Ipsilateral hemiparesis after putaminal hemorrhage due to uncrossed pyramidal tract.

OBJECTIVE: Previous case reports supported the presence of the uncrossed pyramidal tract in exceptional patients. However, most of these case reports have not fully discussed involvement of the motor cortex controlling the ipsilateral limbs. DESIGN AND METHOD: The authors investigated a 62-year-old man who developed right hemiparesis after right putaminal hemorrhage by using MRI, transcranial magnetic stimulation, functional MRI (fMRI), and sensory evoked potentials. He had moderate weakness including the face, spasticity with brisk deep tendon reflexes and Babinski sign, and impaired vibration and position sense, all on the right side. RESULT: A MRI study showed hemorrhage in the right putamen and the wedge-shaped medulla. A fMRI study during a sequential finger opposition task showed activation in the motor cortex ipsilateral to the finger movements, but not on the contralateral side. Sensory evoked potentials showed cortical response ipsilateral to the side of stimulation. CONCLUSION: The pyramidal tract and the dorsal column-medial lemniscus pathway did not cross in the medulla in this patient. In view of the presence of the abnormal shape in the medulla and congenital scoliosis, a congenital factor might be responsible for the uncrossed pyramidal tract and dorsal column-medial lemniscus in this patient.

Mixed cavernous angioma and glioma (angioglioma) in the hypothalamus--case report.

A 54-year-old female presented with a huge mixed cavernous angioma and astrocytoma in the hypothalamus manifesting as headache, visual field defect, gait disturbance, and convulsion. Radiological studies revealed a huge suprasellar tumor encasing all the major cerebral vessels. Craniotomy disclosed a hemorrhagic tumor poorly demarcated from the surrounding brain which was partially removed. Histological examination of the operative specimen revealed cavernous angioma with low grade glioma in the periphery. The residual tumor responded to radiation therapy remarkably well. An autopsy conducted 3 years later revealed a small hypothalamic astrocytoma with abundant vasculature.

[Acute relapsing disseminated encephalomyelitis (ARDEM) mimicking a temporal lobe tumor].

A case of ARDEM presenting as a temporal lobe tumor is reported. A 19-year-old male was admitted to the hospital, because of headache, right homonymous hemianopsia, and general convulsion. CT scan and MR imaging revealed localized right medial temporal enhanced mass lesion with surrounding brain edema. The craniotomy revealed an elastic hard ill-defined subcortical tumor. Histology showed a demyelinating process with perivascular lymphocyte cuffings. The patients' postoperative course was essentially uneventful until the 7th day when he developed fever, persistent hiccup, vertigo followed by obtundation and respiratory distress. Repeated MR imaging revealed extensive lesions in the left thalamus, brain stem, upper spinal cord and cerebellum. The patient responded to steroid pulse therapy well. Six months later, however, he returned to the hospital with severe memory disturbance. Repeated MR imaging showed diffuse bilateral parieto-occipital white matter lesions. He again responded to steroid pulse therapy well. An immunosuppressant Mizoribine was added to his steroid therapy to prevent recurrence. With the advent of MR imaging, more non-surgical diseases such as multiple sclerosis and Behçet disease are visualized on imaging study. The differentiation of these diseases from intraparenchymal neoplasm is difficult when they present as a single mass lesion. ADEM or ARDEM should be included in the list of such lesions requiring differential diagnosis.

Nontraumatic intradiploic arachnoid cysts--report of five cases.

Five cases of nontraumatic intradiploic arachnoid cysts in elderly patients are reported. All cysts were located in the occipital bone and appeared as well-demarcated radiolucent lesions. The cysts were multiple in three cases. Presenting symptoms included headache or dizziness, but most lesions were asymptomatic and found incidentally. In the most recent three cases, magnetic resonance (MR) imaging revealed intradiploic cysts containing cerebrospinal fluid (CSF) with cerebellar herniation. Operation found the cysts filled with CSF and dural defects through which cerebellar tissue was herniating. In two patients, CSF leakage from the outer table occurred. Intradiploic arachnoid cyst seems to be congenital in origin but commonly found in the elderly. MR imaging is the most useful diagnostic method for differential diagnosis from other osteolytic skull lesions.

