapy to brain tumors. MATERIALS AND METHODS: Rat brains were subjected to focused ultrasound irradiation via a transducer with or without prior intravenous injection of photosensitizer, and lesions were examined histologically by electron microscopy. RESULTS: Electron microscopically, swelling of astroglial processes, denatured cells, protoplasm of endothelial cells, and mitochondria were observed in the center and border of regions of ultrasonic irradiation. There were numerous pinocytotic vesicles in the cytoplasm of the endothelial cells. In addition, disruption of the cytoplasmic membrane of endothelial cells and astroglia was found in these regions. CONCLUSION: These findings suggest that sonodynamic therapy with a photosensitizer affects the blood-brain barrier, and that blood vessel permeability increases not only as a result of destruction of the blood-brain barrier but also by disruption of the cytoplasmic membrane of endothelial cells.

Efficacy of temozolomide treatment in patients with high-grade glioma.

BACKGROUND: Numerous studies have reported the clinical efficacy of temozolomide (TMZ) treatment for high-grade glioma, but information on Japanese populations has been limited. This study assessed the safety and early outcomes of TMZ treatment, with or without combination therapy. PATIENTS AND METHODS: The subjects comprised ten patients with high-grade glioma [glioblastoma multiforme (GBM), n=3, gliosarcoma (GS), n=1, anaplastic oligodendroglioma (AO), n=3, anaplastic mixed oligoastrocytoma (AOA), n=1, and anaplastic ependymoma (AE), n=2]. All the patients were initially treated with conventional radiotherapy following surgical resection with or without adjuvant chemotherapy. As second- or third-line chemotherapy, patients received TMZ for recurrence or tumor progression. As combination therapy, the local administration of tumor necrosis factor-alpha and the addition of carboplatin and etoposide were included for three patients during the course of oral TMZ treatment. RESULTS: Partial response (PR) to TMZ therapy was achieved by four out of the ten patients (objective response rate, 40%), while three patients displayed stable disease (SD) and three showed disease progression (PD). One of the patients receiving combination therapy has continued to show shrinkage of the relapsed tumor. Despite prior radio- and chemotherapy, most patients experienced only grade 1-2 hematotoxicity that was well-controlled by conservative therapy. CONCLUSION: TMZ chemotherapy is effective for the treatment of high-grade glioma in some patients without serious toxicity. Assessing the true efficacy of TMZ will require a larger study with comparison of long-term outcomes between other agents or combined therapeutic modalities.

Management of pilomyxoid astrocytomas: our experience.

BACKGROUND: Pilomyxoid astrocytoma (PMA) shows a higher rate of recurrence and cerebrospinal fluid (CSF) dissemination than does pilocytic astrocytoma (PA). In this article, we discuss the treatment of PMA. MATERIALS AND METHODS: Between 1992 and 2007, the authors treated 5 patients. Two of these were male, three female. Their ages ranged from 3 months to 11 years. RESULTS: Three patients showed CSF dissemination on the initial radiographic examination. All patients received chemotherapy; the most commonly used combination drugs were cisplatin (CDDP)/carboplatin (CBDCA) and etoposide. When these drugs were unsuccessful, they were changed or other drugs added to the combination. After chemotherapy, four patients showed remarkable tumor regression. Nevertheless, one patient died 22 months after initial diagnosis, due to tumor progression. CONCLUSION: While our series was limited to a small number of patients, we have a positive impression of the value of chemotherapy. Even if initial chemotherapy is ineffective, we recommend continued CDDP/CBDCA-based chemotherapy with new drug combinations.

Survival and late effects on development of patients with infantile brain tumor.

BACKGROUND: Most infants with brain tumor may have a poor prognosis. The aim of the present study was to retrospectively analyze the survival and outcome with regard to mental and physical development in 11 subjects with brain tumor; these tumors were diagnosed when the patients were under 1 year of age. METHODS: The histological diagnoses of these tumors were astrocytoma, n = 3; pineocytoma, n = 2; teratoma, n = 1; ependymoma, n = 1; atypical teratoid/rhabdoid tumor, n = 1; glioblastoma, n = 1; medulloblastoma, n = 1; and choroid plexus papilloma, n = 1. Surgical resection was performed in eight patients, and adjuvant chemotherapy was administered to all except one patient with choroid plexus papilloma. Radiotherapy was additionally performed for four of the 10 chemotherapy patients. RESULTS: Six patients survived. Among the surviving patients, five were under no treatment for 50-167 months after the diagnosis (median duration, 89 months), while one received chemotherapy for 20 months. Five patients exhibited mental retardation, and one patient experienced normal development after surgical removal of his choroid plexus papilloma. Diencephalic syndrome developed in one patient with pilomyxoid astrocytoma that necessitated hormone replacement therapy, and bodyweight over +2 SD was observed in two patients. The remaining five patients died 11-111 months after diagnosis (median duration, 24 months). CONCLUSION: The prognosis of infantile brain tumor with regard to mortality and developmental outcome remains poor. Furthermore, survivors require comprehensive medical and social support for an extended period.

