Pineal and leptomeningeal metastases from a parotid carcinoma ex pleomorphic adenoma.

Carcinoma ex pleomorphic adenoma (CEPA) is an uncommon complication of an untreated pleomorphic adenoma (PA), but one that has a life-threatening significance. This case report documents the clinical, radiological and histopathological features of an extremely rare case of biopsy-proven pineal metastasis, with cerebellopontine and leptomeningeal spread, from CEPA of the parotid gland in spite of the patient having undergone parotidectomy, ipsilateral neck dissection and adjuvant radiotherapy. In spite of the current surgical and oncological treatment of CEPA, the rates of recurrence and distant metastases are high, with a subsequently poor prognostic outcome in most patients. Distant spread is usually to the bones and the lungs; however, more unusual locations have been documented. Our finding of pineal metastasis from CEPA has not previously been reported in the literature. Although this is a rare complication of an unusual condition, the aggressive behaviour of these malignancies warrants close clinical follow-up, with a low threshold for re-imaging and investigation if indicated.

Management of Chiari I malformation in children: effectiveness of intra-operative ultrasound for tailoring foramen magnum decompression.

PURPOSE: Patients with Chiari I malformation (CM-1) commonly undergo foramen magnum decompression (FMD). However, there is no consensus on how this should be achieved. An approach would be to rationalize surgical steps based on pre-operative imaging and intra-operative findings. The aim of this study is to assess the usefulness of intra-operative ultrasound scanning (IOUS) in tailoring foramen magnum decompression in children with CM-1 and whether the use of IOUS is effective in reducing the risk of complications without increasing the need for re-operation. METHOD: We performed a retrospective study. IOUS was utilized during FMD: a subjective assessment was made on whether there was adequate cerebellar tonsillar and/or CSF pulsation following suboccipital craniectomy. If there was adequate pulsation, the dura was not opened. Additional data were collected including age and gender of patients, presence of pre-operative syringomyelia, intra-operative ultrasound findings, length of follow-up, complications and radiological and clinical outcome. The statistical analysis was performed with XLStat®(Addinsoft SARL™, France). RESULTS: Nineteen patients underwent FMD from June 2011 to December 2012. The mean age was 10.5 years; there were nine females and ten males. Eleven patients had syringomyelia at diagnosis. Based on IOUS, eight patients underwent dural decompression and 11 patients bony decompression only. One patient had a post-operative pseudomeningocoele and two patients required re-operation. There was no significant statistical difference between the two groups regarding post-operative improvement in the syrinx. CONCLUSION: We found that tailoring FMD for patients with CM-1 using intra-operative findings using ultrasound scan was useful in avoiding unnecessary manoeuvres, while not compromising on the outcome.

Clinical features of central isolated unilateral foot drop: A case report and review of the literature.

BACKGROUND: Intracranial cause of isolated unilateral foot drop is very rare. There may be a delay in the diagnosis of the cause of central foot drop or patients with such lesions might be misdiagnosed and subjected to unnecessary interventions. One of the reasons for the diagnostic uncertainty might be the absence of upper motor neuron (UMN) signs in the initial examination of such patients. CASE DESCRIPTION: We present a very rare case of a 78-year-old woman who had presented with a five-year progressive right-sided unilateral isolated foot drop from a left-sided parasagittal tumor. Previously, she had undergone biopsy of an abnormality on the right C7/T1 facet, which was found to be benign. On examination of the patient, she had UMN signs in the ipsilateral foot. On magnetic resonance imaging scan of her head, a 3-cm left parasagittal lesion, consistent with it being a meningioma, was noted. The patient had significant medical history and declined to undergo surgical removal of the lesion. CONCLUSION: We review the literature on central foot drop from various intracranial pathologies and discern its clinical features. Patients with central foot drop often have UMN signs; however, these may be absent causing diagnostic uncertainty, and physicians should be vigilant of these variations in the presentation.