The usefulness of magnetic resonance angiography in surgery for intracranial aneurysms that have bled.

BACKGROUND: Once it was confirmed that magnetic resonance imaging (MRI) including angiography (MRA) could demonstrate intracranial aneurysms, a study was set up to establish whether satisfactory images could be obtained to plan and execute early surgery on ruptured intracranial aneurysms without recourse to intra-arterial digital subtraction angiography (IA.DSA) in the acute phase of the illness. METHODS: All patients presenting with a subarachnoid haemorrhage (SAH) were considered for MR studies. The patient selection was based on whether they were considered fit enough to tolerate scanning and did not have a known contraindication. A standard protocol was used--a three-dimensional time-of-flight with T1 and T2-weighted sagittal and axial images. If an aneurysm was demonstrated and early surgery was undertaken they were entered into the study. RESULTS: Over a 25-month period, 122 patients were submitted for MR studies, these being selected from over 200 patients presenting with an SAH. Aneurysms were believed to be present in 55 patients who were clinically suitable for early surgery. There were 21 males and 34 females, with an age range of 23-79 years, a mean of 50.5 years. Sixty-three aneurysms in all were demonstrated and 55 of these were surgically dealt with. There were two false positives. CONCLUSION: MRI is the investigation of choice to plan surgery in those patients presenting with an SAH who, on clinical grounds, would be considered suitable for early surgery. The imaging is easily obtained, non-invasive, avoids radiation, and in view of the multiple images obtained is often superior to conventional DSA.

Magnetic resonance angiography in the management of aneurysmal subarachnoid haemorrhage: a study of 51 cases.

We report preliminary experience with the use of magnetic resonance angiography (MRA) in the assessment of intracranial aneurysms. The aims of the study were to confirm that aneurysms could be detected and to assess the quality of the images with a view to early surgery if clinically indicated. We studied 51 patients with recent spontaneous subarachnoid haemorrhage with MRA, using a three-dimensional time-of-flight technique. The results of MRA were subsequently confirmed on intra-arterial digital subtraction angiography (IA-DSA) for anatomical correlation, and were considered satisfactory in 38 patients (74.5%). In 20 patients early surgical obliteration of their aneurysm was possible on the MRA results without recourse to IA-DSA. A total of 37 aneurysms were identified in 32 patients, while the remaining 6 patients did not have an aneurysm. MRA was misinterpreted in 4 patients (7.9%), and in 9 other patients (17.6%) MRA was unsatisfactory due to movement artefacts.

Magnetic resonance angiography for anterior midline aneurysms.

Over an 18-month period (June 1993-December 1994), all patients presenting with a subarachnoid haemorrhage (SAH) were considered for magnetic resonance angiography (MRA) as part of their investigation. Our experience to date leads us to believe that anterior midline aneurysms can be confidently and rapidly diagnosed with MRA alone without recourse to invasive intra-arterial digital subtraction angiography. This assumes, of course, that images can be obtained; some patients cannot be investigated by MR because of the presence of metallic foreign bodies; in a small proportion without anaesthesia the images will be so degraded as to be valueless and some patients will be judged unsuitable from the outset because of their clinical state. In 30 patients, a diagnosis of an anterior midline aneurysm was made on MRA and 21 of these patients underwent surgery on the MR images alone. Surgery, undertaken via a midline approach in these 21 patients, confirmed the MR findings.

Primary cerebral gliosarcoma: report of 17 cases.

A retrospective study of 17 cases of primary cerebral gliosarcoma is presented. These uncommon highly aggressive intracranial neoplasms were seen at the Royal Preston Hospital, between 1973 and 1992. The patients' ages ranged from 21 to 73 years (mean 52), nine were males and eight were females. They presented with signs and symptoms of a rapidly expanding brain tumour. The diagnosis was suspected on radiological findings and confirmed by histological examination. Treatment involved surgical excision in 15 cases and biopsy in two followed by radiotherapy. Chemotherapy was given in three cases. Despite active management, median survival was only 9 months. The clinical, radiological and pathological features of these lesions are highlighted with emphasis on combined histochemistry and immunohistochemistry. The features of gliosarcoma and glioblastoma are compared and contrasted.

Chronic simultaneous bilateral extradural haematomas.

Bilateral extradural haematomas are rare, usually acute, and generally associated with severe trauma and a high mortality. We report the case of a 39-year-old man who presented with chronic simultaneous bilateral extradural haematomas in whom the trauma appeared to be trivial and initially unrecognised and in whom a unilateral evacuation was curative.

De novo development of saccular aneurysms: report of two cases.

The development of de novo aneurysms after previous successfully treated aneurysms is uncommon. If risk factors are not present the patient may be reassured that the risk of developing a further aneurysm following successful treatment is minimal. Two cases of second aneurysms developing six and eighteen years after successful treatment of a first aneurysm are reported. The risk factors associated with the formation of second aneurysms are emphasized.

Minimally invasive neurosurgery using CRW-3 stereotaxy.

The Cosman-Roberts-Wells (CRW-3) scanner independent stereotactic system is a recent arc-radius design developed from the Brown-Roberts-Wells system. The results of 74 supratentorial non-basal tumor suspect cases treated with this second generation computed tomography (CT) guided stereotactic apparatus are presented. Using a simple stereotactic target classification coupled with biopsy, trephine or mini-craniotomy, it has been possible to biopsy, excise and develop new strategies using microneurosurgical techniques with extremely low morbidity.

Optochiasmal arachnoiditis induced by muslin wrapping of intracranial aneurysms. A report of two cases and a review of the literature.

