Coexistence of cerebral aneurysm and meningioma--pure accident?

OBJECTIVES: Coexisting intracerebral aneurysms and meningiomas occur relatively rarely, without a clear relationship, although an aneurysm can be located within a meningioma. The aim of this retrospective study was to identify possible explanations for the coexistence of these conditions and to present a rationale for treatment strategies. PATIENTS AND METHODS: Ninety-five patients with coexistent meningioma and aneurysm were found in the National Library of Medicine, and 11 more patients were retrieved from our own database. RESULTS: Co-occurrence of both pathologies, sometimes solitary, sometimes multiple, was mostly found in women (3:1). Clinical symptoms in the majority of patients were caused by tumour growth, whereas aneurysm rupture was seen only in a few cases. Consequently tumour resection was performed first in 58 out of the 95 patients, and aneurysm treatment in 38 patients. From available data, the mortality rate three decades before was approximately 40%, but decreased in the last years, due to microsurgical and endovascular techniques. All of our patients were alive after 1 year of follow-up. In patients with intratumoural aneurysms, only three published and one our own case, were treated for both pathologies. CONCLUSIONS: The coexistence of meningioma and aneurysm seems to be a coincidence. Treatment should primary focus on the cause of presenting symptoms, but in cases with intratumoural aneurysm, the aneurysm should be treated first. Due to the development of microsurgical and endovascular techniques peri-procedural mortality and morbidity has decreased.

Spontaneous spinal epidural haematoma: a therapeutical challenge? Report of an unusual case.

We report the conservative treatment of a spontaneous spinal epidural haematoma attending with acute extensive neurological deficits, which resolved spontaneously. Spontaneous remission of spontaneous spinal epidural haematoma with severe neurological deficit is rare in the literature. An 80 year old man was admitted to our hospital presenting sciatica followed by rapid development of paraparesis and cauda equina syndrome, which represents a neurosurgical emergency. Magnetic resonance imaging revealed a multilevel epidural haematoma from L1 to L5. During the initial diagnostic procedure the symptoms started to decline unexpectedly, so the surgical intervention could be withdrawn. Twenty four hours after admission the patient was almost free of symptoms, mobile, and continent. Awareness and high index of suspicion, and a willingness to seek the prompt help of the imaging department, are crucial to successful management before the opportunity to treat is lost.

Treatment strategy of pineal tumors in consideration of their pathomorphology.

BACKGROUND: Tumors of the pineal gland are rare pathology. This paper reports on therapeutical considerations of histologically heterogeneous pineal tumors in a group of 15 patients and is presenting a special case of neuroaxial seeding. METHODS: Surgery and/or additional therapeutic procedures were performed in 13 of our 15 patients ("youngster" and "adults") in respect of pathomorphology. Details are reported concerning a 52-year-old man suffering from pineocytoma (WHO grade II), who underwent different kinds of therapy within 10 years follow-up. RESULTS: In the six "youngster" the histological assessment revealed two teratomas, one mixed pineocytoma/pineoblastoma, one astrocytoma and one epidermoid cyst. All neoplasms were treated surgically with good results. Additional radio-/chemotherapy was used in a case of teratoma and pineocytoma/pineoblastoma. From five successfully surgically treated "adults" (germinoma, pineoblastoma, pineocytoma, two cystic formations) in two of them (germinoma, pineoblastoma) additional radiotherapy was needed, another two patients (cystic formations) were healed after stereotactic puncture. The patient with pineocytoma showed recurrent neuroaxial seeding within 10 years in spite of repeated radiotherapy, though his neurological status remained stable (Karnofsky performance score of 100). CONCLUSION: Precise histopathological assessment of pineal tumors is essential to guide optimal modern therapy modalities in order to assure a local tumor control. (Fig. 3, Ref. 18.).

Revascularization procedures in internal carotid artery pseudo-occlusion.

