A case of intraroot cauda equina cavernous angioma: clinical considerations.

STUDY DESIGN: Case report and literature review. OBJECTIVE: Intradural-extramedullary cavernoma is a rare condition with only 23 cases reported in the literature. Most cases described adhere to spinal root or spinal cord. We report an example of this rare entity located within the sheets of one cauda equina nerve root. SETTING: Rome, Italy. METHODS: The authors report clinical, radiological, surgical, and pathological features of intraroot cavernoma with a literature review. RESULTS: Patient was operated. One year after surgery, he was healthy. CONCLUSION: Lumbar intradural cavernous angioma may present with sciatalgia, low-back pain, neurological deficit, or, more rarely with subarachnoid hemorrhage or hydrocephalus. They are treated successfully with surgical resection but preoperative status is a predicting factor for outcome. Sometimes the sacrifice of the spinal root is inevitable because, as in present case, the cavernous angioma is included in the nerve root. These lesions are rare and benign lesions. It is important for neurosurgeons to be aware of the existence of this entity to avoid preoperative misdiagnosis with tumor.

Primary leptomeningeal melanomatosis: early leptomeningeal enhancement on MRI.

One unusual case of primary leptomeningeal melanomatosis is presented. The patient, 53-year-old male, was admitted to our observation for 1 month history of psychasthenia and amnesia. Despite several polyspecialistic clinical, neuroradiological and cytological examinations, conclusive diagnosis was made only with a biopsy of leptomeningeal nodule. The present case allows as to identify 2 stages in the evolution of primary diffuse leptomeningeal melanomatosis. The initial phase is characterized by slight mental impairment without hydrocephalus; during the later phase there is severe, diffuse neurological impairment and both CT and MRI show hypercaptation of the intracranial leptomeninges and multiple, leptomeningeal tumoral nodules.

Cervical synovial cysts: case report and review of the literature.

The authors describe the case of a 58-year-old man with a 6-month history of severe myelopathy. CT scan and MRI of the spine revealed a cystic formation, measuring about 1 cm in diameter, at C7-T1 at a right posterolateral site at the level of the articular facet. At operation the mass appeared to originate from the ligamentum flavum at the level of the articular facet and was in contact with the dura mater. Once the mass had been removed, there was a significant amelioration of the patient's symptoms. As previously suspected, histological aspect was synovial cyst. Cervical synovial cysts are extremely rare and, as far as we know, only 22 cases have so far been described in the literature. Diagnostic radiological investigations used were CT scan and MRI. At CT scan the most important diagnostic findings are a posterolateral juxtafacet location of the mass, egg-shell calcifications on the wall of the cyst, and air inside the cyst. At MRI the contents of the cyst are iso/hypointense on T1- and hyperintense on T2-weighted images. There may also be a hypointense rim on T2-weighted images, which enhances after i.v. administration of gadolinium. Surgical treatment consists of removal of the mass. Fixation of the vertebral segments involved is not always necessary.

Cavernous angioma of the VIIIth cranial nerve. A case report.

We report a case of a 24-year-old woman affected by a cavernous angioma of the right VIIIth cranial nerve associated with a venous angioma. The malformation was diagnosed by MRI, performed in relation to an acute onset of right anacusia. The case report is indicative that, even if unusual, an acute onset of an cerebellopontine angle syndrome can be subsequent to a bleeding cavernous angioma. This occurrence must be kept in mind in the differential diagnosis of the cerebellopontine angle tumors.

MRI in the diagnosis of cystic meningiomas: surgical implications.

Nine cases of cystic meningioma diagnosed by MRI are described. All cases were surgically confirmed. The lesion was extra-axial with a clear dural attachment. On T1-weighted images the solid component was iso-hypo-intense in 6 cases and iso-hyperintense in 3; on T2-weighted images it was hyperintense in 7 cases, iso-intense in 2. After i.v. injection of gadolinium, the solid component enhanced in all cases and a "dural tail" were visible in 8 cases. No gadolinium enhancement of the cyst wall was observed in Nauta's types II and III. The authors found MRI to be very useful for diagnosis of cystic meningioma but insufficient for differential diagnosis between types II and III according to Nauta. This aspect requires further study, especially in view of the implications of this differentiation in terms of surgical management.

Aneurysms of the posterior cerebral artery: do they present specific characteristics?