Metastatic adenocarcinoma in the brain: magnetic resonance imaging with pathological correlations to mucin content.

BACKGROUND: Hypointense signal appearance of metastatic adenocarcinoma on T2-weighted imaging (T2-WI) has been infrequently documented. The purpose of this report was to evaluate the degree to which mucin content affects signal manifestations on conventional MR imaging. PATIENTS AND METHODS: This series of 24 cases with intracerebral metastatic adenocarcinoma was assessed retrospectively, focusing on the association between hypointense appearance on T2-WI and intratumoral mucin content. RESULTS: Among the 24 metastatic adenocarcinomas, intratumoral mucin was histopathologically confirmed in 8 lesions. Of these, 4 masses were demonstrated as hyperintense signal on T2-WI. The other 4 masses were depicted as isointensity. No cases were identified with hypointense signals in mucin-containing metastatic adenocarcinoma. Conversely, only 2 metastatic tumors originating from the stomach exhibited hypointense signal lesions on T2-WI. No histological or magnetic resonance imaging evidence of blood products or other forms of iron were identified as causes of the hypointense appearance on T2-WI. CONCLUSION: This hypointense signal may simply reflect the relatively shorter T2 relaxation time of the primary tissue from which metastases arose. Intratumoral mucin itself may be considered to demonstrate the masses as hyper- or isointense signals in the brain.

Congenital medulloblastoma with atypical MRI appearance.

A 13-day-old female infant was admitted with hydrocephalus that had been diagnosed on prenatal ultrasound at 33 weeks' gestation. She was delivered by Caesarean section at 34 weeks with an Apgar score of 10. On admission, she weighed 2,103 g. The head circumference was 32.3 cm, and the fontanelle was tense. T(1)- and T(2)-weighted MR images revealed an isointense mass occupying the fourth ventricle with multiple cysts in the vermis. The mass was not enhanced after gadolinium administration. CT showed no definite calcification in the lesion. Preoperatively, vermian tumors, including medulloblastoma, ependymoma, astrocytoma, and hamartomas, were considered in the differential diagnosis. Hamartoma was strongly suspected due to the lack of enhancement on MRI. After a suboccipital midline craniotomy, subtotal resection of a soft grayish tumor with areas of hematoma was carried out. The pathological diagnosis was medulloblastoma. Despite chemotherapy, CSF dissemination resulted in death at 11 months. We report this case of congenital medulloblastoma with atypical MRI findings and discuss the clinical characteristics of this lesion.

Complication caused by use of fibrin glue in vessel transposition for trigeminal neuralgia.

A 64-year-old man underwent microvascular decompression of the left superior cerebellar artery (SCA) for left trigeminal neuralgia (TN) using a sling of Teflon tape fixed to the tentorium with fibrin glue. The TN disappeared immediately after surgery, but recurred unusually rapidly at 2 weeks later at the same intensity as before. Second surgery revealed the SCA was suspended from the tentorium, but the trigeminal nerve was stretched and displaced superolaterally because of adhesion to the superior petrosal vein. The adhesion was thought to involve the fibrin glue used during the sling retraction procedure. The nerve was meticulously dissected from the adhesion, and the trigeminal nerve was placed in the correct position. The postoperative course was uneventful, and the TN disappeared completely. We recommend that the smallest amount of the fibrin glue possible be used to avoid adhesion to the surrounding neurovascular elements.

[Case of idiopathic hypertrophic pachymeningitis presenting with hyperostosis].

We report a case of idiopathic hypertrophic pachymeningitis presenting with cranial hyperostosis. A 64-year-old man had suffered from pulsating headache during the last 3 months. CT showed bony thickening of the sphenoid ridge, and MRI with Gd-DTPA revealed a linear or nodular enhanced mass along the left sphenoid ridge, extending to the anterior and middle cranial fossae and cavernous sinus. Preoperative steroid therapy resulted in improved clinical symptoms and shrinkage of the enhanced lesion. To clarify the nature of the lesion, biopsy was performed. Granulation tissue infiltrated by lymphocytes and plasma cells was identified, suggesting inflammatory changes. Histologic examination of the cranial bone showed fibrosis in the bone marrow. We considered the hyperostosis to have resulted from a long-term nonspecific inflammatory reaction. Idiopathic hypertrophic pachymeningitis associated with skull changes is rare. There are only 4 reported cases including ours. This rare condition is important in the differential diagnosis of cranial hyperostosis.

