Spindle cell carcinoma with cystic brain metastasis: Successful treatment with stereotactic radiotherapy and anti­programmed cell death­1 antibodies: A case report.

Cystic brain metastasis is a rare condition that mainly originates from lung or breast adenocarcinomas. By contrast, pulmonary spindle cell carcinoma, a rare type of non-small cell carcinoma, has not been reported with this condition. Cystic brain metastases are characterized by larger tumor sizes with increased peritumoral edema compared with solid metastases. Therefore, specific treatment strategies are required for intracranial disease control. Immunotherapy has recently been demonstrated to be crucial for treating pulmonary sarcomatoid carcinomas based on high programmed cell death-ligand 1 (PD-L1) expression observed in these cancers. The present report describes the case of an 82-year-old man diagnosed with pulmonary spindle cell carcinoma, a rare subtype of sarcomatoid carcinoma. At 7 months after the diagnosis, the patient complained of a walking disturbance for which de novo brain metastasis with peritumoral edema was the causative agent. The brain tumor had a large cystic component, and thus, an Ommaya reservoir catheter was implanted for cyst aspiration but collapsed early without sufficient volume reduction. The patient was transferred to receive twice-split gamma knife treatment, which shrank the solid compartment and reduced the cyst volume, thereby relieving neurological defects. The patient was subsequently treated with immunotherapy targeting programmed cell death-1 based on the high PD-L1 expression in the lung tumor specimen. The thoracic tumors regressed following immunotherapy and progression-free survival was maintained for 16 months. To the best of our knowledge, the present report provides the first description of focal and systemic therapies for pulmonary spindle cell carcinoma with cystic brain metastasis. The report also discusses the treatment strategies for cystic brain metastases and reviews cases of pulmonary spindle cell carcinoma treated with immune checkpoint inhibitors.

Impact of Coronavirus Disease 2019 on Time Delay and Functional Outcome of Mechanical Thrombectomy in Tokyo, Japan.

OBJECTIVES: An association has been reported between delays in the onset-to-door (O2D) time for mechanical thrombectomy (MT) and outbreaks of coronavirus disease 2019 (COVID-19). However, the association between other MT time courses or functional outcomes and COVID-19 outbreaks remains unclear. We compared the time courses of stroke pathways or functional outcomes in 2020 (the COVID-19 era) with those in 2019 (the pre-COVID-19 era) in Tokyo, Japan. MATERIALS AND METHODS: This retrospective observational study used data from the Tokyo-tama-REgistry of Acute endovascular Thrombectomy (TREAT), a multicenter registry of MT for acute large vessel occlusion in the Tokyo Metropolitan Area. Patients who had undergone acute MT from January 2019 to December 2020 were included. Patients were classified by the year they had undergone MT (2019 or 2020). RESULTS: In total, 477 patients were analyzed. O2D time was significantly longer in 2020 (146.0 min) than in 2019 (105.0 min; p = 0.034). No significant difference in door-to-puncture time (D2P) time or modified Rankin Scale (mRS) score 0-2 at 90 days was seen between 2019 and 2020. In the subgroup analysis, O2D time was significantly longer in the first half of 2020 compared with 2019. Multivariable logistic regression analysis revealed that the year 2020 was a independent predictor of longer O2D time, but not for mRS score 0-2 at 90 days. CONCLUSIONS: Although O2D time was significantly longer in the COVID-19 compared with the pre-COVID-19 era, D2P may not be significantly delayed and functional outcomes may not be different, despite the COVID-19 pandemic.

Negative impact of Interhospital Transfer on Clinical Outcomes of Mechanical Thrombectomy for Fast Progressive Stroke.

