Neurosarcoidosis-related intracranial haemorrhage: three new cases and a systematic review of the literature.

BACKGROUND AND PURPOSE: Intracranial haemorrhage in neurosarcoidosis (NS-ICH) is rare, poorly understood and the diagnosis of NS may not be immediately apparent. METHODS: The clinical features of three new NS-ICH cases are described including new neuropathological findings and collated with cases from a systematic literature review. CASES: (i) A 41-year-old man with headaches, hypoandrogenism and encephalopathy developed a cerebellar haemorrhage. He had neuropathological confirmation of NS with biopsy-proven angiocentric granulomata and venous disruption. He responded to immunosuppressive therapy. (ii) A 41-year-old man with no history of hypertension was found unconscious. A subsequently fatal pontine haemorrhage was diagnosed. Liver biopsy revealed sarcoid granulomas. (iii) A 36-year-old man with raised intracranial pressure headaches presented with a seizure and a frontal haemorrhage. Hilar lymph node biopsy confirmed sarcoidosis, and he was treated successfully. Systematic review: Twelve other published cases were identified and collated with our cases. Average age was 36 years and M:F = 2.3:1; 46% presented with neurological symptoms and 31% had CNS-isolated disease. Immediate symptoms of ICH were acute/worsening headache or seizures (60%). ICH was supratentorial (62%), infratentorial (31%) or subarachnoid (7%). Forty percent had definite NS, 53% probable NS and 7% possible NS (Zajicek criteria). Antigranulomatous/immunosuppressive therapy regimens varied and 31% died. CONCLUSIONS: This series expands our knowledge of the pathology of NS-ICH, which may be of arterial or venous origin. One-third have isolated NS. Clinicians should consider NS in young-onset ICH because early aggressive antigranulomatous therapy may improve outcome.

Combined nasal and skull base pathology: adjacent nasal schwannoma and olfactory groove meningioma.

A 55-year-old woman presented with a longstanding history of headache and personality change. Preoperative imaging suggested an olfactory groove meningioma invading the posterior nasal space. Following surgical removal of the lesion histopathology confirmed the presence of both a nasal schwannoma and an olfactory groove meningioma. This dual pathology may represent a variation of neurofibromatosis type 2 (NF-2).

The anatomical distribution of cerebral gliomas in mobile phone users.

We analysed the association between mobile phone use and the anatomical distribution of glial brain tumours in Irish neurosurgical patients. All patients with unilateral histologically proven glioma were enrolled over a 12 month period. We hypothesised that were a cellular phone to cause a glioma then it would do so on the dominant hand side. Fifty mobile phone users and twenty three non-users were identified. The vast majority of patients (69/73) were right handed and the right side of the brain was more common as the tumour site (48/73). Fisher's exact test revealed no statistical significance for glioma location based on the handedness of the patient in the mobile phone user group and location of the tumour in both user and non-user groups. We discuss our findings and the stable trend in the incidence of reported glioma cases.

Quality evaluation of spiral CT-directed skull base coordinate assignment using the Leibinger 'Z-D' frame and 'STP' software.

We employed a phantom model to evaluate the accuracy and precision of spiral CT-directed intracranial skull base coordinate assignment using the Leibinger 'ZD' frame and 'stp' stereotactic software. Whilst the difference between the true and computed coordinates was in the perimillimeter range for anteroposterior, lateral and vertical measurements in a 1-mm slice thickness series of scans, errors of greater than 4 mm were encountered in 60% of vertical measurements in a 2-mm slice thickness series. Potential explanations for this clinically significant observation are discussed.

Localization of inactive cerebrospinal fluid fistulas.

Because of the importance of preoperative localization of dural fistulas, many imaging modalities have been critically evaluated for their role in pinpointing the site of cerebrospinal fluid (CSF) leakage. Twenty-one consecutive patients who were suspected of having a CSF fistula were studied to evaluate magnetic resonance (MR) imaging in locating the fistula. These patients were also studied independently by fine-slice computerized tomography (CT). The MR images demonstrated lesions compatible with dural fistulas in 19 patients, whereas CT demonstrated only seven of these lesions. All of these patients underwent surgical dural repair. The remaining two patients underwent surgical exploration on the basis of the CT findings but no dural fistula was found in either patient. All patients made a good postoperative recovery. One patient developed a postoperative wound infection and in another CSF leakage recurred. Although MR imaging was very precise in locating the CSF fistulas, CT missed a significant number of these lesions and was falsely positive in 9.5% of cases. Therefore, it is concluded that MR imaging is an essential investigation in patients with a suspected dural fistula and should be performed before embarking upon surgery and before assuming natural healing of the CSF fistula.

Total intraventricular migration of unisystem ventriculo-peritoneal shunt.

This is a report of an hydrocephalic adult, in whom a unishunt system migrated upwards into the ventricle despite using the appropriate clips (lock and slip). The shunt migration discovered 3 months following its insertion. Several mechanisms contributed to the migration; negative sucking intra-ventricular pressure, positive pushing intra-abdominal pressure, tortuous subcutaneous track and neck movements. It seams that lock and slip clips are not enough fixation. The best way of preventing such shunt migration is interposing a reservoir between the ventricular and peritoneal catheters.

MRI cisternography, and the localization of CSF fistulae.

Accurate localization of CSF fistulae not only makes the planning of surgery easier, but it also increases the chances of successful dural repair and eliminates negative exploration. CSF fistulae localization has been a problem for many years, and several methods have been used to pin-point the site of CSF leakage with variable degree of success. Recently, contrast CT cisternography (CCTC) has replaced radio-isotope cisternography (RIC) in many centres. However, both methods are invasive, time consuming, contraindicated in patients with intracranial mass lesions and insensitive in detecting inactive CSF leaks. Furthermore, in both, ionizing radiation is used and both techniques may lead to allergic reactions or seizures. On the other hand, T2-weighted Magnetic Resonance Imaging (MRI) shows the CSF as a high signal without the need to inject contrast media intrathecally. Furthermore, MRI demonstrates the intracranial anatomy and pathology in detail in multiple planes within a relatively short time. MRI does not involve ionizing radiation and therefore is safely repeatable. MRI using T2-weighted sequences should be an ideal tool to locate precisely the site of CSF fistulae. This paper describes our experience with MRI cisternography in CSF fistulae localization. Eleven patients with inactive CSF fistulae were investigated. MRI cisternography localized the site of fistula in each case. All patients were explored surgically and the site of CSF fistula was confirmed and repaired intradurally with a pericranial graft and fibrin glue without recurrence or meningitis.

Genito-femoral neuralgia.

A 46-year-old male with bilateral genito-femoral neuralgia is presented. The patient complained of groin and testicular pain, the onset following asynchronous bilateral inguinal herniorrhaphy. Relief was effected by genito-femoral nerve resections. The operative approach is discussed. The differentiation between this syndrome and ilio-inguinal nerve entrapment is tabulated.