MRI and SPECT studies of dural arteriovenous fistulas presenting as pure progressive dementia with leukoencephalopathy: a cause of treatable dementia.

We report two patients with dural arteriovenous fistulas (DAVFs) who presented with pure progressive dementia. Both patients showed only slowly progressive dementia, without headache, papilledema and other neurologic signs associated with diffuse white matter changes in MRI. MR cerebral angiography showed sigmoid sinus DAVFs that were mainly supplied by the occipital artery, together with retrograde filling of the superior sagittal and straight sinus and dilated cortical veins. SPECT studies showed extensive blood flow reduction in the occipital and parieto-occipital areas and right temporal lobe in one patient. Selective embolization for treatment of the DAVF improved cognitive function associated with the abnormal white matter MRI signal. MRI and SPECT showed that severity of dementia correlated with diffuse white matter changes and regional cerebral blood flow. Our cases suggest that gradually impaired cerebral circulation due to venous hypertensive encephalopathy could be involved in slowly progressive dementia with leukoencephalopathy resulting from a DAVF. DAVFs may be particularly important for differential diagnosis in elderly patients with pure progressive dementia. Thus, early diagnosis of DAVFs and treatment by endovascular surgery is important as treatable or reversible dementia.

Cervical epidural rhabdomyosarcoma with a leukemia-like presentation in an aged patient--case report.

A 77-year-old female presented with rhabdomyosarcoma manifesting as leukemia-like indications. Neuroimagings detected cervical and paravertebral masses. Immunohistochemical study of the surgically excised mass lesion from the cervical spine established the correct diagnosis. This leukemia-like presentation of rhabdomyosarcoma requires a multidisciplinary approach to establish the correct diagnosis and treatment.

Primary ductal adenocarcinoma of the lacrimal gland.

The morphological similarity of salivary and lacrimal gland tumors is known. Many clinicopathological studies and characteristics of salivary duct carcinoma, which bears histological similarities to mammary duct carcinoma, have been recently reported; however, only one case of lacrimal duct carcinoma is reported. A second case of lacrimal duct carcinoma is presented. A 67-year-old male with a painless mass in the right upper eyelid underwent total removal of the tumor mass. Microscopic examination of the tumor mass revealed ductal adenocarcinoma of the lacrimal gland, which was the equivalent of salivary duct carcinoma. The immunohistological studies of the lacrimal duct carcinoma showed similar results to those reported for salivary duct carcinoma. The recurrent tumor in the subdural spaces was removed 2 years after the initial surgery and the patient is followed as an outpatient.

Preoperative and postoperative magnetic resonance imaging (MRI) findings of radiculomeningeal arteriovenous malformations: important role of gravity in the symptoms and MRI.

BACKGROUND: The symptoms of radiculomeningeal arteriovenous malformations (AVMs) are reported to be uniform, which suggests it to be a conus medullaris syndrome, and in fact, the lesions on magnetic resonance imaging (MRI) images usually include the conus medullaris. However, the reason why the conus medullaris is always involved in the lesion has not been discussed. METHODS: We encountered seven patients with spinal radiculomeningeal AVMs and operated on all of them. We evaluated the preoperative and postoperative MRI findings in these patients. Postoperative MRI was followed ranging from 6-32 months (mean: 21 months) after surgery. RESULTS: All of our patients showed swelling of the spinal cord, including the conus medullaris, on the preoperative magnetic resonance image. Postoperatively, MRI showed that the swelling of the spinal cord had resolved but that it had finally deteriorated into an atrophic condition. In all of five patients who could be followed up using multiple postoperative MRI scans, sequential T2-weighted images showed that the most rostral level of areas with increased signal in the spinal cord moved in a caudal direction with time. CONCLUSIONS: This and the fact that the conus medullaris was included in the swelling of the spinal cord regardless of the level of the nidus in all our patients, suggested that gravity played an important role in the etiology of radiculomen-ingeal AVM in these patients.

Brain tumors: detection with C-11 choline PET.

