Multiple meningiomas arising during long-term therapy with the progesterone agonist megestrol acetate. Case report.

In this report the authors describe a woman with low-grade endometrial stromal sarcoma who was treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy. After receiving megestrol acetate continuously for 19 years for chronic hormone suppression, she began to experience progressive dementia. Magnetic resonance imaging revealed 11 separate intracranial meningiomas of various sizes. The largest lesions were treated with staged angiographically guided embolization and excision. Despite discontinuation of megestrol acetate, the remaining smaller lesions grew slightly in size, requiring further treatment with a combination of excision and gamma knife stereotactic surgery. All of the excised tumors showed positive staining for progesterone receptors on immunohistochemical examination. Prolonged therapy with megestrol acetate could promote the growth of benign intracranial meningiomas in some patients.

The integration of neurosurgical techniques in current head and neck skull base surgery.

The recent advances in neurosurgery, applied to the growing field of skull base surgery, provide surgeons with new techniques to avoid the devastating complication of CSF leak, to improve patient selection by reducing the risk of stroke while expanding the operative options available to patients with head and neck malignancies, and to aid operative care through improved surgical planning and intraoperative localization.

Neural-dural transition at the medial anterior cranial base: an anatomical and histological study with clinical applications.

OBJECT: Few anatomical studies have been focused on the morphological features and microscopic anatomy of the transition from the intracranial space to the medial anterior cranial base. The authors of the current study performed histological analyses to define the structure of the transition from neural foramina to the cranial base (neural-dural transition) at the cribriform plate, particularly as related to cerebrospinal fluid (CSF) fistula formation and surgical intervention in the region. METHODS: The medial anterior cranial base was resected in six cadaveric specimens. Histological methods were used to study the anatomy of the region on the microscopic level. Results of these examinations revealed a multilayered neural-dural transition at the cribriform plate, which consisted of an arachnoid membrane and a potential subarachnoid space as well as dura mater, periosteum, ethmoid bone, and associated layers of submucosa and mucosa of the paranasal air spaces. A subarachnoid space was identified around the olfactory nerves as they exited the neural foramina of the cribriform plates. The dura mater eventually thinned out and became continuous with the periosteum in the ethmoid bone. The dura, arachnoid membrane, and associated potential subarachnoid space were obliterated at a place 1 to 2 mm into the olfactory foramen. The authors present a case of recurrent CSF rhinorrhea successfully treated using a technique of multilayered reconstruction with pericranium, fat, and bone. CONCLUSIONS: The findings provide an anatomical basis for CSF fistula formation in the region of the cribriform plate and help to explain the unusual presentations in patients who have CSF rhinorrhea and meningitis. These results may facilitate the treatment of CSF fistulas, repair of defects in the medial anterior cranial base, and approaches to tumors and other pathological entities in the region.

Resection followed by radiosurgery for advanced juvenile nasopharyngeal angiofibroma: report of two cases.

OBJECTIVE AND IMPORTANCE: Experience with the management of juvenile nasopharyngeal angiofibroma (JNA) by gamma knife radiosurgery is limited. We report control of the disease in two patients with advanced-stage JNA treated with primary resection followed by gamma knife stereotactic radiosurgery of residual disease. CLINICAL PRESENTATION: An 18-year-old man presented with chronic sinusitis, worsening headaches, diplopia, and left-sided facial numbness. A second patient, a 19-year-old man, presented with recurrent epistaxis and nasal congestion. Magnetic resonance imaging findings and endoscopic evaluation in each patient were consistent with advanced-stage JNA. INTERVENTION: One patient underwent craniofacial resection with approximately 3.0 cm(3) of residual tumor in the region of the cavernous sinus. The other patient underwent preoperative embolization followed by a lateral rhinotomy for tumor resection with approximately 4.7 cm(3) of residual tumor in the right infratemporal fossa. In an attempt to limit radiation to surrounding normal brain, residual tumor in both patients was treated with gamma knife stereotactic radiosurgery. Control of disease was documented by magnetic resonance imaging more than 24 months after treatment. CONCLUSION: Short-term control of late-stage JNA was achieved by use of a strategy of primary surgical resection followed by gamma knife radiosurgery of residual tumor in two patients. Establishing the effectiveness and safety of this strategy over conventional methods of managing advanced JNA will require future prospective studies.

Hypotensive endovascular test occlusion of the carotid artery in head and neck cancer.

OBJECT: To evaluate the reliability of balloon test occlusion with hypotensive challenge (BTO and HC) as a predictor of neurological complications before internal carotid artery (ICA) sacrifice in patients with advanced head and neck cancer, the authors retrospectively reviewed the medical records of patients presenting to their institutions between 1992 and 1997 in whom this preoperative assessment was performed. METHODS: Eleven patents who were candidates for extended comprehensive neck dissection (ECND) and potential ICA sacrifice were included in the study. Eight patients tolerated the test and underwent endovascular occlusion or surgical ligation of the ICA before ECND (four patients), preservation of the ICA at the time of surgery (three patients), or palliative therapy (one patient). Of three patients in whom BTO and HC failed, one patient received palliative treatment only; the other two underwent ECND with preservation of the ICA. In the group of patients who passed the test and underwent ICA occlusion or ligation before ECND, fatal thromboembolic stroke occurred within 24 hours of permanent balloon occlusion in one patient, resulting in a combined neurological morbidity/mortality rate of 25% in this subset of patients and an overall complication rate of 9% in this series. CONCLUSIONS: The authors found that BTO and HC offers a simple and reliable method of preoperative risk assessment when ICA resection is planned for regional control of disease in advanced head and neck cancer. This management option, however, is associated with a potential for neurological complication that must be weighed against the natural course of the disease and the risks and benefits of other treatment modalities.

Magnetic resonance imaging correlation in pediatric spinal cord injury without radiographic abnormality.

OBJECT: The authors conducted a study to determine correlations between clinical syndromes and early magnetic resonance (MR) imaging-documented findings in children with spinal cord injury without radiographic abnormality (SCIWORA). METHODS: The authors retrospectively reviewed the records obtained in 20 patients who presented with SCIWORA to the Children's Hospital of Buffalo between 1992 and 1999. Initial neurological syndromes, subsequent hospital course and outcome, and early MR imaging findings obtained using conventional sequences on a 1.5-tesla unit were recorded. Neurological syndromes on presentation were complete (Frankel Grade A) in two patients (10%), severe partial (Frankel Grade C) in one patient (5%), and mild partial (Frankel Grade D) in 17 patients (85%). Partial neurological deficits resolved in 14 (78%) of 18 patients within 72 hours and lasted more than 72 hours in four patients (22%). Magnetic resonance imaging was performed in both patients presenting with complete injuries and in 17 of 18 patients presenting with partial neurological deficits. The studies were obtained within 24 hours in 17 patients (85%). Neuroimaging revealed spinal cord swelling at the cervical level in one of the children with complete injury and cord edema with associated hemorrhage at cervical and thoracic levels in the other. Neural and extraneural elements were shown to be normal in all 17 patients with partial injuries who underwent MR imaging, including in the four patients with partial motor deficits lasting more than 72 hours. CONCLUSIONS: In this series, the predominant neurological presentation of SCIWORA was a mild, partial syndrome that resolved within 72 hours. Magnetic resonance imaging revealed abnormal features only in those patients with complete neurological deficits. These findings suggest that in the acute setting conventional MR imaging sequences may lack the sensitivity to demonstrate neural and extraneural abnormalities associated with partial or temporary neurological deficits of SCIWORA, even when those deficits persist beyond 72 hours.