BACKGROUND: Surgical treatment of patients with suspected internal carotid artery (ICA) pseudo-occlusion and reduced cerebrovascular reactivity (CVR) is still uncertain regarding the diagnostic procedures, the risks and the optimal timing as well as performance of revascularization. METHOD: From 1983-2001, 781 patients with symptomatic ICA stenosis were treated surgically. In 53 patients, a final diagnosis of extracranial ICA pseudo-occlusion was established by repeating Digital Subtraction Angiography (DSA). Angiographical findings were anterograde "string-like" filling of ICA beyond the carotid bifurcation or retrograde filling of the proximal, so called "occluded" extracranial ICA, extending up to the skull base. The CVR was reduced. All patients underwent direct surgery of extracranial carotid artery. Diagnostic parameters, peri-operative risks and postoperative course of these patients were evaluated. FINDINGS: In 40 patients (75.5%) a successful revascularization of ICA was possible. ICA pseudo-occlusion was in all cases of atheromatous origin, moreover in 8 patients combined with a floating thrombus, distal to the stenosis. Thrombectomy was done by means of Fogarty catheter. In 13 patients (24.5%), a surgical re-opening of the ICA lumen was not possible. Five of these patients showed in DSA an anterograde "string sign", eight presented retrograde filling of ICA reaching the skull base. Peri-operative mortality was 1.9%, peri-operative morbidity was 7.5%. After a 4 years (mean) follow-up, 95% of the reopened ICA remained patent. CONCLUSION: In patients with explicit carotid artery occlusion signs, careful selective DSA should be compulsory with a late series to detect ICA pseudo-occlusion. There is a chance for extracranial reopening ICA, even with compromised CVR, if anterograde "string like" or retrograde filling of proximal so called "occluded" ICA as far as the skull base is angiographically identified.

Inflammatory thromboembolic complication after craniopharyngioma surgery?

Aside from endocrine or visual disturbances an appearance of other complications after craniopharyngioma surgery is rare. We report a case of delayed brain infarction in the postoperative period of craniopharyngioma resection. A 30-year-old man presented with visual impairment and diabetes insipidus. Imaging revealed a partly cystic, partly contrast enhancing intra-/suprasellar mass lesion. The patient underwent craniotomy with resection of the tumour. Histological examination revealed an adamantinomatous craniopharyngioma. Early postoperative an aseptic meningitis, which was diagnosed clinically as well as by laboratory and CSF analysis, resolved spontaneously. One week later a cerebral incident with infarction in the peripheral territory of MCA on the left side occurred. For this unusual event with a review of the literature a thromboembolic origin is suggested on the basis of inflammatory vascular involvement after an attack of aseptic meningitis.

Salmonella enteritidis causing brain abscess and coxitis following intracranial surgery.

We report the case of a 46-year-old woman who underwent surgery for an adamantinous craniopharyngeoma (WHO grade I). The postoperative course, during which the patient received 16 mg/day of dexamethasone, was initially uneventful. After a fortnight the patient developed infectious signs and an intracranial abscess at the operation site with simultaneous purulent coxitis. Both the intracranial abscess and the coxitis were evacuated and drained. In tissue samples and pus obtained during re-craniotomy and during surgery on the hip, Salmonella enteritidis was detected by cultivation. Salmonella enteritidis was also isolated from several stool specimens. There was no known salmonellosis in the patient's medical history. She recovered as a result of antibiotic treatment with ciprofloxacin and chloramphenicol. The intracranial abscess healed without leaving any neurological deficit. Unfortunately the left hip subsequently required further surgery, culminating in removal of the entire femoral head. Prosthetic replacement could not yet be performed due to the recurrent septic course of the hip. Our case illustrates a serious complication with presumed haematogenous spread of the infection from a pre-existing asymptomatic and unknown colon infection. The immunosuppressive effect of corticosteroids in the treatment of the brain neoplasm might have been a contributing factor to the sudden exacerbation of the latent infection.

High uptake of L-3-[123I]iodo-alpha-methyl tyrosine in pilocytic astrocytomas.

