Intracranial hypertension due to meningioma of the unique transverse sinus.

We describe a 28-year-old woman with intracranial hypertension due to a meningioma invading the unique transverse sinus (with absent contralateral sinus). Clinical remission and normalization of orbital echography were obtained by resection of the intradural tumor and peeling of the dural attachment. In such cases, resection and reconstruction of the involved sinus segment is at high risk of venous infarction. Endovascular stenting of the obstructed sinus is a valid alternative when the stenosis is not remarkable. Single tumor removal may lead to partial sinus decompression and increased venous flow, resulting in long-term clinical remission.

MRI features of spinal solitary fibrous tumors. A report of two cases and literature review.

Spinal solitary fibrous tumors (SFT) are very rare neoplasms occurring in the spinal canal, with only 38 cases reported in ten years since the first description. We describe two cases of SFT of the spine and review 33 well-documented cases in the literature to define distinctive radiological and surgical features raising the suspicion of a spinal SFT before histological verification. A 67-year-old man with cervical myeloradiculopathy had a large extramedullary tumor of the cervical spinal canal extending from C4 to C7. On MRI the tumor was isointense on T1-sequences and hypointense on T2-sequences, and had marked contrast enhancement. At surgery, the tumor was intradural extramedullary, with no dural or root attachment, but it was adherent to the cord. Complete tumor removal was achieved with good outcome. A 75-year-old man with progressive thoracic myelopathy had an intramedullary tumor at C6 and C7 level, which was hypointense on T1- and T2-weighted images of MRI. At surgery, the tumor was intramedullary and strongly adherent to the cord; it was successfully removed. Both tumors were composed of elongated cells with a collagen-matrix background. Immunohistochemical staining was positive for vimentin, CD34, and bcl-2, and negative for EMA and S-100 protein. A careful analysis of our own and the other reported cases of spinal SFTs may disclose some peculiar features of this rare tumor. A spinal intramedullary or extramedullary tumor, hypointense on T2-weighted images of MRI, which intraoperatively shows hard consistency, scarce vascularization, no nerve root involvement, no or weak dural attachment, absence of arachnoidal interface, and adherence to the spinal cord may suggest the diagnosis of SFT.

Intracranial extension of salivary gland tumors.

OBJECTIVE: The aim of this report is to describe 3 cases of salivary gland tumors with intracranial extension associated to an extracerebral mass lesion, and to discuss the frequence, pathology and treatment of these very rare localizations. CLINICAL MATERIAL: The 3 patients were 1 woman and 2 men, aged 44, 53 and 74 years, respectively. The primary tumors were an adenocarcinoma and a malignant oncocytoma of the parotid gland and an adenoid cystic carcinoma of the submandibular gland. The location of the intradural extra-axial tumor was the middle fossa and temporal region in 2 cases and the cerebellopontine angle in 1. Surgical treatment consisted in the seemingly complete removal of 2 tumors with middle fossa localization and partial removal of the cerebellopontine angle lesion. Radiotherapy was administered in all 3 cases and chemotherapy in 2. RESULTS: 1 patient is alive and free of recurrence 32 months after removal of the intracranial tumor; 2 other patients died 28 months and 12 months postoperatively. CONCLUSIONS: The intracranial extension of salivary gland tumors is a very rare event. An aggressive surgical resection followed by radiotherapy is justified in cases with significant intracranial mass lesions and scarce bone and dural involvement.

Early clinical and neuroradiological worsening after radiotherapy and concomitant temozolomide in patients with glioblastoma: tumour progression or radionecrosis?

OBJECTIVES: This study investigates the diagnosis and management of patients with resected brain glioblastomas who presented early clinical and neuroradiological worsening after the completion of the Stupp protocol. Its aim is to discuss the occurrence of early radionecrosis. METHODS: Fifty patients with brain glioblastoma treated by surgical resection and Stupp protocol were reviewed; 15 among them (30%) had early clinical and neuroradiological worsening at the 6-month follow-up. The MR spectroscopy and surgical findings of these patients are reviewed. RESULTS: MR spectroscopy was in favour of tumour recurrence in 14 among 15 patients and showed radionecrosis in one. Among 10 patients who were reoperated on, 7 had histologically verified tumour recurrence or regrowth, whereas in 3 histopathology showed necrosis without evidence of tumour. The 7 patients with tumour progression had prevalence of focal neuroradiological signs (6/7) and a survival of 7.5-12 months (median survival 10 months). The 4 patients with early radionecrosis (including one patient who was not reoperated on) had clinical worsening with mental deterioration, confusion and ataxia, and MR spectroscopy positive for tumour recurrence in 3. Three were alive 24-30 months after the end of the radiotherapy, whereas one died at 40 months. CONCLUSION: Early radionecrosis after the Stupp protocol is not a rare event due to the radiosensitization effect of temozolomide. This phenomenon may predict a durable response to radiotherapy. MR spectroscopy may simulate tumour recurrence. A correct diagnosis is necessary to avoid useless reoperations and incorrect withdrawal of temozolomide.

