Natural history of multiple meningiomas.

BACKGROUND: Asymptomatic solitary meningiomas are typically managed with clinical and radiographic follow-up. Multiple meningiomas represents a clinical entity distinct from solitary meningiomas and can be sporadic, radiation-induced, associated with neurofibromatosis, or exhibit other familial inheritance. The growth rate for multiple meningiomas is not known and therefore management of these complicated patients can be difficult. METHODS: A retrospective chart review was performed on 12 patients with a total of 55 meningiomas. Patients with neurofibromatosis were not included. Serial enhanced magnetic resonance imaging was used to determine tumor growth rates. Treatment history was also reviewed and included for analysis. RESULTS: Analysis of all 55 tumors demonstrated an average rate of growth of 0.46 cm(3)/year (range: -0.57-2.94 cm(3)/year). In the 23 tumors that received no treatment, the average rate of growth was 0.34 cm(3)/year (range: -0.03-1.8 cm(3)/year). Ten of the 23 tumors that received no treatment had no history of cranial irradiation. This group demonstrated a growth rate of 0.44 cm(3)/year (range: -0.01-1.8 cm(3)/year). Linear regression analysis did not yield any significant relationship between tumor burden and rates of growth. CONCLUSION: Tumor growth rates in patients with multiple meningiomas did not appear to be higher than reported rates for incidentally found solitary meningiomas. As such, asymptomatic multiple meningioma patients should be managed with clinical and radiographic follow-up.

Cerebral Vasospasm with Ischemia following a Spontaneous Spinal Subarachnoid Hemorrhage.

Cerebral vasospasm is a well-known consequence of aneurysmal subarachnoid hemorrhage (SAH) triggered by blood breakdown products. Here, we present the first case of cerebral vasospasm with ischemia following a spontaneous spinal SAH. A 67-year-old woman, who was on Coumadin for atrial fibrillation, presented with chest pain radiating to the back accompanied by headache and leg paresthesias. The international normalized ratio (INR) was 4.5. Ten hours after presentation, she developed loss of movement in both legs and lack of sensation below the umbilicus. Spine MRI showed intradural hemorrhage. Her coagulopathy was reversed, and she underwent T2 to T12 laminectomies. A large subarachnoid hematoma was evacuated. Given her complaint of headache preoperatively and the intraoperative finding of spinal SAH, a head CT was done postoperatively that displayed SAH in peripheral sulci. On postoperative day 5, she became obtunded. Brain MRI demonstrated focal restricted diffusion in the left frontoparietal area. Formal angiography revealed vasospasm in anterior cerebral arteries bilaterally and right middle cerebral artery. Vasospasm was treated, and she returned to baseline within 48 hours. Spontaneous spinal SAH can result in the same sequelae typically associated with aneurysmal SAH, and the clinician must have a degree of suspicion in such patients. The pathophysiological mechanisms underlying cerebral vasospasm may explain this unique case.

Multifocal and multicentric glioblastoma with leptomeningeal gliomatosis: a case report and review of the literature.

Glioblastoma (GBM) rarely presents as an infratentorial tumor in adults. The authors present a case of concomitant supratentorial and infratentorial GBM in an adult. A 72-year-old man presented with headache, nausea, vomiting, and lightheadedness. Initial MR images revealed enhancing masses in the right cerebellum and right posterior periventricular region. The patient underwent a suboccipital craniotomy and resection of the cerebellar lesion. Final histopathology was consistent with glioblastoma. The patient went on to receive standard radiation treatment for GBM with concurrent and adjuvant temozolomide. However, the patient experienced clinical deterioration within a few days after starting radiotherapy. He and his family decided to forego treatment and pursue palliative care. The patient expired three months after the initial diagnosis. Autopsy findings supported the diagnosis of GBM with leptomeningeal gliomatosis and involvement of the cerebrum, cerebellum, and spinal cord. The authors review the literature and propose that the pathogenesis of multiple and multicentric GBM may involve neural stem cells within the subventricular zone or could result from tumor dissemination along established CNS routes, such as white matter tracts and CSF pathways.

Cervical subarachnoid catheter placement for continuous cerebrospinal fluid drainage: a safe and efficacious alternative to the classic lumbar cistern drain.

BACKGROUND: Cerebrospinal fluid (CSF) drainage serves an important role in the management of patients with established or potential CSF fistulae. Classically, a lumbar CSF drain has been used for this purpose and has been shown to be safe and effective. In certain cases, such as extensive previous lumbar surgery, a lumbar drain cannot be used. In such instances, a cervical CSF drain can be inserted via a lateral C1-2 puncture and provides an excellent and safe alternative. OBJECTIVE: To describe the technique, safety, and effectiveness of placing a cervical drain for CSF drainage. Pitfalls and possible complications and their avoidance are also discussed. METHODS: Twenty-seven cervical drains were placed in 24 patients with a mean age of 56.1 years (range, 19-82 years). There were 13 women and 11 men. All cervical drains were placed via a lateral C1-2 puncture under direct fluoroscopic vision. A standard Hermetic closed-tip lumbar catheter was used in all cases. The drains were in place for an average of 5.96 days (range, 3-11 days). CSF surveillance was performed on the day of placement as well as every 48 hours that the drain was in place. RESULTS: Cervical drain placement was achieved in all cases, allowing for continuous CSF drainage. No permanent procedural complications occurred. There were no instances of meningitis. CONCLUSIONS: Placement of a cervical intrathecal catheter for CSF drainage is a safe and effective alternative when lumbar access is contraindicated or not achievable.

Minimally invasive repair of spontaneous intracranial hypotension.

Spontaneous spinal CSF leakage with the development of intracranial hypotension is a well-described entity. Cerebrospinal fluid leaks, mostly from the thoracic spine, are the major cause of spontaneous intracranial hypotension (SIH). Conservative treatment options include hydration, oral caffeine, and epidural blood patching. Alternatively, open surgical correction of meningeal diverticula is a therapeutic option. The authors describe 4 cases of spontaneous spinal CSF leakage producing symptoms of intracranial hypotension. All patients had multiple spinal diverticula with an identified leaking level. The patients were treated using a minimally invasive approach via surgical correction of the meningeal diverticulum.

Eagle syndrome as a cause of transient ischemic attacks.

Eagle syndrome is an uncommon entity but is well known in the otorhinolaryngology and oral surgery literature. This syndrome results from the compression of cranial nerves in the neck by an elongated styloid process causing unilateral cervical and facial pain. The styloid process can also cause compression of the cervical carotid arteries leading to the so-called carotid artery syndrome together with carotidynia or neurological symptoms due to flow reduction in these arteries. The authors discuss the case of a 70-year-old man who suffered from transient ischemic attacks on turning his head to the left, with immediate remission of symptoms when his head returned to the neutral position. The patient was studied with dynamic angiography, which clearly showed focal flow restriction. Once a diagnosis was made, the styloid process was removed surgically and the patient completely recovered from his symptoms. A postoperative angiogram demonstrated complete resolution of the pathology. Neurosurgeons might encounter patients with Eagle syndrome and should be aware of the symptoms and signs. Once the diagnosis is made, the treatment is clear and very effective.