Molecular insights and the role of 18F-FDG-PET/CT in the diagnosis of spinal gliomas.

BACKGROUND: In recent years, molecular findings on spinal gliomas have become increasingly important. This study aimed to investigate the role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) in the diagnosis of spinal glioma. METHODS: This study included patients diagnosed with spinal cord glioma who underwent 18F-FDG-PET examination at the Department of Neurosurgery, Nagoya University Hospital between January 2016 and November 2023. The gliomas were divided into two groups, high-grade and low-grade, based on pathological and molecular studies. The maximum standardized uptake values (SUVmax) of the tumors were quantified and subsequently represented using receiver operating characteristic (ROC) curves. RESULTS: Eighteen participants were included in this study. Of the participants, seven had high-grade glioma with an SUVmax of 6.76 ± 0.72, and eleven had low-grade glioma with an SUVmax of 4.02 ± 1.78, and a statistically significant difference between the two groups. The ROC curve delineated an SUVmax cutoff value of 5.650, with an area under the curve (AUC) of approximately 0.909. Based on the cutoff value, the results of the diagnostic performance rendered a sensitivity and negative predictive value of 1.0, whereas the specificity and positive predictive value were 0.909 and 0.875, respectively. CONCLUSIONS: The present study shows that 18F-FDG-PET exhibits a markedly sensitive and negative predictive value in the assessment of spinal gliomas. Additionally, these findings have potential implications for the qualitative assessment of spinal gliomas using 18F-FDG-PET/CT. This imaging modality may be useful for making timely treatment decisions in situations where a detailed diagnosis by molecular analysis is not possible.

Primary Bone Lymphoma of the Spine: A Case Report Highlighting Diagnostic Complexities and Treatment.

The diagnosis of primary bone lymphoma (PBL) of the spine is challenging due to its nonspecific symptoms and radiographic features. This report details the case of an 81-year-old female who presented with lower limb weakness and thoracic pain, consequent to a vertebral pathological fracture and spinal cord compression. The initial surgical intervention revealed granulomas with caseous necrosis; however, a definitive diagnosis remained elusive. Following a third surgical procedure and further histopathological examination, the patient was finally diagnosed with diffuse large B-cell lymphoma. The therapeutic course following diagnosis involved chemotherapy, resulting in a marked improvement of the symptoms. Previous studies have highlighted the diagnostic difficulties associated with PBL, reporting the frequent need for multiple biopsies to confirm the diagnosis due to the prevalence of necrosis, crush artifacts, or inadequate sample volume. While PBL of the spine has shown responsiveness to chemotherapy and radiation therapy, early surgical intervention is advocated in cases of severe spinal cord compression or vertebral instability. The presented case highlights the importance of making a definitive pathology diagnosis in cases of suspected PBL of the spine.

Unilateral laminotomy for bilateral decompression and balloon kyphoplasty to decompress lumber canal stenosis aggravated by osteoporotic vertebral compression fractures: A technical note.

Background: The optimal treatment of lumbar canal stenosis (LCS) associated with osteoporotic vertebral fractures (OVFs) remains unclear. Here, we have combined a minimally invasive unilateral laminotomy for bilateral decompression (ULBD) alone with balloon kyphoplasty (BKP) for LCS aggravated by OVF. Methods: ULBD with BKP was performed in three patients who showed LCS associated with OVFs on MR images with progressive lower extremity neurological deficits. Clinical outcomes were assessed using the numerical rating scale (NRS) and the Japanese Orthopaedic Association (JOA) score. Radiological outcomes were evaluated using multiple parameters (i.e., fractured vertebral body height, lumbar lordosis [LL], and focal angle of the fractured vertebral body). Results: Over 6 postoperative months, the NRS and JOA scores were clearly improved while radiological parameters remained maintained (i.e., loss of fractured vertebral body height was only 0.3-1.4 mm in all cases). Two of the three cases showed restoration of LL and focal angle postoperatively. Conclusion: The combination of ULBD with BKP is an effective option for LCS aggravated by OVF.

Intravascular Large B-Cell Lymphoma Diagnosed by Open Brain Biopsy and Achievement of Remission After Early Initiation of Chemotherapy: Case Report.

