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Other iatrogenic immunosuppressive-associated lymphoproliferative disorders (OIIA-LPDs) rarely occur in the central nervous system (CNS). Additionally, they almost always present as lymphoma and withdrawal by cessation of immunosuppressive treatment. We report a case of primary CNS OIIA-LPD that presented as extraosseous plasmacytoma (EP) with a progressive clinical course in spite of immunosuppressive treatment cessation. A 78-year-old man with a history of rheumatoid arthritis (RA) presented with a month-long headache. Magnetic resonance imaging showed mass lesions in the left temporal lobe, left middle fossa, and intradural cervical spine. The left temporal lesion was resected and diagnosed as EP histologically, and OIIA-LPD presented as plasmacytoma integrally due to his history of immunosuppressive treatment using tacrolimus for RA. Despite immunosuppressive treatment cessation, OIIA-LPD lesions did not regress but, on the contrary, showed a progressive clinical course. Considering his advanced age and renal dysfunction, postoperative treatment with radiation and moderate chemotherapy using prednisolone were administrated. Subsequently, the disease state stabilized, and the patient had a Karnofsky performance status score of 90 for 6 months; however, the tumor recurred with meningeal dissemination, and he died 8 months after treatment. Types of OIIA-LPD onset as EP and its progressive clinical course resistant to cessation of immunosuppressive treatment are rare. Moreover, this OIIA-LPD disease state worsened despite its radiosensitivity. We believe the progressive clinical course of this OIIA-LPD case with its high cell proliferation is similar to Epstein-Barr virus negative plasmablastic lymphoma, which could lead to a poor outcome.
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Artrite Reumatoide , Infecções por Vírus Epstein-Barr , Transtornos Linfoproliferativos , Plasmocitoma , Masculino , Humanos , Idoso , Metotrexato/uso terapêutico , Plasmocitoma/complicações , Plasmocitoma/tratamento farmacológico , Infecções por Vírus Epstein-Barr/complicações , Herpesvirus Humano 4 , Recidiva Local de Neoplasia/complicações , Imunossupressores/uso terapêutico , Artrite Reumatoide/complicações , Transtornos Linfoproliferativos/tratamento farmacológico , Transtornos Linfoproliferativos/patologia , Sistema Nervoso Central/patologia , Doença Iatrogênica , Progressão da DoençaAssuntos
Hematoma , Hemofilia A , Hematoma/diagnóstico , Hematoma/etiologia , Hemofilia A/complicações , Humanos , PonteRESUMO
OBJECTIVE: Serum C-reactive protein (CRP), as a reflection of early brain injury at onset, is a prognostic factor in aneurysmal subarachnoid hemorrhage (aSAH). However, in some severe cases, patients exhibit a good prognosis despite their elevated serum CRP level. Therefore, we examined the relationship between serum CRP transitions in the acute phase of aSAH and the prognosis. METHODS: We recruited 63 patients with aSAH and retrospectively analyzed the relationships between the serum CRP transitions during the acute phase and the prognosis, patient background, and clinical course. RESULTS: Serum CRP values on days 1, 3, and 14 were significantly lower in the good prognosis group than those in the poor prognosis group. Moreover, serum CRP values on days 1 and 14 significantly affected the prognosis in the multiple regression analysis. CONCLUSIONS: A low serum CRP value on day 14, in addition to that on day 1 as reported previously, is associated with a good prognosis of aSAH. Furthermore, a good prognosis of aSAH is determined not only by absence of early brain injury at onset but also by appropriate management to obtain a low serum CRP value on day 14.