A series of 7 cases of PCA aneurysm treated between 1978 and 1992 were analytically reviewed together with 79 cases culled from the literature. In comparison to those localized elsewhere, PCA aneurysms are more frequently large, more frequently present with tumour-like symptoms and appear at an earlier age. Surgical outcome was evaluated in relation to clinical onset, site and size of the aneurysm, the surgical procedures adopted for excluding it and pre-operative clinical grading appeared to influence outcome. The fact that site, size and surgical technique do not significantly influence prognosis is probably due to the rich collateral flow present in the areas fed by the posterior cerebral artery. The authors conclude that, clinically speaking, PCA aneurysms should be considered as a separate group.

Spinal cord ischemia diagnosed by MRI. Case report and review of the literature.

The purpose of this paper is to report a case of medullary ischemia diagnosed by MRI and to determine any MRI characteristics that may be useful for the diagnosis in the light of the published data. The patient was a 60 year-old male with hypertension and diabetes, referred to us for flaccid paraparesis and sphincter disorders of acute onset. Physical examination revealed, beside flaccid paraparesis, both superficial and deep hypoesthesia at L1 level and greater on the right. MRI showed a small area of signal hyperintensity on T2 weighted images and in proton density localized in the posterior part of the spinal cord at the level of T12 body. The patient was treated with oral antidiabetic, antiaggregant and antihypertensive drugs as well as neuromotor rehabilitation, and his clinical conditions improved; a control MRI, six months later, showed disappearance of the previous finding and only mild medullary atrophy at the level of the lesion. Medullary ischemia has been observed in a variety of pathological conditions (inflammatory, neoplastic, traumatic degenerative and iatrogenic), and most frequently involves the dorsal portion of the spinal cord. Four clinical-pathological manifestations of medullary ischemia have been described: infarction from occlusion of the anterior spinal artery; "patchy" or "lacunae infarction"; "transverse ischemic infarction"; selective ischemia in the regions of the posterior spinal arteries. A review of the literature yielded 61 cases of spinal ischemia diagnosed by MRI for a total number of 80 MRI scans, 12 of which were long-term controls.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of intraoperative ultrasound imaging in the surgical removal of intramedullary cavernous angiomas.

Five intramedullary cavernous angiomas were surgically removed after being localized by intraoperative ultrasound imaging. Two patients were men, and three were women; in three patients, the symptoms had an acute onset, whereas in the other two, it was gradual. The vascular malformation was localized in the dorsal tract in three patients and in the cervical tract in two. Intraoperative ultrasound imaging visualized the lesion, which appeared hyperechogenous in all cases, and showed its relationship with the surrounding anatomical structures. Surgical removal was always total and was confirmed by both intraoperative echography and postoperative magnetic resonance imaging. In our experience, intraoperative ultrasound imaging was useful for localizing intramedullary cavernous angiomas, especially in cases where the lesion did not appear on the posterior surface of the spinal cord. In this way, it was possible to limit posterior myelotomy and confirm radical tumor removal intraoperatively.

Coagulation study in patients who had undergone surgery for meningioma.

Abnormal fibrinolysis and thrombotic complications have been often observed in patients who had undergone surgery for meningioma. Fourteen patients, affected by meningioma, were studied before surgery, during surgery and 24 h after surgery in order to evaluate the modifications of the fibrinolysis system and the coagulation physiological inhibitors. Before surgery, no patient showed hyperfibrinolysis and/or modifications of coagulation physiological inhibitors. During surgery, an activation of fibrinolysis with pathological levels of tissue plasminogen activator activity (mean = 6.33 U/dl, SD = 7.9, p = 0.02) and increased levels of fibrin degradation products (mean = 0.21, SD = 0.18, p = 0.002) was noted. Modifications of the fibrinolysis parameters occurred only in 9/14 patients (64%). These patients presented a more vascularized tumour, revealed before surgery by computerized tomography scan and cerebral arteriography and directly confirmed during the resection. Twenty-four hours after surgery no patient presented fibrinolysis activation. There was no evidence of disseminated intravascular coagulation in our patients. None of them presented pathological decrease of the physiological coagulation inhibitors or thrombotic complications. In conclusion, during surgery, fibrinolysis parameters show important modifications in patients with vascularized meningioma suggesting an ongoing tumour-host interaction. These variations must be taken in account, in order to plan timely a correct therapeutic approach.