Quantitative assessment of gliomas by proton magnetic resonance spectroscopy.

BACKGROUND: Advanced magnetic resonance (MR) techniques provide physiological and metabolic information that complements the anatomical information available from conventional MR imaging. The purpose of this study was to evaluate the clinical usefulness of proton MR spectroscopy (1H-MRS) in preoperative quantitative assessment of intracranial gliomas. PATIENTS AND METHODS: Eight patients with histologically verified gliomas, comprising 2 cases with glioblastoma multiforme (GBM, grade 4), 5 cases with anaplastic oligodendroglioma (AO, grade 3; high-grade glioma), and 1 case with fibrillary astrocytoma (FA, grade 2; low-grade glioma) were evaluated using the 1H-MRS protocol following conventional MR imaging, diffusion-weighted imaging (DWI), and perfusion-weighted imaging (PWI) preoperatively. RESULTS: High-grade gliomas tended to demonstrate signal hyperintensity by DWI and higher relative cerebral blood volume (rCBV) by PWI. Increased ratios of choline (Cho) to N-acetylaspartate (NAA) (Cho/NAA) and Cho to creatine (Cr) (Cho/Cr) correlated highly with tumor malignancy. The presence of lactate and lipid was predominately detected in patients with high-grade glioma. CONCLUSION: The combination of multiple MR parameters, based on DWI, PWI and 1H-MRS, appears valuable for preoperatively predicting the degree of malignancy in glioma.

Ruptured aneurysm of the distal anterior cerebral artery: clinical features and surgical strategies.

Ruptured aneurysms of the distal anterior cerebral artery (ACA) are relatively rare and surgical management provides some unique technical challenges. This retrospective analysis of 20 patients with distal ACA aneurysms evaluated the clinical features and surgical strategies. The characteristic findings were small and common concurrent aneurysms, and frequent intracerebral hematoma (ICH). Aneurysms were divided by location on the genu (n = 13), infracallosal (n = 5), and supracallosal portions (n = 2). All patients except one underwent surgery via an interhemispheric route. Unilateral craniotomy was performed for aneurysms on the genu portions without massive ICH. Bilateral craniotomies were selected for aneurysm located on the infracallosal portion or combined with massive ICH. No intraoperative rupture was observed. Favorable outcomes were achieved in 15 of 20 patients, and only one patient died. The preoperative Hunt and Kosnik grade was closely correlated with the outcome.

[Ruptured aneurysm of distal posterior inferior cerebellar artery located at caudal loop].

We report an unusual case of subarachnoid hemorrhage (SAH) due to ruptured aneurysm originating at the caudal loop of posterior inferior cerebellar artery (PICA). The patient was a 77-year-old female presented with a sudden onset of headache and vomiting. Initial CT scan demonstrated a SAH with thick hematoma mainly in the cisterna magna. Vertebral angiogram revealed a saccular aneurysm arising from the tonsillomedullary segment of the left PICA, and communicating artery with supplying a territory of contralateral vermis as an anastmotic vessel. At surgery, no vessel branches were confirmed in the vicinity of the aneurysm, and this aneurysm was successfully clipped. In the fetus, numerous basilar and vertebral arteries are organized in plexiform formations around the brain stem. It has been suggested that the pathogenesis of such aneurysm or communicating artery could be related with a remnant of a primitive vertebrobasilar anastomosis. Based on these considerations, congenital vessel-wall weakness and hemodynamic stress associated with communicating artery may contribute to the development of distal PICA aneurysms.

Anti-tumor activity of de novo designed small globular protein (SGP) in vivo.

BACKGROUND: The design and synthesis of a small globular protein (SGP) based on the colicin family of bacteriocins has previously been reported. It has subsequently been shown that this artificial protein possessed cell membrane-disrupting properties. Here, the anti-tumor effects of SGP in subcutaneous nude mice tumor models of human glioma were examined. MATERIALS AND METHODS: Human glioblastoma cells (U-87MG) were transplanted subcutaneously into the backs of nude mice. When tumor volume was between 100 mm(3) and 350 mm(3), tumors were locally injected with SGP three times a week. The four SGP injection groups were 0.5 mM/50 microl, 0.5 mM/100 microl, 1.0 mM/50 microl and 1.0 mM/100 microl (concentration/injection volume). The control group was injected with physiological saline; 100 microl three times a week. RESULTS: Tumor volume exhibited a statistically significant decrease (p=0.001) and survival was significantly longer in the SGP-injected groups (p=0.0001). No clear difference in survival time was observed between the 0.5 mM SGP and 1.0 mM SGP groups (p=0.0654). However, the reduction in tumor volume was significantly affected by SGP concentration (p=0.021). CONCLUSION: SGP has an anti-tumor effect in human glioma animal models. The present results also suggest that applied treatment based on local injection of SGP will be effective against deep brain-seated malignant glioma.