Despite a favourable prognosis, pilocytic astrocytomas may exhibit signs of malignancy on various neuroimaging modalities. This retrospective analysis was conducted to determine whether scintigraphic features of malignancy are also found on single-photon emission tomography (SPET) using L-3-[123I]iodo-alpha-methyl tyrosine (IMT) as a tracer. Twenty patients with pilocytic astrocytomas were retrospectively selected from a large series of patients referred for the evaluation of primary or recurrent brain tumours. IMT SPET was performed in 16 patients, positron emission tomography (PET) using 2-[18F]fluoro-2-deoxy-D-glucose (FDG) was available in 10 of the patients and SPET using technetium-99m tetrofosmin or thallium-201 had been performed in 11. Image analysis was performed using standard protocols to determine how many patients exceeded the respective thresholds of malignancy. Features of malignancy were found in 7/16 IMT SPET studies, in 7/10 FDG PET studies and in 7/11 of the residual SPET investigations. A significant correlation of tumour size and IMT uptake in primary pilocytic astrocytomas indicated partial volume effects to partly account for the differential uptake behaviour (n = 10, r = 0.87, P < 0.05). Differences in IMT uptake in primaries (1.7 +/- 0.6, n = 10) and in recurrent tumours (2.3 +/- 0.7, n = 6) did not attain statistical significance. IMT SPET results indicative of malignancy are regularly found in pilocytic astrocytomas, despite their good prognosis. No uptake may be detected in largely cystic or in small tumours.

Sequential scintigraphic strategy for the differentiation of brain tumours.

Both thallium-201 and iodine-123 alpha-methyltyrosine (123I-IMT) have been shown to be useful in the diagnostic evaluation of brain tumours. The aim of this study was to investigate the respective contributions of 201Tl and 123I-IMT single-photon emission tomography (SPET) in the non-invasive evaluation of intracerebral tumours. We analysed 65 patients with the following brain tumours: 8 non-neoplastic lesions, 4 meningiomas, 12 low-grade gliomas, 28 high-grade gliomas, 11 metastases and 2 high-grade lymphomas. 201Tl SPET and 123I-IMT SPET were performed [start of 201Tl SPET: 15 min p.i. (early) and 180 min p.i. (delayed); start of 123I-IMT SPET: 15 min p.i.]. The intensity of uptake was quantified as the ratio between tracer accumulation in the tumour and in the contralateral hemisphere. None of the non-neoplastic lesions or low-grade gliomas expressed marked 201Tl uptake. All malignant tumours except one small metastasis and all meningiomas except one small, cystic and degenerated lesion showed significant 201Tl accumulation [Tl(15')>2.0]; 123I-IMT uptake was either absent or intermediate in non-malignant lesions except in two low-grade gliomas; the highest levels were observed in high-grade gliomas followed by metastases and lymphomas (mean IMT: 2.7 vs. 2.1 vs. 1.8), with metastases showing a high variability in 123I-IMT uptake (range: 0.8-3.6). Using 201Tl to distinguish non-neoplastic lesions from malignant tumours and meningiomas, 63 of 65 patients were characterised correctly. In the latter group, high-grade gliomas were correctly identified in 27 of 28 cases by their amino acid uptake. It is concluded that the combination of 201Tl and 123I-IMT surpasses the accuracy of each single test in the differentiation of space-occupying lesions of the brain. Based on these preliminary results, a sequential strategy is proposed involving an initial 201Tl SPET study and an additional 123I-IMT SPET study in the event of positive 201Tl uptake.

Evaluation of the extension of cerebral gliomas by scintigraphy.