[Dysembryoplastic neuroepithelial tumor; a case report].

The authors report a case of dysembryoplastic neuroepithelial tumor which is a new entity of glial tumor proposed by Daumas-Duport et al. A 16-year-old male was admitted to our hospital with a 5-year history of uncontrollable complex partial seizure. CT scan showed a non-enhanced homogeneous low density area without mass effect, simulating old infarction or porencephalic cyst in the right posterior temporal lobe. The inner table of the skull over the lesion was eroded. The lesion showed low signal intensity in T1 weighted MR image and high signal intensity in T2 image. Craniotomy disclosed greyish soft solid tumor without cyst. Histologically, the tumor contained multiple cellular nodules in the microcystic astrocytic part which contained neurons. After the surgery the patient was free from the seizure. Dysembryoplastic neuroepithelial tumor is found in young patients with intractable partial seizures. It is characterized by pseudocystic well-demarcated low density appearance on CT scan. Histologically, it is an intracortical multinodular heterogeneous tumor which, is surgically treatable with favorable prognosis. For differential diagnosis, this tumor must be recognized in the list of low-density intracranial lesions found during CT scan.

[Marked growth of arteriovenous malformation 19 years after resection: a case report].

We report a case of arteriovenous malformation (AVM) which recurred as a giant AVM 19 years after resection. At the age of 23, the patient underwent craniotomy for a small AVM with surrounding old hematoma in the right parietal lobe. The AVM was judged to have been removed completely on postoperative angiography, while abnormal small vessels were noted retrospectively. He did well until 19 years later when he had seizures. Repeated angiography showed huge recurrent AVM at the operative site. Considering the risk involved in surgery, he was discharged from the hospital with anticonvulsants. Recurrence of AVM after removal is rare, but patients with AVM surgery should be followed up with CT and angiography for a long period of time.

[Idiopathic massive osteolysis of skull bone: a case report].

A rare case of idiopathic massive osteolysis of the skull is reported. A 49 year-old male was admitted with a diagnosis of a skull tumor. The skull film taken for evaluation of the headache, showed a large lytic lesion with irregular margin in the left parietal area. CT showed that some of the bone had been destroyed, but the underlying brain was normal. Technetium 99m-MDP bone scan showed high activity around the margin of the lytic lesion. During surgery for this bone lesion no neoplastic or inflammatory changes were revealed. However, destruction of the bone without new bone formation could be seen. Idiopathic massive osteolysis of skull bone is extremely rare and the authors could find only 6 reported cases in the literature. It is characterized by the spontaneous onset of bone resorption without known causative factors. This destructive process continues for years until eventually it ceases spontaneously. In the case of skull lesion, there seems to be no need for surgery unless both the inner and outer tables are involved. This disease must be included in the differential diagnosis of lytic skull lesion.

[Lateral approach to the anterior foramen magnum tumor: report of two cases].

A procedure for lateral approach to the ventral portion of the foramen magnum and the upper cervical canal is described. The patient was placed in the lateral position and a curvilinear skin incision was made from the retoroauricular area down to the lateral neck across the sternocleidomastoid muscle, and underlying muscle layers were divided. A suboccipital hemicraniotomy and hemilaminectomies were performed with an air drill. Because the medulla and the cervical cord are displaced posteriorly by the tumor, there is no need to retract those structures and all the tumors can be removed under direct vision. This procedure was applied on the two patients with ventrally situated foramen magnum tumors; a neurenteric cyst and neurofibroma, and both of the tumors were successfully removed under direct vision. Major advantages of this approach are that there is no need for retraction of the spinal cord, and there is excellent exposure of an anteriorly located tumor, no postoperative cervical spine instability, no risk for CSF leak and infection, which effects are often found after the anterior approach. The procedure, like the posterior approach, is relatively simple.

