Chronic encapsulated expanding hematoma after stereotactic radiosurgery of cerebral arteriovenous malformation

Stereotactic radiosurgery has become excellent alternative treatment for cerebral arteriovenous malformations (AVM). This technique has expanded to treatment of larger AVM which is not amenable to surgical management. However, its variable adverse effects should be also taken into considerations sincerely because of radiobiological characteristics such as delayed onset and progressive neurological deteriorations. Herein, we report a case in which progressively expanding hemorrhagic cyst with repeated bleedings so called chronic encapsulated expanding hematoma was developed on several years after radiosurgery treatment. Neurological and radiological findings were improved by surgical removal.

Metaplastic Meningioma Overspreading the Cerebral Convexity

Meningioma is relatively common, benign, and extra-axial tumor accounting for about 20% of primary brain and spinal cord tumors. The World Health Organization (WHO) classified these tumors into Grade I (benign), Grade II (atypical), and Grade III (anaplastic) meningioma. Grade I meningioma which is slowly growing tumor and have some rare subtypes. Among them, metaplastic subtype is defined as a tumor containing focal or widespread mesenchymal components including osseous, cartilaginous, lipomatous, myxoid or xanthomatous tissue, singly or in combinations. We report a rare metaplastic meningioma overspreading nearly whole cerebral convexity from main extra-axial tumor bulk in the parietal lobe.

The Prevalence and Characterization of Cerebral Microbleeds in Young People Having Intracerebral Hemorrhage

OBJECTIVE: Cerebral microbleeds (CMBs) are known as the neuroimaging markers of risk in stroke and dementia. Many studies on CMBs in elderly patients with hemorrhagic or ischemic stroke have been reported; however, reports on CMBs in young populations with intracerebral hemorrhage (ICH) are lacking. MATERIALS AND METHODS: A total of 272 patients aged 18–54 years presented to our hospital with ICH between December 2009 and August 2017. Among these, CMB presence, count, and topography with respect to ICH were evaluated on magnetic resonance imaging (MRI) gradient echo images (GREs). We also evaluated the prevalence and risk factors of CMBs. RESULTS: Among 272 patients, only 66 underwent GRE T2-weighted MRI. CMBs were detected in 40 patients (61%), with 29 (73%) being of the multifocal type. Among the 219 CMBs, 150 (68.5%) were of the deep type and 69 (31.5%) of the lobar type. CMB prevalence was higher in men. In multivariate logistic regression analysis, history of hypertension (adjusted odds ratio [aOR], 4.048; 95% confidence interval [CI], 1.14–14.32; p = 0.030), and male sex (aOR, 4.233; 95% CI, 1.09–16.48; p = 0.037) were independently associated with CMBs. CONCLUSION: In young patients who presented with spontaneous ICH, CMBs were highly prevalent in 61% of patients and strongly associated with history of hypertension and male sex.

Delayed Burr Hole Surgery in Patients with Acute Subdural Hematoma: Clinical Analysis

OBJECTIVE: To evaluate the effectiveness and efficacy of delayed burr hole surgery in relation to the reduction of postoperative subdural hematoma (SDH) volume in patients with acute SDH. METHODS: We retrospectively analyzed patients with acute SDH who received delayed burr hole surgery at our institute. Age, sex, Glasgow coma scale, maximal SDH thickness, volume of SDH, midline shifts, hounsfield unit (HU), and medical history of anticoagulant agent usage were recorded. Outcome measures were delayed operation day, reduction of SDH volume after operation, and the Glasgow outcome scale (GOS) score at discharge. The patients were divided two groups according to the post-operative reduction of volume of SDH (≥50%, group A; <50%, group B). We also analyzed variables and differences between two groups. RESULTS: Eighteen patients were available for this analysis. The mean delayed of surgery was 13.9±7.5 days. Maximal thickness of SDH was changed from 10.0±3.5 mm to 12.2±3.7 mm. Volume of SDH was changed from 38.7±28.0 mL to 42.6±29.6 mL. Midline shifts were changed from 5.8±3.3 mm to 6.6±3.3 mm. HU were changed from 66.4±11.2 to 53.2±20.6. Post-operative reduction of SDH volume was 52.1±21.1%. Eleven patients (61%) had a discharge GOS score of 1 (good recovery). Ten patients (56%) were enrolled in group A. Midline shifting was greater in group A than in group B (7.4±3.3 vs. 3.0±2.4 mm; p<0.02). The delay of surgery was shorter for group A than group B (9.2±2.3 vs. 19.8±7.7 days; p<0.0008). CONCLUSION: Among well selected patients, delayed burr hole surgery in patients with acute SDH may be effective for reduction of SDH volume. Further studies will be necessary to establish the effectiveness and safety of delayed burr hole surgery in patients with acute SDH.

