Cerebrospinal Fluid Spread Research Articles

Clinical, magnetic resonance imaging, histopathological features, treatment options and outcome of spinal ependymoma in dogs: 8 cases (2011-2022).

This study aims to report on the clinical magnetic resonance imaging, histological features, treatment options and outcomes of spinal ependymomas in dogs. Retrospective evaluation of medical records from dogs histologically confirmed spinal ependymomas with clinical presentations, magnetic resonance imaging findings, histological aspects, treatment options and outcomes. Eight dogs presented with acute to subacute onset of para- or tetraparesis. Magnetic resonance imaging findings included intramedullary oval-shaped space-occupying lesions that appeared hyperintense on T2-weighted images isointense on T1-weighted images and exhibited marked homogeneous or ring contrast enhancement. A peculiar feature, previously described only in human ependymomas, was observed in three patients - a T2-weighted hypointense rim, termed hemosiderin cap sign. Haematomyelia with necrotic foci was observed in one dog. Surgery, when performed, enabling a definitive intra-vitam diagnosis. Histological examination revealed that rosettes and pseudo-rosettes as disposition of neoplastic cells were the most common features reported. Furthermore, cerebrospinal fluid metastases were identified in one case. Clinical and histopathological findings in our case series were consistent with those previously reported in the literature. Magnetic resonance imaging features were fairly typical and highly suggestive of spinal ependymomas. The hemosiderin cap sign may aid in the presumptive intra-vitam diagnosis of these rare spinal tumours. Additionally, we described cerebrospinal fluid spread of neoplastic cells and subsequent multifocal or metastasis presentations. Surgery offered a dual benefit by facilitating intra-vitam diagnosis and, in some cases, extending survival time.

Pediatric Pleomorphic Xanthoastrocytoma with Neoplastic Meningitis: A Case Report with Cytopathological Evidence with Literature Review

AbstractPleomorphic xanthoastrocytoma (PXA) was regarded as grade II tumor and considered to be associated with favorable outcome. The World Health Organization Central Nervous System 5 (WHO CNS5) has classified PXA under circumscribed astrocytic gliomas and graded 2 or 3 depending on histology. Cerebrospinal fluid (CSF) and leptomeningeal spread are observed rarely in these tumors. The present case report describes a PXA, grade 3 tumor in a young male with neoplastic meningitis. This 17-year-old male child presented with history of seizure, signs of raised intracranial pressure, and meningeal irritation. Well-defined, T2 heterogeneously hyperintense lesion (5.5*4.8 cm) was seen in right frontal lobe with mild heterogenous contrast enhancement and adjacent pachy-meningeal enhancement. Right frontal craniotomy and near total excision were done. Postoperative hydrocephalus was treated with CSF diversion. Histopathology showed epithelioid and rhabdoid morphology with significant cellular pleomorphism and atypical mitosis consistent with the PXA, grade 3. The CSF cytology showed numerous tumor cells with marked nuclear and cytoplasmic pleomorphism. PXA is a rare malignancy of children and young adults, commonly seen in the temporal lobes. BRAF point mutations of V600E type are most common in PXA, grade 2. Meningeal dissemination is uncommon in PXA and its presence marks poor outcome. PXA, grade 2 tumors could be followed with serial imaging following gross total resection. PXA, grade 3 tumors are managed with maximal-safe resection, radiotherapy, and/ or chemotherapy. PXA, grade 3 with CSF spread tends to have rapid decline in the clinical course and it is advisable to get routine baseline and follow-up craniospinal screening and needs aggressive management.

Pilocytic Astrocytoma of the Cerebellopontine Angle with cerebrospinal fluid Spread in an Adult: A Case Report

Abstract Introduction Pilocytic astrocytoma of the cerebellopontine angle (CPA) is uncommon, and its spread to the cerebrospinal fluid (CSF) at the time of diagnosis has not been reported in the literature. Case Presentation We report the case of a 33-year-old man with multifocal pilocytic astrocytoma diagnosed by magnetic resonance imaging (MRI) and confirmed by histopathological examination, and present the radiological and histopathological findings. Conclusion In the case herein reported, we observed spread of the pilocytic astrocytoma of the CPA to the CSF at the initial diagnosis, and early detection by MRI is very important regarding the treatment modality and prognosis.

Magnetic Resonance Imaging (MRI) and Positron Emission Tomography (PET)/Computed Tomography Features of Atypical Teratoid/Rhabdoid Tumors: Case Series and Review.

Purpose: The purpose of this article is to explore the clinical and neuroradiologic properties of atypical teratoid/rhabdoid tumors. Methods: Data from 6 pediatric patients with atypical teratoid/rhabdoid tumors, which mainly contained the features of magnetic resonance imaging (MRI) and positron emission tomography (PET)/computed tomography (CT), was retrospectively analyzed. Follow-up was conducted in all patients through clinic services and/or telephone consultation. Results: The patients included 4 males and 2 females, aged from 3.2 to 83.1 months at the initial diagnosis. All patients had MRI scans. Two patients underwent 18F-fluorodeoxyglucose PET/CT scintigraphy preoperatively and 4 postoperatively. All primary lesions were located in the cranial cavity and the average diameter of lesions was 37.2 mm. Cerebrospinal fluid spread on enhanced T1-weighted images were found in 2 patients. Multiple metastases were found on MRI and PET/CT scans, which were located at cranial cavity, spinal cord, lung and lymph node. The primary and metastatic lesions showed evident uptake of 18F-fluorodeoxyglucose. Two patients underwent total tumor removal, and 4 patients underwent subtotal removal. None of the patients received shunt surgery. Follow-up was performed in all 6 patients. One patient survived event-free 38.4 months after resection. The mean overall survival of the remaining 5 patients was 5.1 months. Conclusion: We identified specific PET/CT and MRI features that can facilitate the recognition of atypical teratoid/rhabdoid tumors prior to biopsy.