A 60-year-old man presented with progressive disturbance of consciousness. His father had died of malignant lymphoma, while his mother and sister died of acute leukemia. Magnetic resonance imaging (MRI) revealed multiple high-intensity lesions in the bilateral cerebral hemispheres on diffusion-weighted images. Serum soluble interleukin 2 receptor was 5,640 U/mL. Screenings of blood antibodies known to rise in autoimmune diseases were all normal. Cerebrospinal fluid examinations demonstrated slight elevation of protein and glucose, while the oligoclonal band and myelin basic protein were not elevated. Biopsies of bone marrow and random skin did not show any malignant features. His consciousness gradually deteriorated over a week, with lesions in his right frontal, left temporal, and bilateral parietal lobes shown to be growing. Therefore, open brain biopsy was performed, and one block of the right frontal lesion was harvested. Histological examination revealed atypical large cells only in the capillaries. Although immunohistochemical examinations showed positive staining for CD20, they were negative for CD3. Histopathological diagnosis was intravascular large B-cell lymphoma. After undergoing six cycles of intravenous chemotherapy with rituximab, cyclophosphamide, doxorubicin, and prednisone, his consciousness and neurological symptoms improved, and he appeared to achieve remission. Two years later, there have been no apparent recurrences, and the brain lesions have disappeared.

Dural-based Cavernous Malformation at the Temporal Convexity Presenting with Hemorrhage in a Pregnant Woman: Case Report.

Intracranial cavernous malformations (CMs) are benign vascular malformations that arise mostly within the brain parenchyma, but occasionally from the dura mater. Here, we report an extremely rare case of a 29-year-old pregnant woman presenting with hemorrhage in a dural-based CM at the temporal convexity. She presented with headache at 38 weeks of pregnancy. Imaging showed a hemorrhagic mass lesion in the left temporal lobe. Consciousness was clear, with no apparent neurological symptoms or headache. Her baby was delivered by emergency Caesarean section. Magnetic resonance (MR) imaging revealed an enhanced lesion around the hematoma and flow void appearances. Cerebral angiography confirmed the left middle meningeal artery feeding the lesion with apparent contrast medium pooling. Surgical removal of the lesion as a single block was performed. Histological examinations were consistent with CM. The lesion was located outside the brain and attached to the dura mater of the convexity, so the final diagnosis was dural-based CM. The patient was discharged home with her baby without any neurological deficits, and no recurrence has been seen for 2 years. Dural-based CM at the temporal convexity was detected, presenting as headache induced by hemorrhage during pregnancy. The relationship between bleeding of the lesion and pregnancy remains unclear, but female hormones and vascular growth factors during pregnancy can induce morphological changes and angiogenesis in CMs.

Predictors of long-term tumor control after stereotactic radiosurgery for Koos grade 4 vestibular schwannomas.

PURPOSE: To evaluate the predictors of long-term tumor control following stereotactic radiosurgery (SRS) for Koos grade 4 vestibular schwannomas (VSs). METHODS: Overall, 203 sporadic VS patients with compression of the brainstem were treated with SRS. The median tumor volume was 6.7 cm3 (range, 2.0-28.9 cm3) and the median marginal dose was 12 Gy (range, 9-13.5 Gy). RESULTS: The median follow-up period was 152 months (range, 12-277 months). Tumor control (TC) rates at 3, 5, and 10 years were 89%, 85%, and 82%, respectively. Operation-free survival (OFS) rates at 3, 5, and 10 years were 92%, 85%, and 83%, respectively. Middle cerebellar peduncle (MCP) compression on pre-SRS magnetic resonance imaging scans was significant for both TC (p < 0.001, hazard ratio 1.332) and OFS (p < 0.001, hazard ratio 1.306). The 3-, 5-, and 10-year OFS rates were 98%, 94%, and 92% in the low-risk group (MCP compression < 9.8 mm and > 48 years old), and 58%, 25%, and 17% in high-risk group (MCP compression ≥ 9.8 mm and ≤ 48 years old), respectively. Ten patients (4.9%) developed delayed cyst-related complications. Eleven patients (5.4%) developed newly developed or worsened trigeminal neuralgia. No patient developed persistent facial palsy as an adverse radiation effect. A ventricular peritoneal shunt was required in six patients (3%) who developed hydrocephalus after SRS. CONCLUSION: SRS is an acceptable treatment option in selected patients with Koos grade 4 VSs. Risk group classification based on patient age and MCP compression is useful in decision-making of Koos grade 4 VSs.

Long-Term Outcomes of Sporadic Vestibular Schwannomas Treated with Recent Stereotactic Radiosurgery Techniques.

