Acute tetraplegia and cardiac arrest following high cervical leptomeningeal metastasis of giant cell glioblastoma.

Giant cell glioblastoma multiforme (gcGBM) is an unusual subtype of high-grade glioma (grade IV, World Health Organization classification). We report a patient with a rare acute tetraplegia, followed by lethal cardiac arrest, who had undergone a prior resection of a supratentorial gcGBM. Neuroradiological workup revealed a large, high cervical compressive leptomeningeal mass consistent with a drop metastasis. Due to the possibility of a rapid clinical deterioration in patients with high cervical cord compression, the diagnosis of drop metastasis to the spine should be considered in patients with a previous history of supratentorial GBM who present with acute diffuse motor weakness.

Surgical management of melanoma brain metastases in patients treated with immunotherapy.

OBJECT: Despite the increasing use of immunotherapy in the treatment of metastatic melanoma, the effects of this therapy on the management of patients with associated brain metastases are not completely defined. The authors undertook this study to determine the effectiveness of resection and the effects of immunotherapy on brain metastasis management. METHODS: The authors analyzed data pertaining to consecutive patients with metastatic melanoma treated with immunotherapy within 3 months of discovery of brain metastases that were surgically resected. RESULTS: Forty-one patients (median age 44.4 years, range 19.2-63.1 years) underwent resection of 53 brain metastases (median number of metastases 1, range 1-4). The median metastasis volume was 2.5 cm(3). Fifteen patients underwent whole-brain radiation therapy (WBRT) and 26 patients did not. Duration of survival from brain metastasis diagnosis was not significantly different between patients who received WBRT (mean 24.9 months) and those who did not (mean 23.3 months) (p > 0.05). Local and distant brain recurrence rates were not statistically different between the WBRT (7.1% and 28.6%, respectively) and non-WBRT (7.7% and 41.0%) groups for the duration of follow-up (p > 0.05). An objective systemic response to immunotherapy was associated with increased duration of survival (p < 0.05). CONCLUSIONS: Resection of melanoma brain metastases in patients treated with immunotherapy provides excellent local control with low morbidity. An objective response to systemic immunotherapy is associated with a prolonged survival in patients who have undergone resection of melanoma brain metastases. Moreover, adjuvant WBRT in melanoma immunotherapy patients with limited metastatic disease to the brain does not appear to provide a significant survival benefit.

Mucosa-associated lymphoma tissue of the dura presenting as meningioma.

Mucosa-associated lymphoma tissue (MALT) of the dura is extremely rare, with only a few reported cases worldwide. We present a unique case of a 61-year-old female who presented with neurologic symptoms of unsteady gait, dizziness, and sharp pain on her scalp for 3 weeks. A subsequent magnetic resonance imaging (MRI) of the brain demonstrated a dural-based mass radiographically consistent with meningioma. However, biopsy revealed the cells to be immunopositive for CD20 and CD79a, and immunonegative for CD5, CD10, CD43, and CD23. The neoplastic small lymphoid B cells were MUM1 positive and showed kappa light chain restriction, consistent with MALT of the dura. No evidence of systemic disease was found. The patient underwent radiation, which resulted in a complete response. MALT lymphoma, while rare, must be considered in the differential diagnosis in patients presenting radiographically with meningioma.

Pleomorphic xanthoastrocytoma presenting with life-threatening hemorrhage in a child.

Pleomorphic xanthoastrocytomas are glial-based tumors that arise most frequently in young patients and usually follow a more benign and indolent clinical course than their other glial-based tumor counterparts. These tumors most frequently present with seizures, and only 3 previous case reports exist of hemorrhagic tumor as the clinical presentation. The authors present the first case of life-threatening intracerebral hemorrhage from pleomorphic xanthoastrocytoma in a child.

Sublabial-endonasal approach to the sella turcica.

In this paper the authors describe the sublabial-endonasal-transsphenoidal approach to the sella turcica, a modification that combines elements of the sublabial-submucosal-transseptal approach and the endonasal approach. It provides a midline, or near midline, trajectory, wide exposure of the sella, and secure speculum placement on the osseous edge of the pyriform aperture, while avoiding dissection of the nasal mucosa, and it can be used for microscopic and endoscopic surgery.

Real-time imaging of convection-enhanced delivery of viruses and virus-sized particles.

OBJECT: Despite recent evidence showing that convection-enhanced delivery (CED) of viruses and virus-sized particles to the central nervous system (CNS) is possible, little is known about the factors influencing distribution of these vectors with convection. To better define the delivery of viruses and virus-sized particles in the CNS, and to determine optimal parameters for infusion, the authors coinfused adeno-associated virus ([AAV], 24-nm diameter) and/or ferumoxtran-10 (24 nm) by using CED during real-time magnetic resonance (MR) imaging. METHODS: Sixteen rats underwent intrastriatal convective coinfusion with 4 microl of 35S-AAV capsids (0.5-1.0 x 10(14) viral particles/ml) and increasing concentrations (0.1, 0.5, 1, and 5 mg/ml) of a similar sized iron oxide MR imaging agent (ferumoxtran-10). Five nonhuman primates underwent either convective coinfusion of 35S-AAV capsids and 1 mg/ml ferumoxtran-10 (striatum, one animal) or infusion of 1 mg/ml ferumoxtran-10 alone (striatum in two animals; frontal white matter in two). Clinical effects, MR imaging studies, quantitative autoradiography, and histological data were analyzed. RESULTS: Real-time, T2-weighted MR imaging of ferumoxtran-10 during infusion revealed a clearly defined hypointense region of perfusion. Quantitative autoradiography confirmed that MR imaging of ferumoxtran-10 at a concentration of 1 mg/ml accurately tracked viral capsid distribution in the rat and primate brain (the mean difference in volume of distribution [Vd] was 7 and 15% in rats and primates, respectively). The Vd increased linearly with increasing volume of infusion (Vi) (R2 = 0.98). The mean Vd/Vi ratio was 4.1 +/- 0.2 (mean +/- standard error of the mean) in gray and 2.3 +/- 0.1 in white matter (p < 0.01). The distribution of infusate was homogeneous. Postinfusion MR imaging revealed leakback along the cannula track at infusion rates greater than 1.5 microl/minute in primate gray and white matter. No animal had clinical or histological evidence of toxicity. CONCLUSIONS: The CED method can be used to deliver AAV capsids and similar sized particles to the CNS safely and effectively over clinically relevant volumes. Moreover, real-time MR imaging of ferumoxtran-10 during infusion reveals that AAV capsids and similar sized particles have different convective delivery properties than smaller proteins and other compounds.

A history of cerebral localization.

The brain has been known to be the center of voluntary movement, sensation, and intelligence for centuries. Nevertheless, it was not until the latter third of the 19th century that the functions of its different areas were discovered. It was the labor of several key men that made possible the accurate localization and, furthermore, the resection of brain neoplasms.