Microscopic biopsy after unsuccessful endoscopic biopsy for primary central nervous system lymphoma of the corpus callosum: A case report.

INTRODUCTION AND IMPORTANCE: Primary central nervous system lymphoma (PCNSL) is a rare tumor with a poor prognosis. Early brain biopsy is essential to avoid a diagnostic delay. To date, reports of successful diagnosis for PCNSL of the corpus callosum by endoscopic biopsy are rare. CASE PRESENTATION: Herein, we report the case of an elderly woman with PCNSL of the corpus callosum who initially presented with rapidly progressive dementia. The condition was finally diagnosed by microscopic biopsy after unsuccessful endoscopic biopsy. Moreover, the postoperative course was uneventful. She is currently receiving systemic chemotherapy. CLINICAL DISCUSSION: Early diagnosis and subsequent systemic chemotherapy with or without whole brain radiotherapy are critical for PCNSL. Endoscopic biopsy may be a diagnostic option for suspected PCNSL, although stereotactic needle biopsy is most commonly used. CONCLUSION: Utilizing neuronavigation and 5-aminolevulinic acid (ALA) fluorescence guidance could be helpful in identifying lesions insufficiently exposed by endoscopic visualization. However, cerebrospinal fluid (CSF) loss due to the endoscopic approach through the ventricle might be a cause of neuronavigation misregistration.

Idiopathic unilateral oculomotor nerve palsy: A case report.

Cranial nerve III palsy, also known as oculomotor nerve palsy, may result from various causes; however, the etiology remains unknown in some instances. The aim of this case report is to present the authors' experience with two cases of idiopathic cranial nerve III palsy, together with a review of the literature. Case 1 is a 78-year-old woman and case 2 is a 75-year-old man, both having no history of trauma and no vascular risk factors. They presented to the authors' hospital with diplopia and palpebral ptosis and were diagnosed with idiopathic unilateral cranial nerve III palsy. They received oral steroids for treatment. One patient recovered completely within 3 months, while the other patient did not recover regardless of long-term follow-up. Idiopathic cranial nerve III palsy can occur in otherwise healthy individuals and often recover in several months. Careful examinations to rule out other causes and then steroid treatment should be considered after early diagnosis.

Frontotemporal epi- and subdural approach to a cavernous sinus tumor for sphenobasal vein preservation--technical case report.

In cavernous sinus (CS) surgery, venous complication may occur in some types of venous drainage. The sphenobasal vein (SBV) drains from the superficial middle cerebral vein (SMCV) to the pterygoid venous plexus at the temporal skull base. A frontotemporal epi- and interdural approach (Dolenc approach), which is one of the CS approaches, may damage the SBV's route. We report a case of intracavernous trigeminal schwannoma that contained the SBV and discuss our modified surgical procedure that combined epi- and subdural approaches to preserve the SBV. A 64-year-old man complained of right progressive oculomotor palsy and was referred to our hospital for surgery. MR images revealed a hemorrhagic tumor in the right CS. Three-dimensional venography revealed that the SMCV drained into the pterygoid venous plexus via the SBV. After identifying the first branch of the trigeminal nerve epidurally, we incised the dura linearly along the sylvian fissure and entered the subdural space to visualize the SBV. The incision was continued to the meningeal dura of the lateral wall of the CS along the superior margin of the first branch of the trigeminal nerve, and the Parkinson's triangle was opened from the subdural side. The tumor was grossly totally removed, and the SBV was preserved. In conclusion, a frontotemporal epi- and subdural approach to the intracavernous trigeminal schwannoma can effectively preserve the SBV.

Subarachnoid hemorrhage causing cardiopulmonary arrest: resuscitation profiles and outcomes.

Aneurysmal subarachnoid hemorrhage (SAH) is a common cause of cardiopulmonary arrest (CPA). The outcomes of SAH patients presenting with CPA are extremely poor, and long-term survivors have occasionally been reported, but the circumstances under which SAH-CPA patients achieve long-term survival are unclear. Neurosurgeons will have to determine whether a SAH-CPA patient is brain-dead or not more often after enactment of the revised Organ Transplantation Act. Prediction of survival length may be important not only to neurosurgeons, but also to the transplantation team. A retrospective study was conducted to elucidate how often brainstem function was recovered in resuscitated SAH-CPA patients and whether the recovery was associated with longer survival. Among 315 patients with non-traumatic SAH admitted to our institution during 6 years, 35 (11%) presented with CPA. Ventricular fibrillation (VF) as initial cardiac rhythm was rare, observed only in 1 patient. The survival length ranged from 1 to 15 days (mean 3.5 ± 0.7 days), and none achieved long-term survival. Return of brainstem function, represented by spontaneous respiration and/or reactive pupils, was observed in 6 patients (17%), but was only partial and transient. Cardiac arrest to return of spontaneous circulation interval tended to be shorter in patients with transient recovery of the brainstem function than in those without recovery. However, the survival length was not significantly different between the two groups. In addition to the 35 SAH-CPA patients, another 44 SAH patients lost both brainstem reflexes and spontaneous respiration within 72 hours of admission. As a result, 79 (25%) of the 315 SAH patients were considered to have sustained fatal, irreversible brain damage. Review of previous experience suggests that SAH-CPA patients may survive only if the cause of cardiac arrest is VF and not brainstem damage/respiratory arrest. Approximately one-third of resuscitated SAH-CPA patients may die within 24 hours of arrival, for whom the declaration of brain death may be difficult.