OBJECTIVES: The time-dependence of the clinical outcome of mechanical thrombectomy is higher in the "fast progressor" in whom cerebral ischemia progresses rapidly. The impact of time-consuming interhospital transfer (IT) on the clinical outcome of such patients is unknown. The effect on clinical outcomes of IT of fast progressors was investigated. METHODS: Among the patients enrolled in the Tokyo/Tama REgistry of Acute endovascular Thrombectomy, fast progressor cerebral ischemia cases were retrospectively investigated. In this study, a fast progressor was defined as a case with an Alberta Stroke Program Early CT Score less than 6 and last known well (LKW) to arterial puncture within 6 h. Patients' background characteristics, treatment progress, and the modified Rankin Scale (mRS) score at 3 months were examined. RESULTS: Of a total of 1182 patients, 92 (7.8%) were included, with 76 patients in the direct transfer (DT) group, and 16 patients in the IT group. Median LKW to reperfusion was 190 min and 272 min, respectively (P<.001). The number of patients with mRS scores 0-2 at three months was 22 (28.9%) in the DT group and 1 (6.2%) in the IT group. Interhospital transfer was an independent factor associated with worse outcomes (odds ratio 0.08, 95% confidence interval 0.01-0.87, P=.038). CONCLUSION: This study showed that, among fast progressor patients, the IT group had a worse prognosis than the DT group. To provide good clinical outcomes for fast progressor patients, those who are likely to undergo mechanical thrombectomy should be sent directly to a thrombectomy-capable center.

Neuroendoscopic Removal of Acute Subdural Hematoma with Contusion: Advantages for Elderly Patients.

Background. Large craniotomy for acute subdural hematoma is sometimes too invasive. We report good outcomes for two cases of neuroendoscopic evacuation of hematoma and contusion by 1 burr hole surgery. Case Presentation. Both patients arrived by ambulance at our hospital with disturbed consciousness after falling. Case 1 was an 81-year-old man who took antiplatelet drugs for brain infarction. Case 2 was a 73-year-old alcoholic woman. CT scanning showed acute subdural hematoma and frontal contusion in both cases. In the acute stage, glycerol was administered to reduce edema; CTs after 48 and 72 hours showed an increase of subdural hematoma and massive contusion of the frontal lobe. Disturbed consciousness steadily deteriorated. The subdural hematoma and contusion were removed as soon as possible by neuroendoscopy under local anesthesia, because neither patient was a good candidate for large craniotomy considering age and past history. 40%~70% of the hematoma was removed, and the consciousness level improved. Conclusion. Neuroendoscopic removal of acute subdural hematoma and contusion has advantages and disadvantages. For patients with underlying medical issues or other risk factors, it is likely to be effective.

Primary neuroendocrine tumor in brain.

The incidence of brain metastases for neuroendocrine tumor (NET) is reportedly 1.5~5%, and the origin is usually pulmonary. A 77-year-old man presented to our hospital with headache and disturbance of specific skilled motor activities. Computed tomography (CT) showed a massive neoplastic lesion originating in the left temporal and parietal lobes that caused a mass edematous effect. Grossly, total resection of the tumor was achieved. Histological examination revealed much nuclear atypia and mitotic figures. Staining for CD56, chromogranin A, and synaptophysin was positive, indicating NET. The MIB-1 index was 37%. Histopathologically, the tumor was diagnosed as NET. After surgery, gastroscopy and colonoscopy were performed, but the origin was not seen. After discharge, CT and FDG-PET (fluoro-2-deoxy-d-glucose positron emission tomography) were performed every 3 months. Two years later we have not determined the origin of the tumor. It is possible that the brain is the primary site of this NET. To our knowledge, this is the first reported case of this phenomenon.

Traumatic aneurysm of the supraclinoid internal carotid artery-case report-.

A 23-year-old male was admitted after a motor vehicle accident with acute epidural hematoma, diffuse subarachnoid hemorrhage (SAH) in the basal cistern, and fractures at the anterior cranial base. Angiography revealed an aneurysm of the right supraclinoid internal carotid artery (ICA). His consciousness suddenly worsened on the 23rd day. Expansion of the SAH in the basal cistern and two hump aneurysms were detected. He underwent endovascular embolization of these aneurysms and the right ICA with Guglielmi detachable coil. Traumatic aneurysms are difficult to diagnose in the early period after injury and are associated with a high mortality. Endovascular treatments for traumatic aneurysms have lower mortality rate, and can be performed under local anesthesia.