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Proteína C-Reativa , Hemorragia Subaracnóidea , Humanos , Hemorragia Subaracnóidea/sangue , Hemorragia Subaracnóidea/diagnóstico , Proteína C-Reativa/metabolismo , Proteína C-Reativa/análise , Masculino , Feminino , Pessoa de Meia-Idade , Prognóstico , Idoso , Estudos Retrospectivos , Biomarcadores/sangue , Adulto , Fatores de TempoRESUMO
Hemorrhagic changes in a dural arteriovenous fistula are typically associated with cortical venous reflux and occur as intracerebral or subarachnoid hemorrhages. A convexity dural arteriovenous fistula (DAVF) usually flows directly into the cortical veins and exhibits cortical venous reflux. Herein, we report a rare case of a convexity DAVF without cortical venous reflux presenting with a pure acute subdural hematoma. A 19-year-old man complaining of headache without any history of head injury was diagnosed with a left acute subdural hematoma on magnetic resonance imaging (MRI) and referred to our hospital. The patient was conscious and exhibited no neurological signs. The MRI did not reveal any possible abnormalities leading to hemorrhage. Cerebral angiography revealed a dural arteriovenous fistula in the left parietal cranium with a feeder from the middle meningeal artery and a drainer into the main transverse sinus via a diploic vein. Part of the shunt blood flowed into the superior sagittal sinus from the meningeal vein; however, there was no reflux into the cortical vein or stasis of the cerebral vein, suggesting venous hypertension. A convexity DAVF was diagnosed as the source of bleeding, and transarterial embolization was performed. The patient recovered without any neurological deficits. In the absence of trauma, an acute subdural hematoma requires an appropriate evaluation of the vascular lesions and a treatment plan.
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OBJECTIVE: With advances in endovascular therapy, the number of cerebral aneurysm clippings has been decreasing. However, some patients are indicated for clipping surgeries. In such circumstances, preoperative simulation is important for the safety and educational aspects of the operation. Herein, we introduce a simulation method using the preoperative rehearsal sketch and report its applicability. METHODS: We compared the preoperative rehearsal sketch with the surgical view for all patients who underwent cerebral aneurysm clipping by neurosurgeons below the seventh grade between April 2019 and September 2022 in our facility. The aneurysm, running of parent and branched arteries, perforators, veins, and clip working were evaluated by senior doctors and scored as follows: correct, 2; partially correct, 1; incorrect, 0; and total score, 12. We retrospectively evaluated the relationship between these scores and postoperative perforator infarctions and, in addition, compared that between simulated and not simulated cases. RESULTS: In the simulated cases, the total scores did not correlate with perforator infarctions, but assessments of the aneurysm, perforators, and clip working affected the total score (P = 0.039, 0.014, and 0.049, respectively). Moreover, perforator infarctions were significantly less in the simulated cases (6.3% vs. 38.5%; P = 0.03). CONCLUSIONS: Precise interpretations of preoperative images and considerations of three-dimensional images are imperative to perform safe and accurate surgeries using preoperative simulation. Although perforators are not always detected preoperatively, it is possible to presume in the surgical view using anatomic knowledge. Therefore, drawing the preoperative rehearsal sketch improves the safety of surgical procedure.
Assuntos
Aneurisma Intracraniano , Humanos , Aneurisma Intracraniano/cirurgia , Procedimentos Neurocirúrgicos/métodos , Estudos Retrospectivos , Procedimentos Cirúrgicos Vasculares/métodos , Instrumentos Cirúrgicos , Infarto/cirurgiaRESUMO
Objective: We report a case of spinal cord infarction following mechanical thrombectomy for acute basilar artery occlusion, and describe the pathophysiological mechanism of spinal cord infarction and its possible prevention. Case Presentation: A 70-year-old man developed dysarthria and left-sided sensory impairment and was then diagnosed with acute basilar artery occlusion. Mechanical thrombectomy was performed using a 6-Fr guiding sheath via the left vertebral artery (VA). Complete recanalization was achieved within 1.5 hours. However, toward the end of the procedure, the guiding sheath was wedged in the distal portion of the VA. Postoperatively, left-sided flaccid paralysis and right-sided sensory deficit were observed. Cervical magnetic resonance imaging (MRI) demonstrated an acute spinal cord infarction on the left side, at the level of C3. The cause of infarction was suspected to be the wedging of the guiding sheath during the procedure. Conclusion: Spinal cord infarction is a rare but serious complication of mechanical thrombectomy for acute basilar artery occlusion. The selection of appropriate procedure, device, and safe access route are essential for the success of a mechanical thrombectomy for acute basilar artery occlusion.
