Intracranial hemorrhage after stenting and angioplasty of extracranial carotid stenosis.

BACKGROUND AND PURPOSE: The transluminal angioplasty and stenting procedure has been recently advocated as a potential alternative to surgical endarterectomy for the treatment of severe extracranial carotid stenosis. This study assesses the incidence and significance of intracranial hemorrhage occurring after this procedure. METHODS: We retrospectively reviewed 104 carotid arteries (96 internal, two external, and six common) in 90 patients (63 male; mean age, 69.4 years; range, 48-88 years) who underwent primary stenting and angioplasty by use of Wallstents (103/104) at three centers between January 1996 and January 1999. Seventy-five (83%) patients were referred by neurosurgery departments. Seventy-one (68%) arteries were symptomatic; the mean stenosis percentage was 85% (range, 40-99%). RESULTS: Four intraparenchymal hemorrhages occurred, representing 4.4% of patients and 3.8% of vessels, after angioplasty and stent placement. The mean preoperative stenosis percentage was 95% (range, 90-99%). One hemorrhage occurred immediately after stent placement, whereas the three other hemorrhages occurred in a delayed fashion (mean, 2.8 days). The mean hematoma size was 4.8 cm (range, 2-8 cm). Three patients had associated subarachnoid or intraventricular bleeding; the fourth had associated subdural hemorrhage. Three hemorrhages were fatal; the fourth experienced two seizures only. No acute neurologic symptoms were present prior to hemorrhages, and there was no postprocedural hypertension in these patients. All had been receiving antiplatelet agents as well as intraprocedural IV heparin. CONCLUSION: Intracranial hemorrhage can occur after carotid angioplasty and stenting. We speculate that this represents cerebral hyperperfusion injury. The 3.8% incidence of cerebral hemorrhage observed is approximately sixfold greater than that reported post endarterectomy (0.6%) (95% CI, 0.2-8.7%). This is not statistically significant in this small study group. This trend may reflect patient selection, different anticoagulation protocols, and/or study population size. Additional data are needed to determine the safety and efficiency of carotid stenting as a treatment for carotid stenosis.

Primary primitive neuroectodermal tumor of the cauda equina.

Primitive neuroectodermal tumors (PNETs) are aggressive neoplasms composed predominantly of undifferentiated cells that show evidence of neural differentiation. Although their classification has been controversial, PNETs are well recognized primary tumors of both central and peripheral nervous systems. PNETs must be distinguished from other round-cell tumors, including Ewing's sarcoma, lymphoma, rhabdomyosarcoma, and small cell carcinoma. Intraspinal PNETs are rare neoplasms that are usually metastatic in origin. We describe the eighth reported primary PNET of the cauda equina that developed in a 52-year-old man with no significant medical history. The tumor was characterized by Homer-Wright rosettes and immunoreactivity for CD99, glial fibrillary acidic protein, neuron-specific enolase S100, and synaptophysin. The anatomic location of primary intrathecal PNETs is important as those arising in the spinal cord develop in the central nervous system, whereas those arising in the cauda equina develop in the peripheral nervous system. The histogenesis of intrathecal PNETs may be multifactorial.

Seizure prophylaxis for brain tumour patients. Brief review and guide for family physicians.

Brain tumours are relatively uncommon, but family physicians are sometimes confronted with the somewhat unnerving task of carrying on the day-to-day management of these patients. The authors examine some of the problems encountered in preventing seizures among brain tumour patients. Using illustrative clinical cases and a review of the relevant literature, guidelines are provided for the institution, maintenance, and in some cases discontinuation of seizure prophylaxis for this group of patients.

Patterns of recurrence of malignant astrocytoma following stereotactic interstitial brachytherapy with iodine-125 implants.

The pattern of tumor recurrence was studied in a series of 68 patients who were treated with interstitial brachytherapy for malignant astrocytoma. Thirty-six patients had newly diagnosed tumors and were treated following surgery and external beam therapy, while 32 were treated for recurrent tumors. Recurrence pattern was determined using computed tomography at the time of clinical deterioration. Thirty-eight percent of tumor recurrence occurred within the original tumor margin and 50% occurred at the original site but extended beyond the initial margin. In all, 88.0% recurred at the initial tumor site, 71.4% being confined to within 2 cm of the pretreatment tumor borders while 6.0% recurred intracranially outside of the initial tumor margin. One patient recurred with spinal metastasis while two patients developed systemic metastases. The significance of these findings is discussed.

Calculation of coordinates for depth electrodes placed in temporal lobe structures visualized by oblique CT scan cuts.

A method of direct stereotactic placement of recording depth electrodes in the temporal lobe structures is described. The advantages of this approach, namely its simplicity, accuracy and flexibility, are discussed.

Bilateral extradural hematoma extending from the foramen magnum to the vertex.

We present a 35-year-old man with an extradural hematoma extending bilaterally across the midline from the foramen magnum to the vertex who completely recovered following surgery. Because of the extent of the fluid collection, computed tomographic scanning proved invaluable in facilitating the planning of our surgical approach. He had a long history of alcohol abuse and there were features suggesting preexisting alcoholic brain atrophy in his postoperative computed tomography scan. The possible relationship of this finding to the size of the hematoma and the outcome is discussed.

Primary cranial vault lymphoma mimicking a meningioma.

Primary extra-lymph node lymphomas are not uncommon but they often cause difficulty in diagnosis because they mimic other conditions. We present a case of primary lymphoma arising from the skull vault and masquerading clinically and radiologically as a meningioma, the true diagnosis of which was established only after operation.