Prognostic paradox: brain damage around the glioblastoma resection cavity.

Hyperintense lesions around the resection cavity on magnetic resonance diffusion-weighted imaging (MR-DWI) frequently appear after brain tumor surgery due to the damage of surrounding brain. The putative connection between the lesion and the prognosis for patients with glioblastoma (GBM) was explored. This retrospective study reviewed consecutive sixty-one patients with newly diagnosed GBM. Postoperative MRI was performed within 2 weeks after the initial surgery. We classified the cases into two groups depending on whether DWI hyperintense lesions were observed or not [DWI(+) group and DWI(-) group]. Progression-free survival (PFS) and overall survival (OS) were compared between the two groups. Forty-two patients were identified. The various extents of hyperintense lesions around the resection cavity were observed in 28/42 (66.7%) cases. In the DWI(+) and DWI(-) groups, median PFS was 10.0 [95% confidence interval (CI) 8.4-11.5] and 6.7 (95% CI 4.9-8.5) months, respectively (p = 0.042), and median OS was 18.0 (95% CI 12.2-23.8) and 17.0 (95% CI 15.7-18.3) months, respectively (p = 0.254). On multivariate analysis, the presence of DWI hyperintense lesion was more likely to be an independent predictor for 6-month PFS (p = 0.019; HR, 0.038; 95% CI 0.002-0.582). Tumor recurrence appeared outside the former DWI hyperintense lesion. Hyperintense lesions surrounding the resected GBM on MR-DWI might be a favorable prognostic factor in patients with GBM.

Anaplastic meningioma with extremely rapid recurrence.

A 62-year-old woman presented with an uncommon case of anaplastic meningioma manifesting as recent memory disturbance. Magnetic resonance imaging revealed a mass located in the right temporal lobe. She became unconscious because of uncal herniation and underwent urgent surgery. The tumor was completely resected, except for a lesion tightly attached to arteries. Histological examination indicated the presence of anaplastic meningioma with an extremely high MIB-1 labeling index (70%). After 43 days, the patient developed local recurrence and dissemination in the left temporal lobe. The exceptionally high MIB-1 labeling index corresponded with a short tumor doubling time (8.2 days). Whole-brain irradiation and linear accelerator surgery for disseminated lesions were performed, and the tumor growth halted. Although meningiomas rarely show malignant behavior, corresponding to World Health Organization grade III, it is necessary to consider malignant behavior when treating meningiomas.

Ruptured internal carotid artery aneurysm at the origin of a perforating artery associated with a hyperplastic anomalous anterior choroidal artery--case report.

A 65-year-old man presented with a hyperplastic anomalous anterior choroidal artery (AChA) associated with a ruptured internal carotid artery aneurysm at the origin of a perforating artery manifesting as sudden onset of headache and vomiting. The aneurysm was too small for endovascular embolization, so we performed open surgery via the left pterional approach. Aneurysm clipping with preservation of the perforator was impossible, so we clipped the aneurysm neck and sacrificed the perforator. We also performed dome clipping because dome puncture resulted in continuous bleeding. Head computed tomography obtained 3 days after the operation showed cerebral infarction at the territory of the sacrificed perforator, but the patient suffered no neurological deficits. This case of internal carotid artery aneurysm with a perforating artery arising from the aneurysm dome shows that sacrifice of the perforator may be necessary to prevent rebleeding.

Endovascular treatment for traumatic ear bleeding associated with acute epidural hematoma.

A 44-year-old woman presented with intractable ear bleeding after head trauma. Computed tomography showed a longitudinal petrosal bone fracture and a mastoid air cell hematoma with a small acute epidural hematoma. Conservative therapy for more than 12 hours failed to stop the bleeding, so we planned endovascular treatment rather than open surgery. Angiography of the external carotid artery demonstrated continuous extravasation of contrast material from the middle meningeal artery near the fracture line in the temporal bone. Intravascular embolization was performed using polyvinyl alcohol particles and gelatin sponge pieces, resulting in immediate successful hemostasis. Endovascular management should be considered for the treatment of intractable traumatic ear bleeding.

Subarachnoid hemorrhage associated with von Willebrand's disease--case report.

A 59-year-old woman with type IIA von Willebrand's disease (VWD) presented with subarachnoid hemorrhage (SAH). Computed tomography showed SAH in the right sylvian fissure and intracranial hemorrhage in the right temporal lobe. Angiography demonstrated an aneurysm at the bifurcation of the right middle cerebral artery. Neck clipping was performed on the 3rd day after the onset with intra- and postoperative administration of factor VIII/von Willebrand factor concentrate. No excessive bleeding occurred. Patients with prolonged bleeding time should be screened for VWD before surgery. This is a rare case of VWD presenting with SAH secondary to ruptured intracranial aneurysm. The clinical characteristics and the management of SAH in a patient with VWD are discussed.