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BACKGROUND: Regional cerebral oxygen saturation (rSO2) is a non-invasive method of measuring cerebral perfusion; However, serial changes in cerebral rSO2 values among out-of-hospital cardiac arrest (OHCA) patients in pre-hospital settings have not been sufficiently investigated. We aimed to investigate the association between the serial change in rSO2 pattern and patient outcome. METHODS: We evaluated rSO2 in OHCA patients using portable monitoring by emergency life-saving technicians (ELTs) from June 2013 to December 2019 in Osaka City, Japan. We divided the patterns of serial of rSO2 change into type 1 (increasing pattern) and type 2 (non-increasing pattern). Patients in whom measurement started after return of spontaneous circulation (ROSC) were excluded. The outcome measures were 'Prehospital ROSC', 'Alive at admission', '1-month survival' and 'Cerebral Performance Category (CPC) 1 or 2'. RESULTS: Eighty-seven patients were eligible for this analysis (type 1: n = 40, median age: 80.5 [IQR: 72-85.5] years, male: n = 20 [50.0%]; type 2: n = 47, 81 [72-85.5] years, male: n = 28 [59.6%]). In a multivariable logistic regression adjusted for confounding factors, outcomes of 'Prehospital ROSC' and 'Alive at admission' were significantly higher in type 1 than type 2 pattern (11/40 [27.5%] vs. 2/47 [4.26%], AOR 5.67, 95% CI 1.04-30.96, p < 0.045 and 17/40 [42.5%] vs. 6/41 [12.8%], AOR 3.56, 95% CI 1.11-11.43, p < 0.033). There was no significant difference in '1-month survival' and 'CPC 1 or 2' between patterns. CONCLUSION: Type 1 (increasing pattern) was associated with 'Prehospital ROSC' and 'Alive at admission'. Pre-hospital monitoring of cerebral rSO2 might lead to a new resuscitation strategy.
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Partial deletions in chromosomes 1p and 19q are found in a subset of astrocytic tumors; however, it remains unclear how these alterations affect their histological features and prognosis. Herein, we present 3 cases of isocitrate dehydrogenase (IDH)-mutant astrocytoma with chromosome 19q13 deletion. In the first case, the primary tumor harbored an IDH1 mutation with chromosome 1p/19q partial deletions, which covered 19q13 and exhibited a durable initial response to radiotherapy and temozolomide (TMZ) treatment. However, the tumor lost the chromosome 1p/19q partial deletions at recurrence and became resistant to TMZ. Histologically, an oligodendroglioma-like feature was found in the primary tumor but not in the recurrent tumor. Capicua transcriptional repressor (CIC), located on 19q13, was less expressed in the primary tumor but was highly expressed in the recurrent tumor. Similar histological findings were observed in 2 other astrocytic tumors with IDH1 or IDH2 mutations. These tumors also had chromosome 19q13 deletion, including the CIC gene, weakly expressed CIC, and oligodendroglioma-like morphology. These tumors recurred at 6 and 32 months, respectively. These findings suggest that IDH-mutant astrocytoma with chromosome 19q13 partial deletion, including the CIC gene, may induce an oligodendroglioma-like phenotype, but the clinical prognosis may not be similar to that of genetically defined oligodendroglioma.
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Astrocitoma/genética , Neoplasias Encefálicas/genética , Deleção Cromossômica , Cromossomos Humanos Par 19/genética , Isocitrato Desidrogenase/genética , Oligodendroglioma/genética , Adulto , Animais , Astrocitoma/diagnóstico por imagem , Neoplasias Encefálicas/diagnóstico por imagem , Feminino , Humanos , Masculino , Camundongos , Camundongos SCID , Mutação/genética , Oligodendroglioma/diagnóstico por imagemRESUMO
BACKGROUND: Craniopharyngioma has two subtypes: adamantinomatous and squamous-papillary. Squamous-papillary craniopharyngioma may develop from remnants of the craniopharyngeal duct, anterior pituitary cells with squamous metaplasia, suprasellar epidermoid cyst, or Rathke cleft cyst. AIM: While ciliated craniopharyngioma is considered to represent a transitional stage between Rathke cleft cyst and squamous-papillary craniopharyngioma, ciliated craniopharyngioma following Rathke cleft cyst at the same site has not previously been described. RESULTS: We report a case of ciliated craniopharyngioma developing from Rathke cleft cyst. CONCLUSION: The clinical course for this case is discussed together with a review of the pathological literature for ciliated craniopharyngioma.