BACKGROUND: Single photon emission computed tomography (SPECT) with 201Tl and 123I-alpha-methyl tyrosine (123I-IMT) are routine methods for the evaluation of brain tumors. 123I-IMT transport across the blood brain barrier is mediated by an amino acid carrier, 201Tl accumulation is analogous to cerebral potassium uptake. PATIENTS AND METHODS: To determine the differences in glioma extension as shown by the 2 methods, 17 patients with malignant gliomas were included in this comparative imaging study: astrocytoma III: n = 6, ependymoma III: n = 1, oligodendroglioma III: n = 1, glioblastoma IV: n = 9. The tomographic image sets were matched anatomically and the slices showing maximal tumor extension were identified in both image sets respectively. Tumor spread was compared visually and the tumor extension was quantified. RESULTS: In gliomas WHO III tumor extension was delineated significantly larger by 123I-IMT-SPECT than by 201Tl-SPECT (mean +/- SD: 816 +/- 281 pixels vs 600 +/- 220 pixels, n = 8, p < 0.05). The size of glioblastomas was shown in a comparable manner by the 2 methods (977 +/- 571 vs 1.051 +/- 588, n = 9, ns, p = 0.57), but there were considerable regional differences between the area of 201Tl uptake and amino acid retention. In the whole group a weak but significant negative correlation between intensity of 201Tl uptake on the one hand and a ratio of the area as depicted by 123I-IMT vs area as depicted by 201Tl on the other hand, was found (n = 17, r = 0.49, p < 0.05). Thus the differences in the delineation of areas became smaller with increasing 201Tl uptake. CONCLUSIONS: These preliminary data indicate that the extension of gliomas is depicted differently by the 2 methods. 123I-IMT-SPECT shows a larger tumor extension especially in gliomas WHO III. Since 201Tl uptake has previously been shown to correlate with disruption of the blood brain barrier, 123I-IMT-SPECT may delineate tumor parts without endothelial leakage. This additional information may be helpful in planning surgical or radiation therapy. The advantages of 123I-IMT in this respect decrease with increasing 201Tl uptake and with increasing malignancy.

Diagnosis of recurrent glioma with SPECT and iodine-123-alpha-methyl tyrosine.

UNLABELLED: Iodine-123-alpha-methyl tyrosine (IMT) allows the investigation of amino acid transport rate in brain neoplasms. It was the aim of this study to evaluate the potential of IMT-SPECT to diagnose the recurrence of gliomas after primary therapy. METHODS: Using a triple-headed SPECT camera, the cerebral uptake of IMT was determined in 27 patients 22 mo, on average, after surgical removal of a primary brain tumor. Eighteen patients had suffered from high-grade gliomas, and nine had suffered from low-grade tumors. Four patients were examined before and after surgical revision of a presumed tumor recurrence. A total of 31 studies were evaluated. The final diagnosis was based on prospective clinicopathological follow-up. Recurrence was diagnosed in 23 cases, with marked clinical deterioration occurring 3.1 mo, on average, after SPECT, and was confirmed by histopathology in 14 instances. Eight cases were free of recurrence, as evidenced by inconspicuous clinical follow-up, ranging from 6 mo to 17 mo after SPECT in seven cases, and by clinical course and histopathology in the remaining subject. RESULTS: Patients with recurrence had significantly higher ratios of IMT uptake in the tumor area to that in a background region than did patients without recurrence (2.27 +/- 0.59 compared to 1.47 +/- 0.29; p < 0.002). The best cutoff level of the IMT uptake ratio in the differentiation between recurrence and benign posttherapeutic lesion was 1.8. Using this study-specific discrimination threshold, the sensitivity and specificity of IMT-SPECT for detecting glioma recurrence were 18 of 23 (78%) and 8 of 8 (100%), respectively. The area under the binormal receiver operating characteristic curve, fitted to the data, was 0.90 +/- 0.06. CONCLUSION: Iodine-123-alpha-methyl tyrosine-SPECT is a promising new tool in the follow-up of patients with gliomas after primary therapy.

Iodine-123-alpha-methyl tyrosine in gliomas: correlation with cellular density and proliferative activity.

UNLABELLED: Amino acid transport rate in gliomas can be assessed using SPECT and the amino acid L-123I-alpha-methyl tyrosine (IMT). This study attempted to correlate the uptake of IMT by gliomas with the proliferative activity and cellular density of these neoplasms. METHODS: The study used 27 patients with gliomas, including 18 patients with high-grade tumors and nine patients with low-grade neoplasms. Amino acid transport rate was determined using IMT and the triple-headed SPECT camera. Proliferative activity was immunohistochemically assessed as the relative number of cells expressing the Ki-67 nuclear antigen; cellular density was evaluated using light microscopy. RESULTS: Relative IMT uptake correlated significantly with the proliferative fraction of tumor cells (r = 0.6, p < 0.001). There was no significant correlation between IMT uptake and cellular density (r = 0.25, p > 0.05). CONCLUSION: The uptake of the SPECT radiopharmaceutical IMT is related to proliferative activity rather than to the cellular density of gliomas.