Therapeutic hypothermia for severely head-injured patients with acute subdural haematoma.

The benefit of hypothermia therapy for severely head-injured patients has been a matter of controversy, and the appropriate indications have yet to be clarified. The authors have employed mild hypothermia to treat severe acute subdural haematoma (ASDH) patients postoperatively as a means of controlling intracranial pressure. The potential roles of hypothermia in the treatment of severe ASDH patients are discussed. Between 1997 and 2000, 18 ASDH patients with a GCS on admission of 6 or less were treated by haematoma evacuation with postoperative mild hypothermia. The efficacy of hypothermia was evaluated retrospectively by comparing the outcome of these 18 patients with that of 15 ASDH patients who underwent surgery without postoperative hypothermia between 1993 and 1996. Hypothermia significantly increased both the survival and favorable outcome rates of the 18 ASDH patients, compared with the historic controls. However, the benefit of hypothermia was seen only in ASDH patients without associated cerebral contusion, and no significant protective effect of hypothermia was seen in ASDH patients with contusion. Hypothermia may be a useful postoperative therapeutic modality for severe ASDH without concomitant cerebral contusion. A future prospective study is warranted to support the conclusions of this retrospective study.

Rebleeding from a primary brain tumor manifesting as intracerebral hemorrhage (CNN 04/077, revised version).

Symptomatic spontaneous intratumoral hemorrhage is a rare event in a patient with a brain tumor (BT). Although the treatment of choice in such a case is surgical removal of both the tumor and the hemorrhage, the optimal timing for surgical intervention has not been clearly established, particularly in those who present with minimal neurological deficits and a small hemorrhage volume. Two cases of primary BTs manifesting as an intracerebral hemorrhage (ICH) are described, in which rebleeding from the tumor occurred shortly after the initial hemorrhage. The patients each presented with the sudden onset of a headache and minimal neurological deficits, and the neuroradiological workup was consistent with a diagnosis of hemorrhagic BT. Each patient remained neurologically stable, and elective surgery had been planned within 7 days of their admission, but rebleeding occurred 5 and 6 days, respectively, after admission. A BT manifesting as an ICH may rebleed shortly after the initial bleeding, and should be treated on an emergency basis instead of an elective basis regardless of the patient's neurological status on admission or hematoma volume on the initial CT scans.

Treatment of spontaneous intracranial hypotension secondary to C-2 meningeal cyst by surgical packing--case report.

A 41-year-old man presented with progressive worsening of postural headache. Computed tomography (CT) showed bilateral subdural hematomas without prior history of trauma. The diagnosis was spontaneous intracranial hypotension (SIH). Conservative treatment with oral steroids failed to prevent gradual deterioration of the patient's consciousness. CT myelography revealed massive cerebrospinal fluid (CSF) leakage between the C-1 and C-2 levels. The leak was repaired surgically via a laminectomy. A cyst, thought to be a meningeal cyst, was discovered adjacent to the right C-2 nerve root, and CSF was seen seeping out from around the cyst after a Valsalva maneuver. The presumed dural defect of the cyst was sealed by packing with muscle fragments and fibrin glue. The symptoms disappeared soon after surgery. He was discharged 1 month after surgery without deficits. Most SIH cases are benign and can be managed conservatively, or by the epidural blood patch method. Surgery is more invasive than the epidural blood patch method, but should be performed in patients with a high cervical lesion and massive CSF leakage.

Cerebellar hemorrhage secondary to cranial metastasis of prostate cancer--case report.