Muslin wrapping of intracranial aneurysms has been used for many years, but muslin-induced optochiasmal arachnoiditis was first reported only in 1978, as a complication with catastrophic loss of vision. In this study of 54 cases wrapped with muslin over the last six years, two cases of optochiasmal arachnoiditis occurred. Three patients had early rebleeding among the 27 who had wrapping as the only treatment of the aneurysm.

Intracranial meningeal melanocytoma: a report of two cases and a review of the literature.

Two rare cases of intracranial meningeal melanocytoma are reported with clinical, radiologic, and pathologic findings. In one of these the diagnosis was established by ultrastructural studies that showed premelanosomes and melanosomes in nonarachnoid-derived tumor cells. The other case was diagnosed retrospectively after a very long survival and is still alive 35 years after total excision and radiotherapy. The occurrence of these tumors in the cerebellopontine angle is rare as seen in our case.

Multifocal giant cell glioblastoma: case report.

Glioblastoma multiforme (GM) of the cerebellum is a rare tumour. A variant of GM, a multifocal giant cell glioblastoma, initially presenting in the cerebellum, has not previously been reported. A giant cell glioblastoma occurring in a 46-year-old man who presented initially with a cerebellar tumour is described. One month after excision of the tumour, the patient had a grand mal seizure. Computed tomography (CT) showed a low-density lesion in the left temporal lobe. Four months later he developed dysphasia and right-sided hemiparesis. Repeat CT scan revealed a large temporal lobe tumour which was excised, and histologically found to be a giant-cell glioblastoma with histopathological similarities to the original cerebellar tumour. The clinical course, computed tomographic and pathological features of this tumour are described and discussed.

Primary malignant non-Hodgkin's lymphoma of cranial vault: a case report.

Primary cranial vault non-Hodgkin's lymphomas are rare and only four such cases are described in the literature. A 65-year-old woman presented with focal neurological deficits and a subcutaneous scalp lump. Computed tomography (CT) scan showed a left parietal cranial vault lesion with soft tissue scalp swelling and underlying intracranial extra axial mass mimicking a meningioma. Histology showed features of a typical B-cell non-Hodgkin's lymphoma, there was no systemic involvement. The characteristic CT findings of this lesion are described and relevant literature is reviewed. We are reporting this case because of its rare occurrence. A diagnosis of primary lymphoma of the skull vault should always be considered in the differential diagnosis when such a lesion is encountered.

Osteoradionecrosis of the petrous bone and recurrent cerebrospinal fluid otorrhoea.

A case is reported of delayed necrosis of the petrous bone following a course of radiotherapy for a well-differentiated squamous cell carcinoma in a 60-year-old female who presented with recurrent intractable cerebrospinal fluid otorrhoea, meningitis and pneumocephalus. Multiple attempts at surgical repair of the necrosed dural deficit and tegmental fistula failed and eventually petrousectomy was necessary leading to a successful outcome.

The anterior interhemispheric trephine approach to anterior midline aneurysms: results of treatment in 72 consecutive patients.

We report the results of a prospective study of an anterior interhemispheric trephine approach in 72 consecutive patients with aneurysms of the anterior communicating artery (64 cases) and anterior cerebral arteries (eight cases). The salient features of the operative technique include a limited forehead crease incision, low anterior frontal midline trephine (4 cm), unilateral dural opening (2.5 cm), opening up of the anterior interhemispheric fissure and exposure of aneurysm and anterior cerebral vessels by a phased dissection. The best anatomical orientation is retained without compromising the superior sagittal sinus, falx cerebri, left frontal cortical veins, or eloquent areas of the brain. The results (excellent to good recovery or mild to moderate disability in 87.5% of cases) confirm that the technique is safe and well tolerated even in the elderly or fragile patients.

Case report: arachnoiditis following intracranial 'Thorotrast'.

A patient is reported with a painless, progressive cauda equina lesion due to arachnoiditis, the result of the contrast medium 'Thorotrast' (thorium dioxide) introduced into the brain over 30 years previously. Contrast medium introduced into the lumbar spine can give rise to aseptic adhesive inflammation (arachnoiditis). It rarely gives rise to clinical problems but, when it does so, is usually associated with back pain and only very rarely with progressive neurological deficit.

Primary cerebral lymphoma: report of 24 patients and review of the literature.

A retrospective study of 24 patients with primary non-Hodgkin's cerebral lymphoma (non-immunocompromised) is presented. All patients were seen at the Royal Preston Hospital, Lancashire between 1976 and 1991. Fifteen patients were over the age of 50 years (range 27-84). The commonest clinical presentation, seen in 16 patients was of an expanding space-occupying lesion. The diagnosis was suspected from the radiological findings but confirmation in every case was by histological examination of biopsy or necropsy material. The tumours were treated either by surgical excision or by biopsy and radiotherapy. Chemotherapy was given in two patients. Despite these measures the mean survival time was 3.6 months. The clinical radiological and pathological features of these tumours are highlighted with particular emphasis on the use of stereotactic biopsy, immunohistochemistry and chemotherapy in diagnosis and treatment.

Cerebrospinal fluid rhinorrhoea associated with colloid cyst.

Three cases of non-traumatic cerebrospinal fluid (CSF) rhinorrhoea secondary to colloid cysts are presented. Non-traumatic CSF rhinorrhoea is rare and in only two previous reports has it been attributed to a colloid cyst.

A simple method of estimating the size of large pituitary adenomas.

A method of measuring the volume of large pituitary adenomas is described. Measurements obtained are useful in the follow-up of patients whose tumours are treated by partial excision and radiotherapy. The method is felt also to be useful in judging whether or not a tumour should be designated a giant one thereby aiding management as well as follow-up. The method is simple and easily repeatable.