PURPOSE: Vestibular schwannomas (VSs) are benign; thus, understanding long-term tumor control and late adverse radiation effects of stereotactic radiosurgery (SRS) through current radiosurgical techniques is important to inform treatment decisions. Our aim was to clarify long-term tumor control rates and incidence of late adverse radiation effects in patients with VSs followed for 5 years or longer after SRS. METHODS AND MATERIALS: Altogether, 615 patients with VSs (excluding neurofibromatosis type 2 and partially treated tumors) followed for 5 years or longer after SRS using recent radiosurgical techniques were evaluated. All patients were treated at a margin dose of less than 14 Gy. All tumors were classified into 4 categories: type A (intracanalicular tumor, 87 patients [14%]), type B (cerebellopontine angle [CPA] tumor, 325 patients [53%]), type C (CPA tumor compressing the brain stem, 138 patients [22%]), and type D (CPA tumor compressing the brain stem with a deviation of the fourth ventricle, 65 patients [11%]). Median tumor volume was 2.0 cm3 and median marginal dose was 12 Gy. RESULTS: Median follow-up period was 158 months. Actuarial 5-, 10-, and 15-year or longer local control (LC) rates were 93%, 91%, and 89%, respectively. Tumor type (P < .001, hazard ratio 2.389) and number of prior surgeries (P = .007, hazard ratio 1.698) were significant for LC. Depending on the tumor type, the actuarial 10-year LC rates were 100%, 93%, 88%, and 70% in type A, B, C, and D tumors, respectively. No patient developed persistent facial palsy. Twenty patients (3.3%) developed delayed cysts. One patient developed malignant transformation (0.2%). CONCLUSIONS: SRS is a safe and effective treatment for VSs in the long term, excluding VSs compressing the brain stem with a deviation of the fourth ventricle. Delayed cysts such as cyst formation, enlarged preexisting cysts or extratumoral cysts, and malignant transformation should be considered possible causes of long-term treatment failures.

[A Case of Unilateral Multiple Cerebral Edema 4 Weeks after Coil Embolization].

Coil embolization for cerebral aneurysms can lead to various complications, such as aneurysm rupture and cerebral embolism. In recent years, foreign substance embolisms-caused by peeling off of coating materials from therapeutic devices-have been described. We report here a case of unilateral multiple cerebral edema four weeks after coil embolization. A 44-year-old woman presented with a subarachnoid hemorrhage from a right internal carotid-posterior communicating artery aneurysm, for which coil embolization was performed. Four weeks after the embolization, she developed numbness in the left side of her mouth and in her left upper extremity. Magnetic resonance images showed multiple edematous lesions in the right cerebral hemisphere. Subsequent treatment with steroids improved her symptoms and edematous cerebral lesions. Although definitive diagnosis by biopsy was not performed, her clinical course and imaging findings resembled a foreign substance embolism by hydrophilic coating. It is important to note that delayed cerebral edema due to foreign substance embolisms might occur after endovascular treatments.

Subarachnoid Hemorrhage After Ischemic Stroke Associated with Systemic Lupus Erythematosus and Antiphospholipid Syndrome.

BACKGROUND: Systemic lupus erythematosus (SLE) is an autoimmune disease associated with increased risk of stroke. Antiphospholipid syndrome is another autoimmune disease that frequently overlaps with SLE. We report the case of a patient presenting with subarachnoid hemorrhage after ischemic stroke associated with SLE and antiphospholipid syndrome. CASE DESCRIPTION: A 22-year-old man presented with cerebral infarction of the right corona radiata. He had no contributory past or family histories. On imaging at this time, a 4-mm fusiform aneurysm of the right anterior cerebral artery was incidentally detected. Several examinations were performed, but no abnormalities or abnormal lesions were seen on echography or whole-body computed tomography. Blood tests yielded positive results for antinuclear antibody, lupus anticoagulant, and anti-beta-2 glycoprotein І antibody. He presented 70 days later with subarachnoid hemorrhage. Cerebral angiography showed the same fusiform aneurysm without any change in shape and no new aneurysms. The balloon occlusion test was performed without any neurologic symptoms, so the right anterior cerebral artery was trapped using coils. After 6 months, he presented with new optic hyperesthesia and facial butterfly-shaped erythema and fulfilled the criteria for SLE. At 2 years after initial presentation, he showed no recurrence of either aneurysm or ischemic stroke. CONCLUSIONS: The patient's first ischemic stroke was induced by antiphospholipid syndrome and underlying SLE. Fusiform aneurysm may have resulted from focal vasculitis, with activation of SLE leading to aneurysm rupture.

Repeated Intracranial Hemorrhage After Delivery Induced by Coagulopathy Associated with Multiple Venous Malformations.

