Nonbacterial Thrombotic Endocarditis Associated with Acute Promyelocytic Leukemia: An Autopsy Case Report.

Valve vegetation is one of the most fearful findings for physicians. The first diagnosis that comes to their mind is infective endocarditis (IE), but it can also be noninfective; nonbacterial thrombotic endocarditis (NBTE). NBTE can be even more challenging than IE for physicians because of the wide range of differential diagnoses such as malignancies, autoimmune disorders and human immunodeficiency virus. A 45-year-old woman presented at the emergency room with a sudden onset of dysarthria and right-sided hemiplegia. Laboratory data showed her blood counts and coagulation test were mostly normal and the magnetic resonance imaging detected a high-signal-intensity change in her left brain. An echocardiogram found a vegetation-like structure on her atrial valve. We highly suspected IE leading to cerebral embolism. The clot was successfully removed by our neurosurgeons and anticoagulation therapy was started concurrently. Her state of consciousness improved, but then she suffered a brain hemorrhage and died. The autopsy revealed that the cause of her vegetation was acute promyelocytic leukemia (APL). Based on these findings, it is important to remember that APL can be the cause of NBTE even if the blood count and coagulation tests are almost normal.

Republished: A novel combined approach using a Penumbra catheter and balloon catheter for cerebral venous sinus thrombosis.

Cerebral venous sinus thrombosis is sometimes fatal. We describe a case of sinus thrombosis in a 43-year-old woman presenting with generalized seizure, delirium, and a 2 week history of headache and nausea. The patient underwent mechanical thrombectomy using a novel combined approach, in which a Shouryu HR balloon catheter (Kaneka) was anchored in the right transverse sinus (TS), sigmoid sinus (SS), and superior sagittal sinus (SSS), while a Penumbra 5 MAX ACE (Penumbra) catheter was moved back and forth between the right TS, SS, and SSS. Additionally, back and forth movement of the inflated balloon with aspiration-the so-called 'dental floss technique'-was performed. Partial recanalization was eventually obtained. Follow-up angiography on postoperative day 7 showed a dramatic improvement in venous outflow. The patient was transferred to a rehabilitation hospital on postoperative day 42. We describe our combined approach using aspiration, and Penumbra and balloon catheters, to achieve mechanical thrombectomy for sinus thrombosis.

A novel combined approach using a Penumbra catheter and balloon catheter for cerebral venous sinus thrombosis.

Cerebral venous sinus thrombosis is sometimes fatal. We describe a case of sinus thrombosis in a 43-year-old woman presenting with generalized seizure, delirium, and a 2 week history of headache and nausea. The patient underwent mechanical thrombectomy using a novel combined approach, in which a Shouryu HR balloon catheter (Kaneka) was anchored in the right transverse sinus (TS), sigmoid sinus (SS), and superior sagittal sinus (SSS), while a Penumbra 5 MAX ACE (Penumbra) catheter was moved back and forth between the right TS, SS, and SSS. Additionally, back and forth movement of the inflated balloon with aspiration-the so-called 'dental floss technique'-was performed. Partial recanalization was eventually obtained. Follow-up angiography on postoperative day 7 showed a dramatic improvement in venous outflow. The patient was transferred to a rehabilitation hospital on postoperative day 42. We describe our combined approach using aspiration, and Penumbra and balloon catheters, to achieve mechanical thrombectomy for sinus thrombosis.

Intra-axial pseudotumors in the central nervous system: clinicopathological analysis.