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Cistos do Sistema Nervoso Central/complicações , Cistos do Sistema Nervoso Central/patologia , Craniofaringioma/etiologia , Craniofaringioma/patologia , Hipófise/patologia , Neoplasias Hipofisárias/patologia , Transformação Celular Neoplásica/patologia , Rinorreia de Líquido Cefalorraquidiano/etiologia , Rinorreia de Líquido Cefalorraquidiano/patologia , Rinorreia de Líquido Cefalorraquidiano/cirurgia , Cílios/patologia , Craniotomia , Células Epiteliais/patologia , Hemianopsia/etiologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/prevenção & controle , Recidiva Local de Neoplasia/cirurgia , Procedimentos Neurocirúrgicos , Quiasma Óptico/patologia , Hipófise/anormalidades , Hipófise/metabolismo , Hormônios Hipofisários/sangue , Hormônios Hipofisários/metabolismo , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/patologia , Complicações Pós-Operatórias/cirurgia , Reoperação , Sela Túrcica/patologia , Resultado do TratamentoRESUMO
The authors report a case of inflammatory pseudotumor that developed in the choroid plexus of the lateral ventricle. The patient was a 73-year-old man who had undergone surgery for rectal cancer at another hospital 5 years earlier. He was referred to the authors' department, with his chief symptoms consisting of disorientation, right hemiparesis, and gait disorder that had gradually developed during the preceding month. On computed tomography and magnetic resonance imaging, a well-demarcated and homogeneously contrasted tumorous lesion was noted in the region from the trigone to the medial wall of the inferior horn of the left lateral ventricle. Expansion of the inferior horn was also evident. Intraoperative findings showed that the tumor originated from the choroid plexus of the lateral ventricle, and the histopathological diagnosis was inflammatory pseudotumor. There are only 4 previously reported cases of inflammatory pseudotumor that developed in the choroid plexus; the authors review the literature and discuss the clinicopathological characteristics of the condition.
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Encefalopatias/diagnóstico , Plexo Corióideo/patologia , Granuloma de Células Plasmáticas/diagnóstico , Idoso , Confusão/diagnóstico , Diagnóstico Diferencial , Transtornos Neurológicos da Marcha/diagnóstico , Humanos , Ventrículos Laterais/patologia , Imageamento por Ressonância Magnética , Masculino , Paresia/diagnóstico , Tomografia Computadorizada por Raios XRESUMO
A 28-year-old woman presented with a rare case of endodermal cyst located ventral to the lower brain stem manifesting as recurrent aseptic meningitis. Computed tomography and magnetic resonance imaging demonstrated a cystic mass located ventral to the lower brain stem and extending from the prepontine to the upper cervical (C-2) cistern. The lesion was totally removed through a retrosigmoid craniotomy and C1-2 hemilaminectomy. Histological and immunohistochemical examination showed the cyst was derived from the endoderm. The histological diagnosis was endodermal cyst. Early diagnosis and surgical removal are important for patients with these cysts.
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Neoplasias do Tronco Encefálico/patologia , Tumor do Seio Endodérmico/patologia , Adulto , Neoplasias do Tronco Encefálico/cirurgia , Tumor do Seio Endodérmico/cirurgia , Feminino , HumanosRESUMO
Plasma cell myeloma (PCM) of the skull base is rarely encountered in neurosurgical practice. PCM has a wide spectrum of pathology, including a quite benign, solitary plasmacytoma (SPC), and an extremely malignant, multiple myeloma (MM) at the two ends of the spectrum. We have described two patients with PCM of the skull base, of which one harbored SPC, and the other progressed to MM. In case 1, a 46-year-old man presented with left multiple cranial nerve impairments and had a large skull base tumor. Subtotal removal was performed. The specimen and general examination, including bone marrow aspiration, revealed SPC. Postoperatively 50Gy of external radiotherapy was administered. The patient has no manifestation of MM 24 months after the initial presentation. In case 2, a 53-year-old woman presented with left abducens palsy and had a left petroclival osteolytic mass. Gross total resection was performed. The specimen revealed a plasmablastic tumor, i.e., myeloma. General examination established the diagnosis of MM. She was administrated adjuvant chemotherapy and autologous bone marrow transplantation. She is alive without local recurrence 30 months after the initial presentation.