Ultrasound-guided brain biopsy: a personal experience with emphasis on its indication.

Between January 1989 and June 1991, 40 ultrasound-guided biopsies of supratentorial brain lesions exceeding 15 mm in diameter were performed. The apparatus used was Berger's neurobiopsy set, intraoperative 5 = MHz transducer, and a B-mode scanner. In 38 cases (95%) the procedure provided a histological diagnosis at the first attempt; in two patients, early in the present series, biopsy was repeated by computed tomography-guided technique due to insufficient samples. Operative mortality was zero and there were no septic complications. Clinical symptoms were stationary after the procedure in 34 cases; two cases temporarily worsened due to postbiopsy edema and subcortical hemorrhage, respectively; and four other cases showed an improvement as a result of evacuation of neoplastic cysts. Histologically, there were 24 primary malignant tumors, eight low-grade glial tumors, five metastatic tumors, two abscesses, and one lymphoma. The ultrasound method for brain lesion biopsy was found to be a simple, quick, and low-cost method that gave reliable results. It is indicated for supratentorial lesions over 15 mm in diameter that do not demand absolute anatomical accuracy.

"Dural tail" adjacent to acoustic neuroma on MRI: a case report.

A "dural tail" on Gd-DTPA-enhanced MRI has been often observed adjacent to meningiomas and considered to be useful in distinguishing meningioma of the cerebellopontine angle from acoustic neuroma. However, demonstration of a dural tail adjacent to an acoustic neuroma indicates that this sign is not specific.

The echo-guided removal of cerebral cavernous angiomas.

Twenty cavernous angiomas were surgically removed after being localised by intra-operative echography. 10 patients were males and 10 females, with an average age of 34 years. Four patients had had intracerebral haemorrhage; all the remaining patients presented with headaches or seizures. The size of the lesion ranged from a minimum of 2.5 to a maximum of 4.0 cm. Its localisation was subcortical in 14 cases, paraventricular in 4 and in another 2 originated from the floor of the IV ventricle. Echography showed a blackberry-like cavernous angioma, hyperechogenous with respect to the surrounding parenchyma; the lesion was well-defined in all cases due to the absence of perilesional oedema with a clear demarcation from healthy tissue. After operation, pre-operative cranial nerve deficits (brought on by haemorrhage) only persisted in the two cases where the cavernoma involved the floor of the IV ventricle. In all cases post-operative radiological investigation recorded the complete removal of the cavernous angioma, the diagnosis of which was invariably confirmed by histological analysis. The authors draw the conclusion that intra-operative echography is capable of localising cavernous angiomas, providing the surgeon with real-time guidance during microsurgical removal. It is also useful for establishing as to whether complete removal has been accomplished.

Non-traumatic brain abscess.

Between 1953 and 1989 eighty cases of non-traumatic brain abscess were treated in our department. We have re-examined the clinical and neuroradiological features of this pathological process and present our therapeutic approach and results. We believe that the optimal treatment for brain abscess consists of surgical removal. The prognosis for these lesions has undergone a marked improvement over the last two decades in response to neuroradiological, microbiological and surgical advances. The most influential prognostic factor seems to be preoperative clinical status.

Neurinoma of the third, fourth, and sixth cranial nerves: a survey and report of a new fourth nerve case.

A rare case of trochlear nerve neurinoma is described. Including this case, the number of reported intracranial tumors arising from the sheaths of the third, fourth, and sixth cranial nerves is 38. By site and relationship to the nerve segment, they fall into three groups: cisternal, cisternocavernous, and cavernous. In cisternal tumors of the third and sixth nerves, paresis of the nerve hosting the tumor is the unique nerve deficit; by contrast, in those of the fourth nerve, paresis of the trochlear nerve can be absent and that of the third nerve present. In the latter tumors, a peculiar ataxic hemiparesis syndrome is produced by midbrain compression. Cisternocavernous neurinomas often cause symptoms of intracranial hypertension, while cavernous neurinomas bring about two clinical features: paresis of one or more nerves of the cavernous sinus and a clinicoradiological orbital apex syndrome. At surgery, generally cisternal neurinomas are totally removed and the nerve source of the tumor identified; in cisternocavernous and cavernous neurinomas, total removal of tumor and identification of the parent nerve have been reported in only half of the cases. In the majority of parasellar neurinomas, clinical differences can be found between those arising from the nerves governing eye movement and those arising from the gasserian ganglion.

