Peripheral T-Cell Lymphoma Presenting as a Scalp Mass.

Peripheral scalp T-cell lymphoma is a very rare disease. We report a case of a 22-year-old man who presented an indolent large scalp mass in the right frontal scalp region. The patient's physical examination demonstrated no palpable mass in the chest, abdomen, and extremities. The brain CT revealed a high-density large scalp mass of the subgaleal layer in the right frontal and a small scalp mass of the subgaleal layer in the left frontal. The brain MRI showed multifocal enhancing masses in the bilateral dura, the subgaleal layer of the scalp, and the skull. The patient underwent removal of the tumor found in the right frontal scalp. The histologic diagnosis was peripheral T-cell lymphoma. Bone marrow aspiration showed the involvement of T-cell lymphoma. The patient received chemotherapy with cyclophosphamide, vincristine, doxorubicin, and prednisolone (CHOP protocol) for 3 cycles. The patient was discharged without neurological deficit. The patient showed no evidence of recurrence 15 months after surgery. We report a rare case of peripheral T-cell lymphoma mimicking benign scalp tumors.

Embolization with Gamma Knife Radiosurgery of Giant Intracranial Arteriovenous Malformations.

AIM: Giant arteriovenous malformations (i.e., those greater than 6 cm maximum diameter or volume > 33 cc) are difficult to treat and often carry higher treatment morbidity and mortality rates. In our study, we reviewed the angiographic results and clinical outcomes for 11 patients with giant arteriovenous malformations who were treated between 1994 and 2012. MATERIAL AND METHODS: The patients selected included 9 males (82%) and 2 females (18%). Their presenting symptoms were hemorrhage (n=2; 18%), seizure (n=7; 64%), and headache (n=2; 12%). Nine patients were Spetzler-Martin Grade III, 2 were Spetzler-Martin Grade IV. The mean arteriovenous malformation volume was 41 cc (33-52 cc). The mean age of the patients was 45.1 years (24-57 years) and the mean radiation dose delivered to the margin of the nidus was 14.2 Gy. RESULTS: Ten patients received pre-Gamma Knife radiosurgery embolization and Gamma Knife radiosurgery, 1 patient received pre-Gamma Knife radiosurgery embolization and Gamma Knife radiosurgery twice and the interval between Gamma Knife radiosurgeries was 3 months. The complete obliteration rate following Gamma Knife radiosurgery was 36%, subtotal obliteration ( > 70% decreased size of nidus) was 36%, and partial obliteration was 28%. One patient experienced a small hemorrhage after embolization. CONCLUSION: Combined embolization and Gamma Knife radiosurgery showed successful obliteration of the arteriovenous malformation nidus. The use of embolization to initially reduce nidus size followed by Gamma Knife radiosurgery improves the treatment results. Repeated Gamma Knife radiosurgery should be a treatment option when there is a small nidus remnant.

A case of primary dural lymphoma: diffuse large B-cell type.

Primary leptomeningeal lymphoma is very rare disease that is a subtype of primary central nervous system (CNS) lymphoma. Primary dural lymphoma is a subentity of primary leptomeningeal lymphoma and arises from the dura mater without systemic disease. A 47-year-old woman presented with an indolent mass in the right frontal region. The patient's physical examination demonstrated no focal neurological abnormality. Magnetic resonance imaging (MRI) study revealed a mass lesion in the right frontal region. The patient underwent a right frontal craniectomy and removal of tumor. Histological diagnosis was diffuse large B-cell lymphoma (DLBCL). The patient received chemotherapy with rituximab, cyclophosphamide, adriamycin, vincristine, and prednisolone (R-CHOP protocol) every 3 weeks for six cycles. The patient was discharged without neurological deficit and no evidence of tumor recurrence. There was no systemic dissemination of disease 72 months after the surgery. Until the optimal standard management protocol is established, the treatment should be with an individualized multidisciplinary approach and continued follow-up and clinical surveillance are recommended for every patient.