Spontaneous intracranial hypotension presenting without orthostatic headache complicated by acute subdural hematoma after drainage for chronic subdural hematoma--case report.

A 28-year-old man presented with a case of spontaneous intracranial hypotension (SIH) manifesting as a bilateral chronic subdural hematoma (CSDH) without orthostatic headache. He developed life-threatening acute SDH as a complication of CSDH drainage. Neurosurgeons should be aware that SIH patients do not always present with orthostatic headache. Brain magnetic resonance imaging with gadolinium may be recommended for young adults with non-traumatic CSDH before drainage to exclude SIH, even if they do not present with orthostatic headache.

Fulminant ependymitis following intraventricular rupture of brain abscess.

A 48-year-old man with a history of a penetrating brain injury was referred with a presumptive diagnosis of bacterial meningitis. Examination revealed a brain abscess in addition to meningitis. Blood and cerebrospinal fluid (CSF) cultures were negative for bacteria, and empirical IV antibiotic therapy with vancomycin (VCM) and meropenem was initiated. Despite initial improvement, however, his condition rapidly deteriorated into coma following intraventricular rupture of the abscess and hydrocephalus. Thereafter, an emergency ventriculostomy was performed and the abscess was evacuated. Bacterial cultures of the pus were negative. To manage the hydrocephalus, 150-200 ml of CSF were drained daily. Intraventricular administration of VCM (20 mg q.d.) was added to the IV antibiotic therapeutic regimen after surgery. Although the primary abscess rapidly decreased in size, ependymitis developed in the fourth ventricle. This new lesion, which resulted from CSF dissemination from the primary abscess, was refractory to treatment, and eventually disappeared after the intraventricular VCM dosage was increased from 20 to 30 mg and continued for 30 days. A possible reason for the development of fulminant ependymitis and why it was refractory to treatment despite the shrinkage of the primary lesion may be that physiological CSF flow from the lateral to the fourth ventricle was lost due to CSF drainage, and the stagnant CSF flow coupled with an insufficient VCM level in the fourth ventricle facilitated the rapid growth of pathogens. Although intraventricular antibiotic administration is efficacious for treating ruptured brain abscesses, it may be associated with the unexpected development of secondary lesions.

Gliomatosis cerebri mimicking chemotherapy-induced leukoencephalopathy in a patient with non-Hodgkin's lymphoma.

Patients with hematological malignancies may develop white matter lesions, which are usually associated with chemotherapy. Magnetic resonance imaging (MRI) is the imaging modality of choice for identifying chemotherapy-induced, or "toxic", leukoencephalopathy. Brain biopsy in patients with hematological malignancies suspected of sustaining toxic leukoencephalopathy has rarely been performed, because its characteristic MRI findings are considered pathognomotic. Biopsy may be indicated in atypical cases, however, and it may yield unexpected results. We describe a case with white matter lesions that developed in an elderly man treated for non-Hodgkin's lymphoma. The lesions, initially diagnosed with toxic leukoencephalopathy based on MRI findings, turned out to be gliomatosis cerebri.

Does difference in the storage method of bone flaps after decompressive craniectomy affect the incidence of surgical site infection after cranioplasty? Comparison between subcutaneous pocket and cryopreservation.

BACKGROUND: After decompressive craniectomy for brain swelling, bone flaps need to be stored in a sterile fashion until cranioplasty. Temporary placement in a subcutaneous pocket (SP) and cryopreservation (CP) are the two commonly used methods for preserving bone flaps. Surgical site infection (SSI) is a serious complication of cranioplasty, and the storage method associated with a lower SSI incidence is favored. It is unclear, however, whether one storage method is superior to the other in terms of SSI prevention. METHODS: During a 9-year period, 70 patients underwent decompressive craniectomy and subsequent cranioplasty. Bone flaps from 39 patients were stored using SP and those from the other 31 were stored using CP. Demographic data and SSI incidence was compared. RESULTS: There were no significant demographic differences between the groups. SSI occurred in seven patients: 2 (5.1%) in the SP group and 5 (16.1%) in the CP group. The difference was not statistically significant (p = 0.23). When each group was further divided into two categories based on etiology (traumatic brain injury [TBI] versus non-TBI), CP showed a significantly higher SSI incidence compared with SP (28.6% versus 0%, p = 0.02) in the TBI category. However, the difference in incidence was not significant in the non-TBI category. CONCLUSIONS: SP and CP may be equally efficacious for storage of bone flaps of non-TBI etiology; however, SP may be the storage method of choice for TBI. It remains to be verified in a prospective fashion whether SP is truly the better method of storing bone flaps in TBI.