Mechanisms of small globular protein-induced plasma membrane permeability and cytotoxicity in U87-MG human malignant glioblastoma cells.

BACKGROUND: Small globular protein (SGP) is an artificially designed protein that forms small pores on lipid bilayer membranes. The anti-tumor effect of SGP has been reported in several papers. However, the exact mechanism underlying SGP-induced cell death remains to be determined. MATERIALS AND METHODS: The mechanisms of SGP-mediated cytotoxicity were examined using cultured malignant glioblastoma cells (U87-MG). Morphological changes were observed under a light microscope. Ultrastructural changes were examined by electron microscopy. Changes in membrane permeability were evaluated by measuring the extracellular release of lactate dehydrogenase (LDH) and intracellular calcium concentration ([Ca2+]i). A new cell viability assay was also conducted using DAPI/calcein fluorescent-double staining methods. RESULTS: SGP cytotoxic effects were strongly influenced by fetal bovine serum (FBS) concentration in culture media. After 30 min of incubation, cytotoxic effects were noted at SGP concentrations greater than 1.5 microM. [Ca2+]i increased immediately after SGP addition. Extracellular efflux of LDH increased linearly with SGP doses (r(2) =0.936), and occurred even at concentrations less than 1.5 microM. Non-viable and viable cells were simultaneously detected by fluorescent staining with DAPI and calcein-AM, respectively. After 30 min of incubation with SGP, DAPI-positive nuclei were evident at concentrations higher than 1.5 microM. Cultures were then maintained in 10% FBS-containing media for 24 h before addition of calcein-AM. Calcein-positive cells were found at SGP concentrations lower than 1.5 5M. Cells positive for both DAPI and calcein appeared at a concentration of 1.5 microM. CONCLUSION: Our results indicate that SGP induces rapid but transient cytotoxicity, which may be beneficial in local therapy of malignant brain tumors.

Evaluation of intratumoral administration of tumor necrosis factor-alpha in patients with malignant glioma.

BACKGROUND: This study assessed safety and efficacy for intratumoral administration of tumor necrosis factor-a (TNF-SAM2) into the post-operative tumor cavity through an Ommaya reservoir for patients with malignant glioma. MATERIALS AND METHODS: Seven patients with malignant glioma, comprising 3 cases with glioblastoma multiforme (GBM), 3 cases with anaplastic astrocytoma (AA) and 1 case with malignant ependymoma (ME) were included in the study. All patients were pathologically diagnosed and initially treated with adjuvant therapy (radiation and/or ranimustine and/or systemic TNF-SAM2 infusion) following surgical resection. TNF-SAM2 was administrated into the post-operative tumor cavity through a reservoir at a concentration of 1x10(4) U/body when recurrence was detected, or as initial induction therapy concomitant with radiotherapy. RESULTS: Partial response to this regional immunotherapy was seen in 4 out of 7 patients, and 1 patient with GBM has remained clinically stable for >184 weeks without tumor progression. With AA, 2 cases appeared to display slowed advance and longer times to tumor recurrence or regrowth. No serious adverse effects, such as brain edema, hemorrhage or seizure were observed, nor systemic toxicities. CONCLUSION: Local immunotherapy with TNF-SAM2 may safely contribute to therapeutic efficacy in some patients with malignant glioma.

[Unilateral sudden deafness as a primary symptom of brainstem and cerebellar infarction].

We report a case with a unilateral sudden sensorineural hearing loss caused by an infarction of brainstem and cerebellum. The patient was a 74-year-old male presented with a sudden onset of hearing loss and tinnitus in the right ear and dizziness. Steroid was administered on suspicion of idiopathic sudden deafness. However, the initial symptoms were deteriorated approximately 2 weeks later. He newly complained of the numbness of the right face and double vision, and he was transferred to our hospital for further evaluation. Neurological examination demonstrated horizontal nystagmus, diminution in the right facial sensation, right peripheral facial palsy, right hearing loss and cerebellar ataxia. Urgent MRI disclosed fresh infarctions of the right middle cerebellar peduncle and cerebellum localized in the territory of anterior inferior cerebellar artery. In general, idiopathic sudden deafness and Meniere's disease are frequent diagnosis in cases of sudden hearing loss with vertigo, but these symptoms may rarely be caused by cerebrovascular disorder. In patients with risk factors for arteriosclerosis, cerebrovascular disorder should be taken into consideration even if idiopathic sudden deafness may be suspected clinically. We emphasize the diagnostic importance of careful observation on neurological findings and early detection of radiological abnormalities on MRI.