Posterior inferior cerebellar artery (PICA) aneurysm presenting with SAH and contralateral crural monoparesis: a case report.

A patient with contralateral monoparesis of the leg due to subarachnoid hemorrhage (SAH) from an aneurysm of the first posterior inferior cerebellar artery (PICA) segment is reported. The monoparesis may well be associated with the close anatomical relationships between the site of the aneurysm and the PICA blood supply of the corticospinal fibers to the contralateral leg.

Cervico-medullary junction hemangioblastomas. Report of two cases and review of the literature.

Reporting two cases of dorsally located cervico-medullary hemangioblastomas the Authors discuss clinico-biological features, diagnosis and therapy of this vascular neoplasms, analyzing the cases reported in detail in the available literature. In this site the tumor has often an exophitic development, adhering more or less extensively to the posterior surface of medulla oblungata, where progressively creates a niche. Transient neurogenic arterial blood hypertension, by possible involvement of the dorsal nucleus of vagal nerve, together with the lack of postoperative respiratory disturbances constitute the main clinical features of differentiation with intraaxial hemangioblastomas of the brainstem. Actually MRI represents the radiological investigation of choice, even if angiography still plays an important role in the correct preoperative diagnosis of hemangioblastomas. The therapy of dorsally located cervico-medullary hemangioblastomas is the total removal of the lesion also in asymptomatic patients, being the late surgical results generally successful.

Intramedullary spinal cord ependymomas--a study of 45 cases with long-term follow-up.

Of the 62 patients with intramedullary spinal cord ependymoma treated surgically at our Neurosurgery Division between January 1951 and December 1990 45 had a follow-up of at least 3 years and the longest 30 years. The 28 conus-cauda equina-filum ependymomas operated during the same period are not considered in this study. An analysis of our cases and of the larger published series shows that favourable prognostic factors, apart of course from total tumour removal, which is now usually possible, are a site below the high cervical segments and a mild pre-operative symptom pattern. Patient age at diagnosis, tumour size and "low dose" (< 40 Gy) radiotherapy seem to have no influence on the prognosis. Aggressive surgical removal is the treatment of choice and also for long-term recurrence.

Intracranial cavernous angioma.

We report 14 cases of intracranial cavernous angioma, analyzing the clinical features, with special reference to the risk of bleeding, radiological images and treatment in these and in 153 published cases, 167 in all. Cerebral hemorrhage occurred in 44%: typical (intraparenchymal or subarachnoid) in 24.6%, and masked by epilepsy, headache or neurological deficits in 19.2%. In patients with the typical hemorrhagic pattern posthemorrhagic mortality was 12.2%. Of the patients who had a hemorrhage 42.5% were left with more or less disabling neurological deficits, and 16.4% had a rebleed. In discussing treatment we consider four groups of intracranial cavernous angioma: A) symptomatic in a zone of low surgical risk; B) asymptomatic with low surgical risk; C) symptomatic with high surgical risk; D) asymptomatic with high surgical risk. The treatment is surgical, except in the high risk asymptomatic variety, best followed initially with sequential CT scan and MRI and then considered for surgery if the lesion becomes symptomatic, increases in size or presents neuroradiological signs of bleeding.

Achondroplasia: unusual bone abnormalities of the cervical spine.

We report the case of an achondroplastic child in whom severe morphological and postural abnormalities of the cervical vertebrae were coupled with only mild and stable neurological deficits. The pathogenesis of the abnormalities is discussed.

Aphasia in polyglots: report of two cases and analysis of the literature.

Two cases of aphasia in polyglot patients who experienced different symptoms in each of the languages they knew are reported. The authors discuss the problem and analyze the available literature in an attempt to formulate a pathogenetic hypothesis of the different involvement of the known idioms sometimes observed in aphasic polyglots. In particular, when time has elapsed between the learning of the mother tongue and other languages, and all the known languages are, consequently, functionally independent, it is possible that the two or more known idioms have distinct anatomical representations, probably localized separately in the two hemispheres. This could explain why, in some polyglots, aphasia affects one of the known languages preferentially. In subjects in whom the different known idioms were learned during early childhood, the anatomical representation of the languages is similar, which explains why, in this kind of polyglot, all the known languages can be equally affected by cerebral damage that causes aphasia.