Fronto-ethmoidal and orbital osteomas with intracranial extension. Report of two cases.

Osteomas involving the anterior cranial base are quite rare lesions. Intracranial and orbital extension of these tumors, causing neurological and ophthalmological symptoms and signs is a rare event. Two such cases are reported. In the first one, the tumor arose from the frontal sinus and extended upward to the medial and superior wall of the right orbital cavity and the lower part of the right frontal convexity. In the second case the osteoma arose from the left orbital roof and extended to the lower part of the homolateral frontal convexity and the splenoid wing. After the operation the symptoms disappeared and the cosmetic deficits were corrected. Skull-films, CT and MR well define the bony extension and the displacement of the orbital and intracranial structures. Indications to the surgery include progressive ophthalmologic and neurologic signs and significant cosmetic deformations. The surgical techniques and the postoperative complications are briefly discussed.

Central neurocytoma: clinico-pathological study of 5 cases and review of the literature.

Five cases of central neurocytoma, confirmed by immunohistochemical and electron microscopy studies, are reported and 127 cases from the literature are reviewed. Central neurocytomas are more frequent than previously thought, and will be diagnosed with increasing frequency in the future, if intraventricular tumors with histological aspect of oligodendroglioma or ependymoma will be routinely studied by immunohistochemistry and electron microscopy. The occurrence of an intraventricular tumor with a typical MR aspect in a young patient should suggest preoperatively the diagnosis of neurocytoma. The positivity for synaptophysin and neuron specific enolase, the negativity for neurofilament protein and glial fibrillary acid protein, and the finding of elements of neuronal differentiation on electron microscopy, are the main pathological features of these tumors. Complete removal of the tumor mass without radiotherapy is the treatment of choice. The prognosis is usually favorable without recurrence.

Post-radiation cerebral lesions in adults.

For many years, the human brain was considered relatively resistant to therapeutic doses of radiation. With the increasing length of survival of patients irradiated for brain tumors, there have been reported long-term effects of radiation therapy due to inappropriate dosage, period of delivery, fractionation or field. Thus, randomized studies are needed both to optimize the radiation therapy technique than to integrate new therapeutic modalities into the management of patients with primary brain tumors.

Leptomeningeal carcinomatosis: review of the literature.

Metastases from solid tumors that seed the leptomeninges (meningeal carcinomatosis) are an important neurologic complication of systemic cancer. Recently many authors have reported that its incidence is increasing; particularly it has been demonstrated for breast cancer and small cell bronchogenic carcinoma. A cytologic examination of cerebrospinal fluid (CSF) establishes the diagnosis. Gadolinium-enhanced MRI has demonstrated superiority over other imaging with the clinical context and CSF analysis may lead to a rapid diagnosis and treatment of leptomeningeal carcinomatosis. Despite all measures, prognosis remains poor because of the presence of multiple metastases elsewhere.

Spontaneous cure of a ruptured intracranial aneurysm.

A rare case of spontaneous cure of an internal carotid artery aneurysm is reported; the progressive resolution of the spasm and the disappearance of the aneurysm have been confirmed by serial angiograms respectively performed two weeks, two months and four months after the hemorrhage. The other 14 reported cases of angiographically documented spontaneous cure of intracranial aneurysms are reviewed and the possible causes of spontaneous aneurysmal thrombosis, such as retarded cerebral circulation, arterial spasm, size of the neck, thrombosis of the feeding artery and antifibrinolytic therapy, are discussed.

Prognostic significance of lymphoid infiltration in cerebral malignant gliomas.