A 77-year-old man with a 9-year history of prostate cancer presented with high fever and dysphagia. The initial diagnosis was aspiration pneumonia, but the patient became comatose 2 days after admission, and neuroradiological workup revealed cerebellar hemorrhage, obstructive hydrocephalus, and extensive destruction of the occipital bone secondary to cranial metastasis. The diagnosis was cerebellar hemorrhage secondary to cranial metastasis of prostate cancer. Tumor resection was abandoned because of the patient's poor health. Shunt surgery and palliative radiotherapy were temporarily effective in restoring his consciousness, but he died of systemic infection 3 weeks after surgery. Metastasis of prostate cancer to the cranium, particularly to the skull base, rarely causes lower cranial nerve paresis, and awareness of this sign may lead to earlier detection of the cranial metastasis and prevention of cerebellar hemorrhage.

Postoperative communicating hydrocephalus in patients with supratentorial malignant glioma.

Postoperative communicating hydrocephalus in adult patients with supratentorial malignant glioma is a relatively uncommon condition that occurs months after the initial operation of tumor excision. It occurred in only five of 50 consecutive cases treated in our department during the past 10 years. The hydrocephalus appeared to be attributable to leptomeningeal dissemination of tumor cells and subsequent impairment in cerebrospinal fluid (CSF) absorption. The tumors were located adjacent to the lateral ventricles in all five patients, and the proximity of the tumor to the cerebral ventricles may have facilitated dissemination of the tumor cells into the CSF space, resulting in hydrocephalus. The hydrocephalus was treated by a shunt surgery in all five cases, and the symptoms temporarily improved. None of the five patients experienced shunt malfunction or abdominal symptoms attributable to metastasis to the peritoneal cavity, and all five patients died of regrowth of the intracranial tumor or of pneumonia.

"Occult" ruptured cerebral aneurysms revealed by repeat angiography: result from a large retrospective study.

Not infrequently, cerebral angiography performed immediately after the onset of subarachnoid hemorrhage (SAH) fails to reveal any causative lesion. Although the cause of the SAH in most of these cases remains unknown, repeat angiography sometimes discloses a lesion not detected by the initial angiography. The frequency of finding a ruptured aneurysm by repeat angiography and the angiographic characteristics of such aneurysms have been investigated retrospectively. Nineteen among 316 non-traumatic SAH patients (6%) showed initially negative angiogram, and 7 of 19 patients (36%) were identified as harboring an "initially occult" aneurysm. It was possible to identify the expected cause of these initial false-negative angiograms in four of those seven patients. The aneurysm was located in the anterior communicating artery (ACoA) complex in four of the seven patients. When interpreting the angiograms of patients with SAH, neurologists and neurosurgeons should bear in mind the finding that the ACoA complex is the most frequent site of "initially occult" aneurysms. One patient had a dissecting aneurysm of the internal carotid artery, and although such lesions have been considered rare, they should be included in the differential diagnosis of SAH of unknown origin.

Subcortical hemorrhage caused by methamphetamine abuse: efficacy of the triage system in the differential diagnosis--case report.

A 32-year-old woman was brought to the emergency room with hemiplegia on the left and consciousness disturbance. Her prior medical history and the circumstances of the onset were unknown. Brain computed tomography showed intracerebral hemorrhage (ICH) with a midline shift of more than 10 mm in the right parietal lobe. Cerebral angiography failed to show any vascular anomalies. Urine analysis with the triage system, a qualitative screening test for psychotropic drug abuse, showed positive reaction for amphetamines. Subsequent laboratory examination confirmed a highly elevated serum concentration of methamphetamine. The patient underwent evacuation of the hemorrhage via a craniotomy, and was discharged 40 days after admission. Abuse of illegal drugs including amphetamines among young adults is increasing in many developed countries, and the suspicion of possible drug abuse should always be raised in young patients with angiographically negative ICH. A urinalysis screening test for psychotropic agents should be a part of routine emergency room diagnostic procedures for such patients.

Ring-enhanced mass in the brain of a woman with systemic lupus erythematosus and elevated serum CA19-9 level: brain abscess or metastatic tumor?--case report.