Primary Intracranial Leptomeningeal Melanomatosis

Primary intracranial malignant melanoma is a very rare and highly aggressive tumor with poor prognosis. A 66-year-old female patient presented a headache that had been slowly progressing for several months. A large benign pigmented skin lesion was found on her back. A brain MRI showed multiple linear signal changes with branching pattern and strong enhancement in the temporal lobe. The cytological and immunohiostochemical cerebrospinal fluid examination confirmed malignant melanoma. A biopsy confirmed that the pigmented skin lesion on the back and the conjunctiva were benign nevi. We report a case of primary intracranial malignant melanoma and review relevant literatures.

Spontaneous Regression of Cervical Disc Herniation: A Case Report

Spontaneous regression of cervical disc herniation is a rare, and such reports are few. A 39 year-old woman complained of severe neck pain associated with tingling and numbness of right upper extremity. The MRI of the cervical spine revealed a posterior disc extrusion at the C4-C5 level in the right para-central location. The patient was treated with conservative management without any surgical treatment. The patient's symptoms were significant improvement. After two years later, we performed follow-up cervical MRI that revealed significant spontaneous regression of the C4-C5 intervertebral disc extrusion.

The Efficacy of Pulsed Radiofrequency Treatment of Cervical Radicular Pain Patients

OBJECTIVE: Cervical radicular pain is defined as pain arising in the arm caused by irritation of a cervical spinal nerve or its roots. Although many treatment modalities are described in the literature, the available evidence for efficacy is not sufficient to allow definitive conclusions. The goal of this study was to establish the benefits and prognostic factors of pulsed radiofrequency (PRF) on the adjacent cervical dorsal root ganglia (DRG) of cervical radicular pain patients. METHODS: A retrospective study of PRF treatment of patients with cervical radicular pain was carried out. Two times diagnostic block of cervical DRG were performed before PRF. PRF was applied for 2 minutes at a setting of 2 Hz and 45 V by two times on the same targets, with the end point being an electrode tip temperature 42degrees C. Numerical rating scale (NRS) score was evaluated post-treatment 2 week, 1 month, 3 months and 6 months, which were compared with pretreatment value. A successful outcome was defined that NRS change was improved more than 50% at 6 months. RESULTS: The mean age was 54 years. The success rate was 68%(15/22) after six months of follow-up. PRF induced complications were not observed. Between success and failure group, we do not find any positive outcome prognostic factor. Interestingly, PRF treatment on foraminal stenosis is better outcome than herniated cervical disc. CONCLUSION: PRF on adjacent cervical DRG is effective and safe treatment option for cervical radicular pain patients. However, more long-term follow up and larger patients are needed to establish effectiveness PRF treatment on cervical radicular pain patients.