Differences in myocardial sympathetic degeneration and the clinical features of the subtypes of Parkinson's disease.

Parkinson's disease (PD) can be divided into the akinetic-rigid (ART), mixed (MT), and tremor-dominant (TDT) subtypes according to the clinically dominant symptoms. We analyzed the correlations between (123)I-meta-iodobenzylguanidine (MIBG) uptake and the clinical features of patients with various PD subtypes. In addition, we evaluated the relationship between MIBG uptake and the severity of the cardinal motor symptoms among patients with PD subtypes. The mean Unified Parkinson's Disease Rating Scale motor scores differed significantly among patients with different PD subtypes (± standard deviation [SD]) (ART, 34.6 ± 18.28; MT, 24.63 ± 7.78; TDT, 16.22 ± 4.15, p=0.002), especially between the ART and TDT subtypes (p=0.022). The mean MIBG uptake (± SD) was decreased in the TDT (1.69 ± 0.39), MT (1.35 ± 0.32), and ART (1.35 ± 0.22) subtypes (p=0.049). The MIBG uptake values differed significantly between the ART and TDT subtypes (p=0.02). The MIBG uptake was inversely correlated with the severity of hypokinesia in the ART subtype (r=-0.75; p=0.01) and the MT subtype (r=-0.8; p=0.02), but it was not correlated with the severity of any of the parkinsonian motor symptoms in the TDT subtype. These results imply that hypokinesia is strongly associated with sympathetic myocardial degeneration and that sympathetic myocardial degeneration can reflect the progression of the disease in patients with the ART and mixed MT subtypes of PD.

What Is the Significance of a Large Number of Ruptured Aneurysms Smaller than 7 mm in Diameter?

OBJECTIVE: The International Study of Unruptured Intracranial Aneurysms (ISUIA) reported that the 5-year cumulative rupture rate of small unruptured aneurysms less than 7 mm in diameter is very low depending on the aneurysm's location. However, we have seen a large number of ruptured aneurysms less than 7 mm in clinical practice. The purpose of this study was to review our experience and to measure the size and location at which aneurysms ruptured in our patient population. METHODS: We reviewed the characteristics of aneurysms, such as size and location, from the original angiograms of patients who were admitted to our hospital between January 2004 and December 2007. All aneurysms were treated surgically or through endovascular procedures. RESULTS: Interventional or surgical treatment was given to a total of 889 patients, including 568 females and 321 males. At the time of our study, 627 cases were ruptured aneurysms and 262 cases were unruptured aneurysms. Of the ruptured cases, the mean diameter of the aneurysm was 6.28 mm. We found that 71.8% of ruptured aneurysms were smaller than 7 mm in diameter, and 87.9%, were smaller than 10 mm. Based on location, the data show that anterior communicating artery aneurysms most often presented with rupture sizes less than 7 mm (76.8%) and 10 mm (92.1%) in diameter. Most ruptured aneurysms were less than 7 mm in size, although recent studies have noted that small aneurysms are less likely to rupture. CONCLUSION: Although the natural history of unruptured intracranial aneurysms remains controversial, the aneurysm size and location play a signigicant role in determining the risk of rupture. Larger sample sizes and a long term study are needed to reveal the natural history and the rupture risk of unruptured intracranial aneurysms because the size of most ruptured aneurysms was less than 7 mm in diameter in our series.

Size and location of ruptured intracranial aneurysms.