A 70-year-old woman with systemic lupus erythematosus presented with a brain abscess manifesting as progressive monoparesis of the right lower extremity over 4 days. She had had no episodes of fever, and did not complain of headache or exhibit any signs of meningeal irritability. Computed tomography of the brain showed a round, low-density mass with strong ring enhancement in the left frontal lobe. Laboratory examination found a moderately elevated serum level of CA19-9, a marker of some digestive organ cancers. Together with the absence of febrile episodes, headache, and a rise in leukocyte count, the initial suspicion was metastatic brain tumor rather than brain abscess. However, diffusion-weighted magnetic resonance imaging depicted the mass as a very hyperintense area. The neuroimaging diagnosis was brain abscess. After conservative treatment with intravenous antibiotics for 6 weeks, the brain abscess completely resolved, and the patient was discharged without neurological deficits.

Normokalemia and hyperglycemia in subarachnoid hemorrhage patients resuscitated from prehospital cardiopulmonary arrest.

Severe metabolic acidosis develops following prolonged periods of cardiopulmonary arrest (CPA), and excessive hydrogen ions derived from lactate and other noxious acids cause marked hyperkalemia in most CPA patients. This study investigated whether the serum electrolyte imbalance in resuscitated CPA patients is affected by the etiology of the CPA. Between 1999 and 2000, return of spontaneous circulation (ROSC) was achieved and serum electrolyte concentration measurements and blood gas analysis (BGA) were performed in 65 of 270 CPA patients treated. Of the 65 patients, subarachnoid hemorrhage (SAH) was the cause of the CPA in ten, cardiac attack was the cause in 16 and asphyxia was the cause in nine patients. The clinical and laboratory data of these 35 patients were retrospectively compared among the three groups. The SAH group had significantly lower serum potassium concentrations than the other two groups and significantly higher glucose concentrations than the asphyxia group. Massive amounts of catecholamines are released into the systemic circulation of SAH patients and our results may indicate that the amount of catecholamines released in resuscitated SAH patients is greater than in heart attack or asphyxia patients, resulting in a lower serum potassium concentration despite the presence of severe metabolic acidosis. It should be clarified in a prospective study whether the presence of normokalemia and hyperglycemia in resuscitated CPA patients reliably predicts the presence of SAH.

Endovascular treatment for poorest-grade subarachnoid hemorrhage in the acute stage: has the outcome been improved?

OBJECTIVE: Patients with poor-grade subarachnoid hemorrhage (SAH) have been considered good candidates for endovascular treatment. The results of treatment of Grade V SAH, the poorest grade, however, have not been fully elucidated. METHODS: The clinical characteristics and outcome parameters of 22 World Federation of Neurosurgical Societies Grade V SAH patients treated endovascularly in the acute stage between 1998 and 2000 are summarized and compared with those of 18 Grade V SAH patients treated conservatively between 1995 and 1997. RESULTS: Among the 22 patients treated endovascularly, 8 patients (36.4%) survived. The rate was significantly higher than that of the 18 patients treated conservatively (5.6%), only one of whom survived. The favorable outcome rate, however, was not significantly different between the two groups (4.5% versus 6.0%). Subdivision of both treatment groups according to Glasgow Coma Scale (GCS) score showed that the improved survival among those treated endovascularly was attributable to the improved survival in those with a preprocedural GCS score of 6 but not of 4 or 5. CONCLUSION: Endovascular treatment of the 22 World Federation of Neurosurgical Societies Grade V SAH patients improved their survival rate but not their favorable outcome rate in comparison with conservative treatment. Further accumulation of clinical data is essential to determine whether endovascular treatment can improve the functional outcome of those with GCS scores of 6 and whether there is no role for endovascular treatment in those with GCS scores of 4 or 5.

Early resolution of third nerve palsy following endovascular treatment of a posterior communicating artery aneurysm.

A 69-year-old man underwent successful endovascular treatment of a posterior communicating artery aneurysm that had caused a third nerve palsy. Pupil size became normal within 10 days and ptosis and ocular ductions became normal within 3 weeks of the procedure. Based on the reported recovery rates of third nerve palsy after aneurysmal clipping, recovery may occur more rapidly in patients who undergo endovascular treatment. Further data are necessary to substantiate this hypothesis.