Intra-axial pseudotumors in the central nervous system often mimic malignant brain tumors and cause difficulty in diagnosis and treatment. The present study investigates their radiologic and histological features to elucidate diagnostic clues. Six cases were included in the study, one man and five women, ranging in age from 44 to 87 years (mean age, 61 years). Histologically, three cases had demyelination, and one case each had abscess, angiitis, and non-Langerhans cell histiocytosis. All cases were evaluated radiologically on MRI, most of them by thallim-201 single photon emission tomography ((201)Tl-SPECT). These cases were examined using H&E, special stains, and immunohistochemical studies with a variety of antibodies. MRI demonstrated perifocal edema and ring-like or solid enhancement, mimicking the malignant tumors. Diffusion-weighted MRI showed a hypo-iso-intensity with a hyperintensity on the apparent diffusion coefficient. A (201)Tl-SPECT study revealed no uptake. Although there were various kinds of pathology, inflammatory cells were observed, associated with vascular proliferation and reactive astrocytosis. In addition, some cases showed demyelinating or destructive changes. These results suggested that intra-axial pseudotumors in the central nervous system contain various kinds of pathology, and detailed clinicopathological analysis is important from the point of view of differential diagnosis.

The usefulness and problem of intraoperative rapid diagnosis in surgical neuropathology.

Intraoperative rapid diagnosis has been a useful neurosurgery tool for maximal resection and minimal morbidity. However, only a few studies have been conducted regarding diagnostic accuracy and associated problems. The present study reviews our experience in treating patients and investigates the accuracy and problems associated with intraoperative rapid diagnosis in surgical neuropathology. There were 180 cases of intracranial lesions excluding pituitary lesions. The patients consisted of 89 males and 91 females, ranging from 5 months to 84 years, with a mean age of 46 years. Of the 180 cases, 152 cases received open surgery, 28 cases had stereotactic surgery including a biopsy and were histologically verified. The correlation between the intraoperative diagnosis and the final diagnosis overall was seen in 172 of 180 cases, proving a high diagnostic sensitivity of 95.6%. No correlation was seen in 8 cases (4.4%). The diagnostic inaccuracy was seen in the grading of gliomas and the diagnosis of undifferentiated malignant tumors such as undifferentiated metastatic carcinomas, primitive neuroectodermal tumors (PNETs), and sarcomas. It was also recognized in rare types of histology such as gliomatosis and xanthomatous lesions. These results suggested that the intraoperative rapid diagnosis was quite useful, but that we should also maintain a cautious attitude.

Two cases of ringlike enhancement on MRI mimicking malignant brain tumors.

The present study was performed to investigate two cases with ringlike enhanced lesions mimicking malignant tumors on magnetic resonance imaging (MRI) and to determine the utility of thallium-201 single-photon emission tomography (201Tl-SPECT) and diffusion-weighted MR imaging (DWI) for differential diagnosis between neoplastic and nonneoplastic lesions. One patient was a 50-year-old man who presented with a right caudate lesion. The 201Tl-SPECT study revealed no uptake in the lesion. Stereotactic biopsy was performed, and pathological findings indicated cerebral infarction. The other patient was a 58-year-old woman who presented with a right frontal lesion with edema. DWI showed a hypointense signal, and the apparent diffusion coefficient (ADC) revealed a hyperintense signal in the lesion. Stereotactic biopsy with endoscopy was performed, and the pathological findings suggested a demyelinating disease. Combined 201Tl-SPECT and DWI studies may be useful for differential diagnosis between neoplastic and nonneoplastic lesions. However, stereotactic biopsy should be performed for the final pathological diagnosis.

Distant metastasis of dermatofibrosarcoma protuberans of the scalp--case report.

A 49-year-old man presented with a rare dermatofibrosarcoma protuberans (DFSP) of the scalp associated with local recurrence and distant metastasis to the lung and abdomen. An elastic-hard small mass on the right occipital scalp was initially treated by simple resection in another clinic. Ten years later, recurrent tumor was associated with infiltration to the calvarium, and resection was performed again also in another clinic. Approximately 1.5 years later, the patient was transferred to our clinic because of recurrence with intracranial involvement. Repeated relapses and metastasis to the lung were recognized despite surgery, chemotherapy, and local radiation. Eventually, the patient died of distant metastasis to the abdomen 17 years after the initial diagnosis. Scalp DFSP is very uncommon but is an aggressive scalp tumor, so initial wide local resection and local radiation therapy after surgery are important to prevent local recurrence and distant metastasis.