Non-invasive grading of primary brain tumours: results of a comparative study between SPET with 123I-alpha-methyl tyrosine and PET with 18F-deoxyglucose.

Use of iodine-123-alpha-methyl tyrosine (123I-IMT) allows investigation of the amino acid transport rate in gliomas. It was the aim of this study to compare the value of measurement of glucose metabolism with that of measurement of 123I-IMT uptake for the non-invasive grading of brain tumours. The study population comprised 23 patients with histopathologically proven primary brain tumours; 14 had high-grade gliomas, and nine low-grade brain neoplasms. Glucose metabolism was studied using an ECAT EXACT 47 positron emission tomography (PET) camera and fluorine-18 fluorodeoxyglucose (18F-FDG); 123I-IMT uptake was measured with the triple-headed single-photon emission tomography (SPET) camera, MULTISPECT 3. 18F-FDG and 123I-IMT uptake was quantified as ratios between the uptake by the tumour and contralateral regions of reference. Glucose metabolism and amino acid uptake of the brain tumours correlated significantly (r=0.71, P <0.001). Assuming discrimination thresholds between high-grade and low-grade tumours of 0.8 for 18F-FDG uptake and 1.8 for 123I-IMT uptake, the accuracy values of 18F-FDG PET and 123I-IMT SPET for differentiating between high-grade and low-grade tumours were 21/23 (91%) and 19/23 (83%), respectively. The difference in diagnostic performance was not significant on receiver operating characteristic analysis (P >0.4). It is concluded that there is no major difference between the PET investigation of glucose metabolism and the less expensive SPET measurement of amino acid uptake in terms of their accuracy in evaluating the malignancy grade of primary brain tumours. This encourages the performance of further studies to analyse the potential impact of 123I-IMT SPET on the therapeutic management of patients with brain tumours.

Uptake of iodine-123-alpha-methyl tyrosine by gliomas and non-neoplastic brain lesions.

Using single-photon emission tomography (SPET), the radiopharmaceutical l-3-iodine-123-alpha-methyl tyrosine (IMT) has been applied to the imaging of amino acid transport into brain tumours. It was the aim of this study to investigate whether IMT SPET is capable of differentiating between high-grade gliomas, low-grade gliomas and non-neoplastic brain lesions. To this end, IMT uptake was determined in 53 patients using the triple-headed SPET camera MULTISPECT 3. Twenty-eight of these subjects suffered from high-grade gliomas (WHO grade III or IV), 12 from low-grade gliomas (WHO grade II), and 13 from non-neoplastic brain lesions, including lesions after effective therapy of a glioma (five cases), infarctions (four cases), inflammatory lesions (three cases) and traumatic haematoma (one case). IMT uptake was significantly higher in high-grade gliomas than in low-grade gliomas and non-neoplastic lesions. IMT uptake by low-grade gliomas was not significantly different from that by non-neoplastic lesions. Diagnostic sensitivity and specificity were 71% and 83% for differentiating high-grade from low-grade gliomas, 82% and 100% for distinguishing high-grade gliomas from non-neoplastic lesions, and 50% and 100% for discriminating low-grade gliomas from non-neoplastic lesions. Analogously to positron emission tomography with radioactively labelled amino acids and fluorine-18 deoxyglucose, IMT SPET may aid in differentiating high-grade gliomas from histologically benign brain tumours and non-neoplastic brain lesions; it is of only limited value in differentiating between non-neoplastic lesions and histologically benign brain tumours.

Influence of size of regions of interest on the measurement of uptake of 123I-alpha-methyl tyrosine by brain tumours.