Microanatomy and Histological Features of Central Myelin in the Root Exit Zone of Facial Nerve

OBJECTIVE: The aim of this study was to evaluate the microanatomy and histological features of the central myelin in the root exit zone of facial nerve. METHODS: Forty facial nerves with brain stem were obtained from 20 formalin fixed cadavers. Among them 17 facial nerves were ruined during preparation and 23 root entry zone (REZ) of facial nerves could be examined. The length of medial REZ, from detach point of facial nerve at the brain stem to transitional area, and the thickness of glial membrane of central myelin was measured. We cut brain stem along the facial nerve and made a tissue block of facial nerve REZ. Each tissue block was embedded with paraffin and serially sectioned. Slices were stained with hematoxylin and eosin (H&E), periodic acid-Schiff, and glial fibrillary acid protein. Microscopy was used to measure the extent of central myelin and thickness of outer glial membrane of central myelin. Thickness of glial membrane was examined at two different points, the thickest area of proximal and distal REZ. RESULTS: Special stain with PAS and GFAP could be differentiated the central and peripheral myelin of facial nerve. The length of medial REZ was mean 2.6 mm (1.6-3.5 mm). The glial limiting membrane of brain stem is continued to the end of central myelin. We called it glial sheath of REZ. The thickness of glial sheath was mean 66.5 microm (40-110 microm) at proximal REZ and 7.4 microm (5-10 microm) at distal REZ. CONCLUSION: Medial REZ of facial nerve is mean 2.6 mm in length and covered by glial sheath continued from glial limiting membrane of brain stem. Glial sheath of central myelin tends to become thin toward transitional zone.

Lymphomatosis Cerebri

Lymphomatosis cerebri is considered a diffuse form of primary central nervous system lymphoma and very rare. It is not well recognized and may be misdiagnosed with infiltrating tumors, degenerative disorders, ischemic diseases, and infectious diseases developed in the brain. Awareness of the possibility of this rare disease and early biopsy are required for differential diagnosis and preventing poor clinical outcomes. We report a case with lymphomatosis cerebri who presented with rapid neurological deteriorations and review the relevant literatures.

Analysis of Risk Factors and Management of Cerebrospinal Fluid Morbidity in the Treatment of Spinal Dysraphism

OBJECTIVE: Spinal dysraphism defects span wide spectrum. Wound dehiscence is a common postoperative complication, and is a challenge in the current management of cerebrospinal fluid (CSF) leaks and wound healing. The purpose of this study is to evaluate the risks of CSF-related morbidity in the surgical treatment of spinal dysraphism. METHODS: Ten patients with spinal dysraphism were included in this retrospective study. The median age of the cohort was 4.8 months. To assess the risk of CSF morbidity, we measured the skin lesion area and the percentage of the skin lesion area relative to the back surface for each patient. We then analyzed the relationship between morbidity and the measured skin lesion area or related factors. RESULTS: The overall median skin lesion area was 36.2 cm2 (n=10). The percentage of the skin lesion area relative to the back surface ranged from 0.6% to 18.1%. During surgical reconstruction, 4 patients required subsequent operations to repair CSF morbidity. The comparison of the mean area of skin lesions between the CSF morbidity group and the non-CSF morbidity group was statistically significant (average volume skin lesion of 64.4+/-32.5 cm2 versus 27.7+/-27.8 cm2, p<0.05). CSF morbidity tended to occur either when the skin lesion area was up to 44.2 cm2 or there was preexisting fibrosis before revision with an accompanying broad-based dural defect. CONCLUSION: Measuring the lesion area, including the skin, dura, and related surgical parameters, offers useful information for predicting wound challenges and selecting appropriate reconstructive surgery methods.

Migration and Coiling of Peritoneal Catheter into the Subgaleal Space: A Very Rare Complication of Subgaleoperitoneal Shunt

Upward migration of the peritoneal catheter of a subgaleo-peritoneal (SP) shunt and coiling into the subgaleal space is an extremely rare complication of a SP shunt. A 32-year-old male patient visited our hospital presenting with a large skull defect due to a prior craniectomy performed elsewhere. The patient underwent a cranioplasty with methylmetacrylate, but subsequently developed progressive pseudomeningocele and subgaleal cerebrospinal fluid (CSF) collection. The patient underwent CSF diversion via a SP shunt. After SP shunting, the pseudomeningocele disappeared completely. Six months later, the patient presented with progressive scalp swelling. Skull X-ray showed migration and coiling of the distal catheter of the SP shunt. The patient was treated by removing the entire shunt catheter and the dura was covered with a subgaleal flap. We would like to report our experience with a very rare complication of subgaleo-peritoneal shunting.