OBJECTIVE: The aim of study was to review our patient population to determine whether there is a critical aneurysm size at which the incidence of rupture increases and whether there is a correlation between aneurysm size and location. METHODS: We reviewed charts and radiological findings (computed tomography (CT) scans, angiograms, CT angiography, magnetic resonance angiography) for all patients operated on for intracranial aneurysms in our hospital between September 2002 and May 2004. Of the 336 aneurysms that were reviewed, measurements were obtained from angiograms for 239 ruptured aneurysms by a neuroradiologist at the time of diagnosis in our hospital. RESULTS: There were 115 male and 221 female patients assessed in this study. The locations of aneurysms were the middle cerebral artery (MCA, 61), anterior communicating artery (ACoA, 66), posterior communicating artery (PCoA, 52), the top of the basilar artery (15), internal carotid artery (ICA) including the cavernous portion (13), anterior choroidal artery (AChA, 7), A1 segment of the anterior cerebral artery (3), A2 segment of the anterior cerebral artery (11), posterior inferior cerebellar artery (PICA, 8), superior cerebellar artery (SCA, 2), P2 segment of the posterior cerebral artery (1), and the vertebral artery (2). The mean diameter of aneurysms was 5.47+/-2.536 mm in anterior cerebral artery (ACA), 6.84+/-3.941 mm in ICA, 7.09+/-3.652 mm in MCA and 6.21+/-3.697 mm in vertebrobasilar artery. The ACA aneurysms were smaller than the MCA aneurysms. Aneurysms less than 6 mm in diameter included 37 (60.65%) in patients with aneurysms in the MCA, 43 (65.15%) in patients with aneurysms in the ACoA and 29 (55.76%) in patients with aneurysms in the PCoA. CONCLUSION: Ruptured aneurysms in the ACA were smaller than those in the MCA. The most prevalent aneurysm size was 3-6 mm in the MCA (55.73%), 3-6 mm in the ACoA (57.57%) and 4-6 mm in the PCoA (42.30%). The more prevalent size of the aneurysm to treat may differ in accordance with the location of the aneurysm.

Gamma knife surgery for intracranial cavernous hemangioma.

OBJECT: The purpose of this study was to assess the benefits of radiosurgery for cavernous hemangioma. METHODS: Sixty-five cavernous hemangiomas were treated with gamma knife surgery (GKS) between October 1994 and December 2002. Forty-two patients attended follow up. The mean patient age was 37.6 years (range 7-60 years). The lesions were located in the frontal lobe in 12 cases, deep in the parietal lobe in five, in the basal ganglia in five, in the temporal in three, in the cerebellum in three, in the pons/midbrain in six, and in multiple locations in eight cases. The presenting symptoms were seizure in 12, hemorrhage in 11, and other in 19. The maximum dose was 26.78 Gy, and the mean margin dose was 14.55 Gy. The mean follow-up period after radiosurgery was 29.6 months (range 5-93 months). The tumor decreased in size in 29 cases, was unchanged in 12, and increased in size in one. In the seizure group, seizures were controlled without anticonvulsant medication in nine cases (81.8%) after 31.3 months (range 12-80 months). After 93 months, one patient developed a cyst, which was resected. Rebleeding occurred in one case (2.3%). On T2-weighted imaging changes were seen in 11 cases (26.2%), in three (7.1 %) of which neurological deterioration was correlated with imaging changes. In other cases these deficits were temporary. CONCLUSIONS: The authors found that GKS was an effective treatment modality for cavernous hemangiomas, especially for those located within the brainstem, basal ganglia, or deep portions of the brain. It can reduce seizure frequency significantly although this takes time. In the group receiving a marginal dose below 15 Gy the patients fared better than when the dose exceeded 15 Gy.

Early development and rupture of de novo aneurysm--case report.

A 38-year-old non-smoker man presented with a ruptured aneurysm one month after clipping of a previous aneurysm. He was first admitted because of sudden onset of severe headache. Brain computed tomography showed subarachnoid hemorrhage. Angiography showed an aneurysm of the left anterior choroidal artery which was surgically clipped. Two weeks later, he was discharged without neurological deficits. One month after the initial hemorrhage, he was readmitted to the emergency room with stuporous mentality. Repeat angiography showed two aneurysms of the A2 portion of the left anterior cerebral artery which were not demonstrated by the initial angiography. The diagnosis was de novo aneurysms. The larger aneurysm was clipped and the other was coated. De novo aneurysm should be suspected if a patient with a previously clipped aneurysm complains of typical headache or any suggestive symptoms or signs of cranial nerve dysfunction, especially if known risk factors are present.