BACKGROUND: Venous malformations are classified as slow-flow vascular malformations. Coagulation abnormalities are known to be frequent among patients with venous malformations. We report a case of repeated intracranial hemorrhage after delivery, induced by coagulopathy associated with multiple venous malformations. CASE DESCRIPTION: A 28-year-old woman presented with left chronic subdural hematoma 1 month after successfully giving birth. She had a history of multiple venous malformations around the pubic region and hips. The hematoma was evacuated by burr hole surgery. Three hours later, her level of consciousness rapidly deteriorated and computed tomography showed acute epidural hematoma. The hematoma was removed immediately by craniotomy under general anesthesia. No bleeding points were apparent in the operative field. Continuous bleeding around the dura mater and subdural space were encountered, and hemostasis was not achieved by electrocoagulation. After using fresh frozen plasma, hemostasis was achieved. Level of consciousness and neurologic symptoms improved postoperatively. Magnetic resonance imaging revealed multiple venous malformations in bilateral lower extremities and the pelvis. Disseminated intravascular coagulopathy was diagnosed, and thrombomodulin and blood coagulation factor XIII were administered. She was discharged home without any neurologic deficits. CONCLUSIONS: The delivery activated localized intravascular coagulopathy in the venous malformations and induced chronic subdural hematoma. Surgical interventions then resulted in progression of the coagulopathy to disseminated intravascular coagulopathy, inducing acute epidural hematoma.

Long-Term Outcomes for Pediatric Patients with Brain Arteriovenous Malformations Treated with Gamma Knife Radiosurgery, Part 2: The Incidence of Cyst Formation, Encapsulated Hematoma, and Radiation-Induced Tumor.

OBJECTIVE: Long-term data about the incidence of late adverse radiation effects (AREs) in pediatric brain arteriovenous malformations (AVMs) treated with Gamma Knife radiosurgery (GKRS) are lacking. This study addresses the incidence of late AREs, including cyst formation (CF), chronic encapsulated hematoma (CEH), and radiation-induced tumor, in pediatric patients with AVM treated with GKRS. METHODS: This is a single-institutional study involving pediatric patients with AVM who underwent GKRS between 1991 and 2014. Among 201 pediatric patients with AVM (age ≤15 years), 189 who had at least 12 months of follow-up were assessed in this study. The median treatment volume was 2.2 cm3, and the median marginal dose was 20 Gy. RESULTS: The mean follow-up period was 136 months. During the follow-up period, symptomatic radiation-induced perilesional edema was found in 5 patients (3%), CFs in 7 patients (4%), CEHs in 7 patients (4%), and radiation-induced tumors in 2 patients (1%). The cumulative incidences of late AREs including CF, CEH, and radiation-induced tumor were 1.2% at 5 years, 5.2% at 8 years, 6.1% at 10 years, 7.2% at 15 years, and 17.0% at 20 years. In the multivariate analysis, treatment volume alone was a significant factor for late AREs (P < 0.001; hazard ratio, 1.111). CONCLUSIONS: GKRS is a reasonable treatment option for pediatric AVMs to prevent future intracranial hemorrhages, particularly in the eloquent regions. However, considerable attention should be paid to late AREs such as CFs, CEHs, and radiation-induced tumors because of longer life expectancy in pediatric patients.

Long-Term Outcomes for Pediatric Patients with Brain Arteriovenous Malformations Treated with Gamma Knife Radiosurgery, Part 1: Analysis of Nidus Obliteration Rates and Related Factors.

OBJECTIVE: Little is known about long-term outcomes for pediatric brain arteriovenous malformations (AVMs) treated with Gamma Knife radiosurgery (GKRS). This study investigated annual hemorrhage rates and nidus obliteration rates, and the factors affecting them, in pediatric AVMs treated with GKRS. METHODS: We examined 189 pediatric AVM patients (age ≤15 years) who underwent GKRS and had at least 12 months of follow-up. The Spetzler-Martin (S-M) grade was I in 29 patients (15%), II in 57 (30%), III in 82 (43%), IV in 16 (9%), and V in 5 (3%). The median treatment volume was 2.2 cm3, and the median marginal dose was 20 Gy. RESULTS: The mean follow-up period was 136 months. During a cumulative latency period to nidus obliteration of 813 years, 23 hemorrhages occurred, resulting in an annual post-GKRS hemorrhage rate of 2.8%. The cumulative hemorrhage rates after GKRS were 3.3%, 8.5%, and 11.9% at 3, 5, and 10 years, respectively. Higher S-M grade was significantly associated with intracranial hemorrhages during the latency period (P < 0.001). The actuarial nidus obliteration rates with repeated GKRS were 64% and 81% at 5 and 10 years, respectively. Absence of pre-GKRS embolization (P = 0.023) and higher marginal dose (P = 0.029) were significant factors predicting nidus obliteration. CONCLUSIONS: GKRS is a reasonable treatment option in pediatric AVMs to prevent future hemorrhages. Because higher S-M grade AVMs are more likely to hemorrhage during the latency period, a combined therapy with endovascular embolization should be considered to prevent AVM rupture.