Ultrasound-guided needle aspiration of epidural hematoma in a neonate after vacuum-assisted delivery.

INTRODUCTION: Epidural hematoma (EDH) is a rare complication of vacuum-assisted delivery in neonates. Although the standard treatment of EDH is surgical evacuation via craniotomy, it is an invasive procedure in neonates, and less invasive methods may be favored for hematoma evacuation. CASE REPORT: We report a case of 5-day-old infant with a massive EDH, cephalohematoma, and a depressed fracture, which were secondary to a vacuum-assisted delivery and cured by ultrasound-guided needle aspiration and drainage. Neonatal EDH may be different from adult counterpart in that the former is more liquefied and is amenable to needle aspiration than the latter. Although needle aspiration is a blind procedure, addition of transcranial ultrasound not only ensures safety by visualizing the tip of the needle but also makes real-time evaluation of the residual hematoma volume possible.

Influence of age and anti-platelet/anti-coagulant use on the outcome of elderly patients with fall-related traumatic intracranial hemorrhage.

Ground-level fall is the most common cause of traumatic intracranial hemorrhage (TICH) in the elderly. Many studies on geriatric TICH have regarded patients aged ≥65 years as a single group, but substantial heterogeneity is likely to exist within this population. Eighty-two elderly patients with fall-related TICH treated in our institution during a 6-year period were stratified into 3 age groups (65-74, 75-84, and ≥85 years), and intergroup differences in the demographics and outcomes at discharge were evaluated. The influence of the use of anti-platelet/anti-coagulant (AP/AC) agent on outcomes was also investigated. Comparison of demographic variables demonstrated significant differences in the frequency of preinjury alcohol consumption and use of AP/AC agents between the 3 groups, indicating that the causes or triggers of fall might be substantially different between the 65-74 years group and the other two groups combined. The frequency of unfavorable outcomes increased with age, and the increase was statistically significant. The 82 patients were divided into two subgroups depending on the use of AP/AC agents. The outcomes of the ≥85 years group taking AP/AC agents were particularly poor compared with those of the ≥85 years group not using AP/AC agents. Advancing age may be associated with unfavorable outcomes in elderly patients with fall-related TICH, and patients aged ≥85 years taking AP/AC have the greatest risk of unfavorable outcomes. Physicians must consider the risk/benefit analysis before prescribing AP/AC agents to patients aged ≥85 years.

Glioblastoma masquerading as a hypertensive putaminal hemorrhage: a diagnostic pitfall.

A 58-year-old man presented with a rare case of glioblastoma masquerading as intracerebral hemorrhage (ICH). He had been medicated for hypertension and diabetes for 10 years before collapsing at home. Brain computed tomography (CT) showed ICH in the right putamen, but CT with contrast medium showed no underlying lesion. He was treated initially with intravenous administration of anti-hypertensive agent under a diagnosis of hypertensive putaminal hemorrhage. ICH aspiration surgery was performed, and serial CT showed ICH resorption. However, he was again admitted for unstable gait and mildly altered mental status 3 months after discharge. Magnetic resonance (MR) imaging with gadolinium showed an enhanced ring-shaped mass around the hematoma cavity. Open biopsy was performed. The histological diagnosis was glioblastoma multiforme, and he was treated with radiation therapy and oral chemotherapy with temozolomide. MR imaging showed marked shrinkage of the tumor, but he died of pneumonia 3 months after the second surgery. In this case, the cause of the hemorrhage was not identified after the seemingly successful hematoma evacuation surgery, and no definitive diagnosis was made until tumor regrowth. Brain tumor should be suspected as a cause of ICH even if the patient has a history of hypertension and the location is typical for hypertensive ICH. Clinical/radiological follow up is essential for detecting subtle neurological deterioration to avoid diagnostic delay.

Tension pneumocephalus as a complication of lumbar drainage for cerebral aneurysm surgery--case report.

A 66-year-old man developed tension pneumocephalus after failed lumbar drainage before clipping surgery for a ruptured anterior communicating artery aneurysm. After puncture with a Tuohy needle, the spinal catheter could not be inserted into the spinal dura, so surgery proceeded without the catheter placement. The patient's neurological status deteriorated suddenly into coma within 15 hours after uneventful clipping of the aneurysm. Computed tomography revealed tension pneumocephalus with marked brain shift. Intracranial hypotension was probably caused by continuous cerebrospinal fluid leakage from the iatrogenic spinal dural tear, resulting in air entry and accumulation into the cranium from an unidentified opening of the cranial dura. The patient was immediately treated with autologous epidural blood patch administration in the lumbar spine, followed by reopening of the craniotomy incision and flap to evacuate the accumulated air. The patient made a quick and uneventful neurological recovery after the rescue procedure.