Data concerning a study on lymphoid infiltration in 61 cerebral malignant gliomas are reported. Lymphoid cellular infiltrates were found in 28 cases (45.9%): 8 (13.1%) with marked and 20 (32.8%) with slight infiltration; the remaining 33 cases (54.1%) did not exhibit lymphoid infiltration. The mean survival time (+/- standard deviation) of patients harboring gliomas with marked lymphoid infiltration was 20.5 (+/-19.9) months, and that of patients with slight lymphoid infiltration in their glioma was 10.3 (+/- 7.5) months; those patients having gliomas without lymphoid cellular infiltrates showed a mean survival time (+/- standard deviation) of 7.2 (+/-6.1) months.

Cerebral gliosarcomas: correlation of computed tomographic findings, surgical aspect, pathological features, and prognosis.

The cases of 5 patients with cerebral gliosarcomas examined by computed tomography are reported and the correlations among the computed tomographic (CT) findings, the surgical and histological aspects, and the prognosis are discussed. In some patients, these tumors appear on CT scan as intracerebral lesions, with large necrotic areas and peripheral contrast enhancement; this CT aspect, similar to that of glioblastomas, corresponds to a diffusely infiltrating growth of the tumor and the prevalence of a gliomatous component. In other patients, the tumor appears on the CT scan as a hyperdense mass with well-defined margins and homogenous contrast enhancement; this CT finding, which may mimic that of a meningioma, corresponds to a rather well-demarcated surgical aspect and the prevalence of sarcomatous component. In our series, we have also noticed a more prolonged survival in a patient with a CT aspect that suggested a meningioma and prevalence of the sarcomatous component.

Intracranial plasma cell granuloma.

An exceptional case of intracranial plasma cell granuloma, located in the right frontoparietal convexity in a 16-year-old boy is reported. Reports of these rare inflammatory lesions locate them primarily in the lungs and in other regions of the body, and only exceptionally in the nervous system; indeed, only three intracranial cases and one other arising from the spinal meninges have been reported. The computed tomographic and surgical aspects suggested a falx meningioma in our case. The pathological diagnosis differentiating these from other intracranial lesions with a plasma cell component, including meningioma with plasma cell infiltration and plasmacytoma, is discussed.

Postoperative cervical pseudomeningocele.

A case of postoperative cervical pseudomeningocele in a woman submitted to laminectomy for protruded disc is reported. The patient was investigated by myelography and metrizamide computed tomography and surgically treated with a good neurological result. The other eight reported cases of postoperative cervical pseudomeningocele are reviewed and the role of metrizamide CT scan in diagnosing this unusual complication of cervical laminectomies is emphasized.

Primary lymphoma of the cranial vault.

An exceptional case of a large intracranial extradural lymphoma arising from the skull and causing intracranial hypertension syndrome, in the absence of other localizations elsewhere in the body is described. Only another similar observation was reported in the literature. The diagnosis of this exceptional localization of lymphomas, which can mimic other intracranial tumors, is discussed on the basis of the computer-tomography findings and the usefulness of the radiotherapy is pointed out.

Craniopharyngioma of the cranial base and nasopharynx.

A rare case of craniopharyngioma extending to the cranial base and nasopharynx is reported and eight other cases in the literature are reviewed. The embryology and the clinical features of these tumors are discussed. Tomograms of the skull and computed tomography are the most useful radiological tools of investigation. A nasoseptal or transpalatal approach to surgery, which has been performed in reported cases of cystic nasopharyngeal craniopharyngiomas, was not performed on our patient because of the hard consistency and the diffusely infiltrating aspect of the tumor.

Cerebral edema associated with meningiomas.

Fifty patients with intracranial meningiomas have been retrospectively examined, and the cerebral edema on computed tomography scan has been correlated with the clinical evolution, size, location, and histological features of the tumor. The degree of brain edema was found to be related to the clinical evolution and the size of the tumor, whereas the histological features were less significant. These results are discussed after reviewing the data of five other series in the literature of this subject. A correlation between the tumor steroid receptors and edema is suggested.

Postoperative intracerebral haemorrhages remote from the site of the initial operation.

Two cases of postoperative intracerebral haemorrhages remote from the site of the initial craniotomy for saccular aneurysms are reported and the other cases from the literature are reviewed. Lack of a good postoperative recovery and the appearance of neurological signs not related to the site of the operation may suggest this complication, which is associated with high mortality and disability rate. The possible pathogeness of those postoperative haemorrhages is discussed.