Orofacial neuralgia associated with a middle cerebral artery aneurysm.

Chronic orofacial pain of neuropathic origin can present diagnostic and management dilemmas to dental practitioners and also affects the patient's quality of life. Intracranial aneurysms are a potential cause of stroke (e.g. sub-arachnoid haemorrhage) that is usually associated with, high rates of mortality and morbidity. A patient who had been previously managed for symptoms of temporomandibular joint disorder (TMD) presented with sharp, shooting pain of moderate intensity. It was precipitated by swallowing, and radiated to the right throat, posterior border of the mandible, ear and temporomandibular joint. Clinical and radiological investigations ruled out odontogenic pain, TMD and other more common types of facial pain. Magnetic resonance imaging revealed a 7 × 6 mm aneurysm in the right middle cerebral artery (MCA) which was subsequently surgically clipped. Interestingly, the facial pain resolved after this procedure. Compression of the insular region of the brain innervated by the trigeminal, glossopharyngeal and vagus nerves provides a plausible explanation for the pain reported. To our knowledge, this is the first case of facial neuralgia associated with an aneurysm in the MCA which emphasizes the importance of a multidisciplinary approach in the diagnosis and management of unusual cases of chronic orofacial pain.

Preoperative magnetic resonance spectroscopy improves diagnostic accuracy in a series of neurosurgical dilemmas.

OBJECT: The purpose of this study was to evaluate the usefulness of preoperative magnetic resonance spectroscopy (MRS) in neurosurgical patients with diagnostically challenging intracranial lesions. METHODS: Included in this study are twenty-three consecutive patients presenting to the neurosurgery service with diagnostically challenging intracranial lesions and who were investigated by conventional MR imaging and proton ((1)H) MRS, followed by surgery with subsequent histopathological diagnosis. An experienced neuroradiologist (RJ) blinded to the final histopathology evaluated the imaging studies retrospectively. Provisional diagnoses based on preoperative clinical and conventional MR data versus preoperative MRS data were compared with definitive histopathological diagnoses. RESULTS: Compared with preoperative clinical and conventional MR data, (1)H MRS improved the accuracy of MR imaging from 60.9% to 83%. We found (1)H MRS reliably distinguished between abscess and high-grade tumour, and between high-grade glioma and low-grade glioma, but was not able to reliably distinguish between recurrent glioma and radiation necrosis. In 12/23 cases (52%) the (1)H MRS findings positively altered our clinical management. Two representative cases are presented. CONCLUSIONS: Our study supports a beneficial role for (1)H MRS in certain diagnostic intracranial dilemmas presenting to neurosurgeons. The information gleaned from preoperative (1)H MRS can be a useful adjunct to clinical and conventional MR imaging data in guiding the management of patients with intracranial pathologies, particularly high-grade tumour versus abscess, and high-grade versus low-grade glioma. Further larger prospective studies are needed to clearly define the utility of (1)H MRS in diagnostically challenging intracranial lesions in neurosurgery.

Cell cycle times of short-term cultures of brain cancers as predictors of survival.

Tumour cytokinetics estimated in vivo as potential doubling times (T(pot) values) have been found to range in a variety of human cancers from 2 days to several weeks and are often related to clinical outcome. We have previously developed a method to estimate culture cycle times of short-term cultures of surgical material for several tumour types and found, surprisingly, that their range was similar to that reported for T(pot) values. As T(pot) is recognised as important prognostic variable in cancer, we wished to determine whether culture cycle times had clinical significance. Brain tumour material obtained at surgery from 70 patients with glioblastoma, medulloblastoma, astrocytoma, oligodendroglioma and metastatic melanoma was cultured for 7 days on 96-well plates, coated with agarose to prevent proliferation of fibroblasts. Culture cycle times were estimated from relative (3)H-thymidine incorporation in the presence and absence of cell division. Patients were divided into two groups on the basis of culture cycle times of < or =10 days and >10 days and patient survival was compared. For patients with brain cancers of all types, median survival for the < or =10-day and >10-day groups were 5.1 and 12.5 months, respectively (P=0.0009). For 42 patients with glioblastoma, the corresponding values were 6.5 and 9.0 months, respectively (P=0.03). Lower grade gliomas had longer median culture cycle times (16 days) than those of medulloblastomas (9.9 days), glioblastomas (9.8 days) or melanomas (6.7 days). We conclude that culture cycle times determined using short-term cultures of surgical material from brain tumours correlate with patient survival. Tumour cells thus appear to preserve important cytokinetic characteristics when transferred to culture.