Spontaneously Rapid Resolution of Acute Subdural Hemorrhage with Severe Midline Shift

Acute subdural hematoma is usually a neurological emergency that requires hematoma evacuation or close observation. However, spontaneous resolutions of an acute subdural hematoma without surgical interventions have been reported rarely. We report on a case who showed rapid resolution of an acute subdural hematoma with neurological improvement and review the relevant literatures.

Middle Cerebral Artery Aneurysm in a Premature Neonate

Intracranial aneurysms in the neonate are very rare and their clinicopathological findings remain unclear. We report a 26-day-old premature neonate who underwent microsurgical clipping on the ruptured middle cerebral artery bifurcation aneurysm successfully with a review of relevant literature.

Intraventricular Cavernous Hemangiomas Located at the Foramen of Monro

Intraventricular cavernous hemangiomas are uncommon. Among them, those occurred at the foramen of Monro in the third ventricle may be of particular interest because of its rarity, development of hydrocephalus, being differentiated from other brain lesions. We present a rare case of intraventricular cavernous hemangioma at foramen of Monro which was resected through microsurgery and also review the relevant literatures.

Infiltrating Spinal Angiolipoma

Spinal angiolipomas are rare lesions usually found in the epidural space of the thoracic spine. The infiltrating type of spinal angiolipomas is extremely rare. This report presents the case and reviews the related literature. A 58-year-old man was presented with a 7-month history of progressive weakness and sensory change of lower extremities. Magnetic resonance images showed a well-enhanced mass infiltrating the vertebral foramen at the T4-5 level. Resection of the tumor was performed. Histological study revealed the tumor as an angiolipoma. The patient was relieved from symptoms after tumor resection.

Transposition of Anterior Choroidal Artery and Posterior Communicating Artery Origin

The anterior choroidal artery has several kinds of variations. Among them, the transposition of anterior choroidal artery and posterior communicating artery origins has been extremely rare. We report a case with cerebral aneurysm arising from posterior communicating artery which origin was distal to the anterior choroidal artery and review the relevant literature.

Spontaneous Regression of an Unruptured and Non-Giant Intracranial Aneurysm

It is well known that spontaneous thrombosis in giant cerebral aneurysm is common. However, spontaneous obliteration of a non-giant and unruptured cerebral aneurysm has been reported to be rare and its pathogenic mechanism is not clear. We describe a case with rare vascular phenomenon and review the relevant literatures.

Erratum: Intraventricular Cavernous Hemangiomas Located at the Foramen of Monro

In the paper by Lee et al., the name of the corresponding author was given incorrectly. The correct name should be Chan-Young Choi as given above.

A Case of Brachial Plexus Neurofibroma

Tumors of the brachial plexus are relatively rare. The most common intrinsic tumors involving the brachial plexus are benign schwannomas and neurofibromas. Neurofibromas are usually associated with neurofibromatosis-1 (NF-1). Solitary neurofibromas unassociated with NF-1 are very uncommon. We report a 56 year-old man with brachial plexus solitary neurofibroma and reviews of literatures.

Intraventricular Atypical Meningiomas

A rare case of intraventricular meningioma that arose in the atrium of the left lateral ventricle was identified in a 51-year-old woman. Gross total removal was performed by transcortical approach. Histopathological findings showed meningothelial meningioma with a focal atypical area which had 8% of Ki-67 labeling index (LI). A large recurrence extending into the ipsilateral quadrigeminal cistern and opposite medial occipital lobe developed approximately 41 months after the first operation. The specimens obtained from the second resection showed atypical meningioma with 20% of Ki-67 LI but there were no anaplastic area. The patient underwent fractionated stereotactic radiotherapy. However, multiple local distant metastases were found in the occipital and cerebellar cortex suggesting cerebrospinal fluid dissemination apparently 24 months after the second operation. This report presents chronological progression of a rare intraventricular atypical meningioma with more aggressive transformation.