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Mieloma Múltiplo/patologia , Plasmocitoma/patologia , Neoplasias da Base do Crânio/patologia , Diagnóstico Diferencial , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Mieloma Múltiplo/terapia , Plasmocitoma/terapia , Neoplasias da Base do Crânio/terapiaRESUMO
We used the combined subtemporal presigmoid and suboccipital retrosigmoid multidirectional approach with the aid of a rotatable head frame (periauricular three-quarter twist-rotation approach) in 20 cases of petroclival meningiomas. Patients were placed in the lateral decubitus (park-bench) position. The head is twisted, rotated, and positioned 30 degrees face down in the Sugita rotatable head frame. By rotating this head frame, a 30- to 60-degree face-down position can be obtained when the suboccipital retrosigmoid route is used. Alternatively, the straight lateral or slightly brow-up position is obtained when the subtemporal presigmoid route is used. This twist-rotation approach provides multiple trajectories through the petroclival region with minimal drilling of the petrous bone, fatigue of the surgeon, and retraction of the brain.
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A case is reported of post-traumatic delayed appearance of a pseudoaneurysm on the posterior meningeal artery. In the immediate post-traumatic stage, the patient had mild disturbance of consciousness, mild subarachnoid hemorrhage, and mid-line skull fracture of the posterior cranial fossa. At 15 hours after the trauma, the patient suddenly developed deep coma and respiratory arrest. CT scanning showed further spreading of the subarachnoid hemorrhage and newly detected subdural hemorrhage. After the patient regained spontaneous respiration, cerebral angiography was performed 24 hours after admission. This initial angiography showed no aneurysm, but at 17 days after the trauma, follow-up angiography demonstrated the delayed appearance of an aneurysmal dilatation on the posterior meningeal artery. The aneurysm was resected surgically and proved to be a pseudoaneurysm. Having developed normal pressure hydrocephalus afterwards, the patient received a V-P shunt, and was discharged 150 days after the trauma with no major neurological deficit. We discussed the indication for and timing of angiography for detecting pseudoaneurysms. Posterior meningeal artery pseudoaneurysms should be resected surgically, because intravascular surgery through the vertebral artery involves considerable risk of embolic complications.
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Falso Aneurisma/etiologia , Hemorragia Cerebral Traumática/etiologia , Traumatismos Cranianos Fechados/complicações , Artérias Meníngeas , Falso Aneurisma/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Fraturas Cranianas/etiologia , Hemorragia Subaracnóidea/etiologia , Tomografia Computadorizada por Raios XRESUMO
An 80-year-old male presented with a chronic encapsulated intracerebral hematoma (CEIH) with surrounding edema under the right frontal lobe manifesting as slow exacerbation of disturbance of orientation and gait. He had a history of cerebral infarction with an asymptomatic cavernous angioma in the right frontal lobe. The CEIH was diagnosed as bleeding from the cavernous angioma, and surgical removal was performed. The hematoma was chronic and covered by a thick capsule. In addition, mass tissue covered with the organized hematoma was found near the capsule, which was excised and found to be a cavernous angioma. CEIH is a special type of intracerebral hemorrhage, and bleeding from a cavernous angioma is occasionally seen. CEIH should be considered in the case of a hemorrhagic intracranial lesion with a chronic, progressive course with capsule formation and edema around the lesion. The source of bleeding is unknown in about half of the reported cases, and occult vascular malformation may be involved, necessitating care in diagnosis.