Sudden appearance of occipital-vertebral arterial anastomoses during therapeutic embolization.

A 66-year-old woman with a dural arteriovenous malformation in the posterior fossa, who developed a vertebrobasilar stroke during therapeutic embolization of the occipital artery, is reported. Postembolization arteriograms demonstrated previously invisible anastomoses of the occipital-vertebral artery. The literature is reviewed with respect to the complications and risks of therapeutic embolization of the external carotid artery, and the possible mechanism underlying the opening of these anastomoses is discussed.

Closure of carotid-cavernous fistulae by use of a fibrin adhesive system.

A case of carotid-cavernous fistula successfully closed by injecting fibrin glue into the cavernous sinus through the superior ophthalmic vein is reported. This case was a recurrent spontaneous carotid-cavernous fistula after ligation of the internal carotid artery. The use of the fibrin adhesive system for the treatment of carotid-cavernous fistulae is discussed.

Parasellar metastases: four autopsied cases.

Four patients with histologically confirmed parasellar metastases are reported. The main symptoms and signs were persistent right facial pain followed by diplopia (patient 1), headache and minimal right abducens palsy (patient 2), acute, total left ophthalmoplegia (patient 3), and acute, total bilateral ophthalmoplegia (patient 4). Positive radiologic evidence was present only in patient 1: there was bony erosion of the petrous apex and computed tomography scan showed an enhanced parasellar mass. This patient underwent partial surgical removal of the tumor. Patient 3 was treated with irradiation. All patients died within 14 weeks of the onset of the initial symptoms and all were autopsied. Their primary lesions were hepatoma, stomach cancer, lung cancer, and mesenteric liposarcoma.

[A case of Forestier's disease causing dysphagia].

A case of Forestier's disease causing dysphagia is reported. A 52-year-old man was admitted to our hospital because of dysphagia, hoarseness and constant urge to clear the throat. On admission, physical examination revealed a hard mass between the larynx and left sternocleidomastoid muscle. Deep tendon reflexes were all hyperactive and Hoffmann's sign was elicited on the right side. Cervical roentogenogram showed extensive anterior excrescences from C-2 to C-7 vertebra with preservation of the relatively normal intervertebral disc space. CT scan of the cervical spine showed anterolateral displacement of the trachea by the anterior excrescences of the cervical vertebrae and narrow flat spinal canal. Esophagram showed marked right lateral displacement of the esophagus by the cervical osteophytes. Myelogram revealed a narrow canal and anterior filling defects by the posterior osteophytes at C3/4 and C6/7. Technetium 99m bone scintigram disclosed abnormal uptake in the cervical and thoracic spines. The patient underwent anterior cervical exploration for removal of the exostotic bone from C-3 to C-7 and decompression of the esophagus and trachea. Postoperative course was uneventful and all of his preoperative symptoms improved remarkably. Pertinent literature were reviewed and pathogenesis of Forestier's disease was discussed.

Cerebral neoplasms initially presenting with massive intracerebral hemorrhage.

In three patients, clinically silent brain tumors led to massive intracerebral hemorrhage. These patients represented 0.6% of 497 consecutive patients with primary or secondary brain tumors and 2.5% of 119 patients with hypertensive or spontaneous intracerebral hemorrhage. Examination by computed tomography and angiography provided no evidence suggestive of the presence of neoplasms. All three patients were surgically treated and the lesions were histologically confirmed to be metastatic bronchogenic carcinoma, metastatic clear-cell carcinoma and low-grade astrocytoma, respectively.

Schwannoma of the skull base with intracranial extension.

A case is reported of solitary schwannoma involving the skull base with extension into the middle cranial fossa and parasellar region. The patient presented with an exophthalmos and ipsilateral facial numbness. The tumor was successfully excised via a two-stage procedure involving an initial intracranial and subsequent transmaxillary approach. The relevant literature on the presentation and treatment of schwannomas of the skull base with intracranial extension is also reviewed.