Esthesioneuroblastoma (olfactory neuroblastoma) with hemorrhage: an unusual presentation.

Esthesioneuroblastoma (olfactory neuroblastoma) is an uncommon neuroectodermal tumor. Its biological activity ranges from indolent growth to local recurrence and rapid widespread metastasis. Treatment options consist of surgical resection followed by radiation therapy for primary lesions and the addition of chemotherapy for advanced, recurrent, or metastatic lesions. Patients often present with nasal obstruction, rhinorrhea, recurrent epistaxis, hyposmia, or anosmia. However, we report the highly unusual case of a patient with an esthesioneuroblastoma who presented with atypical symptoms of headaches, sinus congestion, and fatigue before acutely losing consciousness. Imaging showed a large frontal skull-based tumor associated with intratumoral hemorrhage. The findings prompted an emergent combined anterior craniofacial resection with gross total resection of the tumor. Except for anosmia, the patient recovered almost completely. Postoperatively, she received adjuvant intensity-modulated radiation therapy and chemotherapy. This is the first reported case of an esthesioneuroblastoma presenting with hemorrhage and rapidly declining mental status, an acute neurological manifestation of which clinicians should be aware.

Cerebrospinal fluid (vascular endothelial growth factor) and serologic (recoverin) tumor markers for malignant glioma.

BACKGROUND: Clinically useful tumor markers have yet to be identified for malignant glioma. We report on two potential novel tumor markers, vascular endothelial growth factor (VEGF) and recoverin (protein A). VEGF is a highly specific endothelial cell activator that induces angiogenesis both in vivo and in vitro. Our study was designed to assess whether VEGF could be measured in the cerebrospinal fluid (CSF) of patients with cerebral neoplasms and used as a marker of particular tumors. We also studied serum recoverin levels in patients with various brain tumors and compared these to controls. Recoverin is a detectable serologic protein that is expressed in patients with cancer-associated retinopathy, a paraneoplastic syndrome. METHODS: In the VEGF arm, we used a solid-phase ELISA to determine the levels of VEGF. CSF samples from patients with anaplastic astrocytoma and glioblastoma multiforme (GBM) and with metastatic and nonastrocytic brain tumors were compared with nontumor control samples. In our recoverin study, an immunoenzymetric assay was used to measure the serum recoverin levels patients with glioma and compared with controls. RESULTS: In the VEGF arm, 89% of samples with malignant astrocytoma and 27% of nonastrocytoma samples had detectable levels of VEGF. VEGF was not detectable in normal CSF samples. The levels of VEGF were significantly higher in high-grade astrocytomas than in nonastrocytic tumors. Recoverin levels were 10-fold higher in patients with recurrent GBM relative to controls. In patients with low-grade glioma, anaplastic glioma, and GBM with no evidence of recurrence, a 3- to 5-fold increase was observed. CONCLUSIONS: VEGF is detectable in CSF and may be a potential marker for differentiating astrocytic from nonastrocytic tumors. Recoverin is detectable in serum and may be a useful glioma tumor marker, especially for recurrent active disease. These markers may have application for tumor diagnosis, surveillance, and treatment response.

Familial frontotemporal dementia: a report of three cases of severe cerebral atrophy with rare inclusions that are negative for tau and synuclein, but positive for ubiquitin.

We describe the brain autopsy findings from three of five siblings who suffered dementia with clinical diagnoses including Alzheimer's, Parkinson's, and Pick's disease. Five other living siblings appear unaffected. All of the autopsied brains showed severe atrophy (brain weights 613, 641, and 750 g) of the frontal and temporal lobes, and to a slightly lesser extent of the parietal lobes, while the occipital lobes were relatively preserved. The substantia nigra showed marked neuronal loss with gliosis. No ballooned neurons, neurofibrillary tangles, neuritic plaques, Pick bodies, or Lewy bodies were found in these brains. Immunohistochemistry for tau protein failed to reveal neuronal or glial inclusions, and normal tau protein was found in a separate Western blot study [Adamec et al. (2001) Neurosci Lett 315:21-24]. Rare neurons with ubiquitinated cytoplasmic inclusions were scattered in the neocortex and hippocampus. The overall pathological features were consistent with a severe form of frontotemporal dementia (FTD) with involvement of the substantia nigra. Whether the rare ubiquitinated inclusions are sufficient to classify these cases as FTD with motor neuron disease type inclusions but without motor neuron disease, or FTD dementia lacking distinctive histological features remains unclear. The features of lobar circumscribed atrophy without Pick bodies and without ballooned neurons, however, are consistent with Pick disease group C in the Constantinidis classification [Constantinidis et al. (1974) Eur Neurol 11:208-217].

Diffusion-weighted MRI of cerebral toxoplasma abscess.

OBJECTIVE: This retrospective study reports the diffusion-weighted MRI appearance of Toxoplasma abscesses, rim-enhancing cerebral masses resulting from toxoplasmosis infection. In all patients, the signal intensity of the abscess core on diffusion-weighted MRI was equal to or less than that of normal, unaffected cerebral white matter and the measured apparent diffusion coefficient was greater than that of unaffected white matter. Histopathology revealed necrotic tissue in the center of these abscesses but no purulent fluid. CONCLUSION: Unlike pyogenic abscesses, the core tissue of rim-enhancing Toxoplasma abscesses shows no restriction of water diffusion.

Stress protein expression in the Alzheimer-diseased choroid plexus.

Abnormal patterns of stress protein expression are found in the cerebral cortex and hippocampus of Alzheimer (AD) subjects. In this study, expression of various stress proteins in the Alzheimer-diseased choroid plexus (CP) was assessed immunohistochemically. We observed decreased HO-1 immunoreactivity in the AD CP, commensurate with our earlier report of suppressed HO-1 protein levels in AD cerebrospinal fluid (Schipper et al., Neurology 54:1297-1304, 2000). Heat shock protein (HSP) 90 was up-regulated in the AD CP relative to controls. There was a trend towards increased expression of HSP60, a mitochondrial stress protein; this is compatible with mitochondrial pathology recently documented in AD CP. Up-regulation of HSP90, a steroid receptor chaperone, in the AD CP may indicate abnormal hormone receptor expression in this secretory tissue. Glucose-regulated protein (GRP) 78 and 94 immunostaining was diminished in AD CP, implicating possible derangements in glucose or calcium homeostasis. Oxidative stress, per se, is probably not responsible for our observations because: i) there were no noticeable differences in the expression of HSP 70, ubiquitin, and alpha-B crystallin in the AD CP; and ii) augmentation, rather than the noted suppression, of HO-1 immunoreactivity would have been expected.

Pituitary apoplexy: early detection with diffusion-weighted MR imaging.

Pituitary apoplexy is defined as a clinical syndrome that may include headache, visual deficits, ophthalmoplegia, or altered mental status. It may result from either infarction or hemorrhage of the pituitary gland. Prognosis is significantly improved with early diagnosis and surgical treatment. We report two cases in which diffusion-weighted MR imaging assisted in the early detection of acute pituitary infarction and led, in one case, to surgical intervention early in the course of clinical apoplexy, with resulting complete recovery.