The aim of this study was to assess the influence of variations in the size of regions of interest (ROIs) on uptake values in brain tumours of L-3-iodine-123-alpha-methyl tyrosine (IMT). In addition, we attempted to establish the influence of size of ROIs on levels of significance assessing differences in mean IMT uptake between high-grade and low-grade tumours. Relative IMT uptake was determined in 19 patients with brain tumours using a MULTISPECT 3 triple-headed camera. Reconstructed image resolution was 14 mm at FWHM. Ten of the subjects suffered from high-grade gliomas (WHO grade III or IV) and nine from benign brain tumours, including eight patients with low-grade gliomas (WHO grade II). ROIs were defined by selecting those pixels within the tumour that exhibited uptake values above predefined threshold values. Using threshold values of 100, 95, 90, 85 and 80% of the mean, transaxial ROI size was approximately 0.1, 2.8, 4.3, 6.2 and 8.8 cm2, respectively. Over this range, mean, IMT uptake values decreased significantly from 2.4 to 1.9. High-grade tumours exhibited significantly higher IMT uptake than low-grade tumours at each of the threshold values. The corresponding levels of significance calculated using the Mann-Whitney U-test were between 0.01 and 0.02. Although IMT uptake values in brain tumours are significantly dependent on ROI size, levels of significance assessing differences in IMT uptake between high-grade and low-grade tumours are relatively insensitive to variations in this parameter.

[Intraoperative radiotherapy (IORT) in malignant brain tumors]. / Intraoperative Strahlentherapie (IORT) maligner Hirntumoren.

PURPOSE: Feasibility and morbidity of IORT for malignant brain tumors as well as value of innovative imaging for diagnosis of rest tumors and recurrences were examined. METHODS AND MATERIALS: Between May 1992 and November 1993, 23 patients with malignant brain tumors were treated in Münster with IORT. The patient collective was heterogeneous and negatively selected, i.e. beside of primary treatments, also patients with extensive previous treatment, recurrent tumors or metastases were included. Therapy consisted of radical surgical resection and intraoperative electron radiotherapy using total doses from 15 Gy to 25 Gy relative to the 90% isodose. Afterwards, patients without prior treatment underwent percutaneous irradiation with a maximum dose of 60 Gy, related to the small volume of the tumor area plus a safety margin of 2 cm. RESULTS: No increase of peri-operative morbidity or subacute sequelae was observed. Overall 1-year survival was 67% for grade III gliomas (WHO), and 56% for glioblastoma multiforme. When the Matsutani selection criteria (primary therapy of a supratentorial, peripheral astrocytoma grade III or glioblastoma smaller than 5 cm in diameter with a Karnofsky performance index of more than 60% and possible wide resection) were applied, 1-year survival increased to 75%. Nuclear medical diagnostics using 123I-alpha-methyltyrosin SPECT proved a valuable method for imaging of non-resectable tumor tissue and diagnosis of recurrences. CONCLUSIONS: The results of this study indicate that IORT can contribute to successful tumor treatment while neither increasing peri-operative morbidity nor subacute sequelae.

Angiolipoma of the spinal cord. Magnetic resonance imaging and microsurgical management.

Radiologic diagnosis of intramedullary lipomas has been unreliable for a long time and many of these tumors have not been recognized. The introduction of computed tomography, and lately of magnetic resonance imaging, has led to great progress in the accurate identification of spinal cord tumors as well as in the recognition of type specificity of these lesions. An evaluation of the diagnostic value of magnetic resonance imaging and microsurgical technique for the optimal therapeutic outcome is discussed.

Multiple recurrence of an intracranial hemangiopericytoma.

The multiple multilocular intracranial recurrence of a hemangiopericytoma (HPC) over 21 years in our patient, who has been successfully operated upon and irradiated several times, confirms the known tendency of the majority of HPCs to marked biological activity. The aggressive behavior of HPCs shows an unusually broad scale of variations. On the basis of clinical observations of this particular case, the relative or potential malignancy of HPCs is discussed.