PURPOSE: To evaluate the effectiveness of positron emission tomography (PET) with carbon-11 choline in brain tumor imaging. MATERIALS AND METHODS: A rat glioma cell line (C6) was incubated with C-14 choline; the time course of uptake and metabolism was determined in vitro. C-11 choline was injected intravenously in tumor-bearing rats; the time course of distribution in organs was determined. C-11 choline also was injected intravenously in 20 patients (aged 6-86 years) with brain tumors and two volunteers (aged 38 and 58 years); distribution of the tracer in the brain was determined. Regional cerebral blood flow was measured by using oxygen-15 water on the same day. RESULTS: C-14 choline was metabolized to phosphoryl choline in glioma cells. The uptake of C-11 choline by glioblastoma cells was three to four times higher than that in the rat brain. All brain tumors took up more C-11 choline than did normal brain; thus, brain tumors that were not treated, as well as those that were treated with surgery or radiation therapy, were depicted. The tumor-normal brain uptake ratio of C-11 choline in brain tumor did not correlate with the O-15 water regional blood flow in the corresponding area. CONCLUSION: C-11 choline PET can depict brain tumors effectively. This method was clinically useful in patients who had undergone surgery.

Malignant schwannoma metastasizing to the dura mater--case report.

A 58-year-old female, with a previous history of radical resection of malignant schwannoma arising in the maxillary sinus, presented with a metastasis to the dura mater following lung metastases 15 years after the initial diagnosis. A large mass at the left temporal region was totally removed immediately after an intratumoral hemorrhage. She subsequently died of massive hemoptysis. Although the prognosis is poor for patients with malignant schwannoma, aggressive treatment including radical surgery combined with radiotherapy and chemotherapy is recommended.

Midcervical flexion myelopathy after posterior fossa surgery in the sitting position: case report.

Midcervical Quadriplegia is a well-known complication of posterior fossa surgery performed with the patient in the sitting position. The case of a 24-year-old man with a fourth ventricular choroid plexus papilloma is described. The patient developed reversible quadriparesis after surgery in the sitting position; postoperative magnetic resonance imaging demonstrated a hyperintense area within the cervical cord at C5-C6 on T2-weighted images, which was considered to represent "midcervical flexion myelopathy." It is suggested that the prolonged stretch and compression of the cervical cord is the pathogenesis of this serious complication.

Lumbar adhesive arachnoiditis following attempted epidural anesthesia--case report.

A 30-year-old female experienced a sudden sharp pain radiating down to the left leg from the lower back at epidural intubation for anesthesia at childbirth. She continued to complain of pain in the left leg afterwards. Magnetic resonance images demonstrated a conglomeration of adherent nerve roots due to lumbar adhesive arachnoiditis. Microsurgical dissection of adherent nerve roots was performed. Her symptoms disappeared after surgery, but soon recurred, being less severe and responsive to anti-inflammatory agents. Lumbar adhesive arachnoiditis should be considered for differential diagnosis in patients presenting with back and leg pain syndrome.

Primary empty sella in association with superior sagittal sinus thrombosis and dural arteriovenous malformation. Case report.

A 61-year-old woman under treatment with oral medroxyprogesterone acetate following surgery for breast cancer developed diplopia and papilledema due to raised intracranial pressure (ICP). Radiological studies disclosed an empty sella turcica, a dural arteriovenous malformation (AVM), and superior sagittal sinus thrombosis. The sinus thrombosis was considered to have been a side effect of the medroxyprogesterone acetate medication. The association between a primary empty sella and raised ICP is briefly discussed, along with the cause-and-effect relationship between a dural AVM and venous sinus thrombosis.

Toxic effects of bleomycin on the hypothalamus following its administration into a cystic craniopharyngioma.

A 48-year-old man with a cystic craniopharyngioma developed hypersomnia, personality changes, memory impairment and thermal dysfunction following intracystic administration of bleomycin through an Ommaya reservoir after partial removal of the tumour. The patient's neurological deterioration was thought to be related to the toxic effects of bleomycin on the hypothalamus.

Classification of supratentorial arteriovenous malformations. A score system for evaluation of operability and surgical strategy based on an analysis of 66 cases.

A classification of arteriovenous malformations (AVM) is proposed, which is based on a retrospective analysis of the records and results of radical operation in 57 patients between 1983 and 1990. It represents the new developments and more recent technical facilities which influence operability of supratentorial AVMs. Predictability of outcome has been settled upon three groups of factors: anatomical, haemodynamical, and clinical. Anatomical factors are localisation and sectorisation of AVM, determination, caliber and straightening of feeding arteries. Haemodynamical factors are volume of AVM and vascular autoregulation, circulatory velocity of red blood cells in the main arteries of the neck and brain tissue cellular steal. Clinical factors are age, previous rupture of AVM, associated diseases and malformations of vital organs. Each of these factor groups has been divided into parameters to which a code number from 0 to 5 according to the severity of the considered parameter has been attributed. When a contraindication for radical surgery was clearly obvious, as, for example, an AVM with extension to the upper brain stem, number 10 was given. This grading has been done by a team of four persons (3 neurosurgeons including the senior author, and one biophysicist). By adding up all code numbers an Operability Score for a given patient is defined by the number of points, with a minimum of 3 and a maximum of 69. In cases with a score higher than 30 surgery is not advisable. A score between 21 and 30 indicates that always several staged operations are required, whilst only some of the patients with a score between 11 and 20 may require two stage operative treatment. The AVM in patients with a score under 10 can always be radically excised in a single stage operation. We have been able to demonstrate that the Operability Score allows a reliable prediction of outcome, thus giving indications and contraindications for surgery, and also for the surgical strategy. Moreover, we have explained why surgery had been refused in 9 additional cases during the same period. The causes of 8 fatalities out of 57 surgical cases are analyzed. These 57 cases represent a systematically explored series of the senior author; his experience is based upon 295 personal AVM cases (1958-1990).

[Unruptured intracranial saccular aneurysms less than 20 mm in diameter in adults. Radical surgery in 89 cases]. / Les anévrysmes artériels sacculaires intracrâniens non rompus de l'adulte d'un diamètre inférieur à 20 mm. Chirurgie radicale dans 89 cas.

Between 1972 and 1989, 131 unruptured intracranial saccular aneurysms were clipped in the Neurosurgical Department of La Pitié Hospital, Paris. Only 89 of these are considered here, the remaining 42 aneurysms having been discovered and clipped during surgery for a ruptured aneurysm. All isolated unruptured aneurysms were detected by angiography, computerized tomography or magnetic resonance imaging. Twenty out of the 89 aneurysms were asymptomatic ("incidental") while 69 were accompanied by clinical symptoms indicating radiological examination. It is generally accepted that in ruptured aneurysms the mortality rate during 3 days following the rupture is about 50 percent, and for this reason many neurosurgeons are in favour of unruptured aneurysms being treated either by open surgery with clipping of the aneurysmal neck or by inserting a balloon into the aneurysmal sac. The results obtained in 377 published cases, including ours, justify this approach: no recurrent bleeding was observed after open surgery and the mortality rate was nil when the contra-indications of surgery were respected. There was a permanent morbidity of less than 2 per cent directly related to the surgeon's experience.

Foreign-body granuloma as a complication of wrapping and coating an intracranial aneurysm. Case report.

A rare case is presented in which a foreign-body granuloma developed at the site of muslin wrapping and Aron Alpha A coating of an internal carotid artery aneurysm. The importance of avoiding the use of muslin, especially close to the optic nerve and chiasm, is emphasized.

Haemostatic clips and clamps used in surgical neurology with special reference to non ferro magnetic Phynox spring clips by Aesculap.

This paper concerns the historical developments and technical properties of haemostatic devices used in neurosurgery with the exception of coagulation. Therefore there are described haemostatic clips designed for the scalp, clips used on arteries and veins, a clamp for the reduction of the carotid diameter in the neck, and a clamp for closing the venous dural sinuses. Special reference will be made regarding non ferro magnetic Phynox clips by Aesculap.

Detection of a ruptured aneurysmal sac by MRI in a case of negative angiogram. Successful clipping of an anterior communicating artery aneurysm. Case report.

A case of a ruptured aneurysm is presented in which the angiograms did not disclose the sac. Rupture of an aneurysm of the anterior communicating artery was suspected from the distribution of subarachnoid blood on computerized tomography (CT), and the presence of a sac was highly suggestive on magnetic resonance imaging (MRI), which led us to open surgery. A non-thrombosed aneurysm was discovered at the suspected site, and successfully clipped. The necessity is discussed of MRI investigation in patients with subarachnoid haemorrhage (SAH) of unknown aetiology.