Magnetic Resonance Imaging of Cerebrospinal Fluid Spread in the Epidural Space and Postdural Puncture Headache in Obstetrics: A Proof-of-Concept Study

(Eur J Anaesthesiol. 2021;38:777–784) Labor analgesia that includes epidural catheter placement can be complicated by accidental dural puncture (ADP). In parturients, ADP is followed by postdural puncture headache (PDPH) in up to 70% to 80% of cases. Prompt diagnosis and treatment of PDPH are important as delay can exacerbate sequelae, leading to serious debilitating and chronic complications. The current most effective treatment, epidural blood patch (EBP), is performed based on subjective clinical judgment of the parturient’s progression and severity of symptoms. An evidence-based protocol may benefit parturients with atypical PDPH presentation by allowing an earlier EBP, rather than forestalling until PDPH becomes severe. Egress of cerebrospinal fluid (CSF) into the epidural space following ADP can be readily recognized in T1-weighted and T2-weighted magnetic resonance imaging (MRI) of the brain and spine. The correlations between neuroradiological findings and the severity of PDPH in obstetric patients is presented.

Symptoms: Sudden Hearing Loss and Facial Paralysis

Symptoms: Sudden Hearing Loss and Facial Paralysis

Magnetic resonance imaging of cerebrospinal fluid spread in the epidural space and postdural puncture headache in obstetrics: A proof-of-concept study.

Currently, performing an epidural blood patch (EBP) for postdural puncture headache (PDPH) remains a subjective clinical decision. An evidence-based protocol may be of value in identifying women at high risk of developing a severe PDPH. To investigate a potential correlation between the extent of CSF spread in the epidural space, as noted on Magnetic Resonance Imaging (MRI), and the likelihood of development of severe PDPH in obstetric patients. A prospective double-blind quasi-observational study. Eight tertiary obstetric units, from NHS hospitals. Parturients with accidental dural puncture (ADP) underwent T1 and T2-weighted MRI scans of the brain and lumbar spine within 48 h after delivery. All women were followed up, daily, for 1 week. For each woman, a PDPH severity score was calculated using a four-point Verbal Reporting Scale (none = 0, mild = 1, moderate = 2, severe = 3), with additional points awarded for visual, auditory and emetic symptoms. MRIs were reported by a neuroradiologist, blind to the patient details, using a predefined MRI score. Twenty-two parturients were recruited; 86% (n=19) developed PDPH and 10 of these (53%) required an EBP. The median (range) time for the onset of PDPH was 24 (4 to 126) hours. The median (range) cumulative PDPH severity score was 10 (0 to 21), whereas, the median (range) MRI score was 2.5 (0 to 12). Spearman (rs) analysis identified a significant positive correlation (rs = 0.46; P = 0.024) between cumulative PDPH severity and MRI scores. Of all the radiological features identified in an MRI (lumbar dural shift, caudal brain displacement, epidural or intrathecal blood), the presence of intrathecal blood was most strongly correlated with PDPH severity (P = 0.043). Following an ADP, the extent of CSF spread in the epidural space correlates with the severity of subsequent PDPH. ISRCTN14959004, https://www.isrctn.com/.

Factor analysis of cerebrospinal fluid spread in glioblastoma

Objective: To analyze the prognosis factors of cerebrospinal fluid (CSF) spread after surgery in glioblastoma (GBM) patients when tumors progressed and the effect factors on prognosis. Methods: A retrospective study was conducted on 124 patients who were pathologically diagnosed as glioblastoma after surgery, and found tumor progressed during regularly follow-up at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University between January 2009 and August 2017.There were 82 males and 42 females, aged 47.9 years(range: 19 to 75 years) .Patients were divided into local recurrence group(96 cases) and CSF spread group (28 cases) .Clinical data were recorded in detail and compared by independent sample t test or χ(2) test.Kaplan-Meier survival curves was used to demonstrated the distribution of progression free survival (PFS) overall survival (OS) and post progression survival (PPS), and differences between local recurrence and CSF spread groups were assessed by Log-rank test.Cox proportion hazard regression analysis was used to identify independent prognostic factors. Results: Logistics regression analysis showed ventricle entry was the only prognosis factor of CSF spread (OR=2.667, 95% CI: 1.128 to 6.304, P=0.025).No significant distinction was observed in PFS between CSF spread group and local recurrence group(7.0 months vs.9.3 months, P=0.066).However, OS and PPS were substantially shortened in CSF spread group (13.0 months vs.23.0 months, P=0.011; 6.0 months vs.11.0 months, P=0.022, respectively).Mutations of isocitrate dehydrogenase gene, distant spread, gross-total resection, Ki-67 index>30% were independent prognostic factors of GBM patients. Conclusions: Ventricle entry is a prognosis factor for CSF spread, after which the median OS and PPS are markedly diminished.However, ventricle entry is not independent prognosis factor shortening survival.

Imaging findings of a typical teratoid/rhabdoid tumor of central nervous system with clinical correlation

Objective To evaluate the imaging characteristics of atypical teratoid/rhabdoid tumor (AT/RT) of central nervous system(CNS), and to improve the diagnostic ability of the disease. Methods The clinical and imaging findings of 9 patients were retrospectively analyzed. There were 5 male and 4 female, ages 7 months to 5 years, median age was 1.4 years. MR enhancement studies were obtained in all the cases. One case had CT enhancement examination. Results The lesions were seen in brain in 8 cases and in lumbosacral spinal cord in one case. The tumors size varied from 4.8—7.8 cm, Necrosis was seen in nine cases, cystic change in eight cases and hemorrhage in five cases. The tumors had high signal on DWI, and low signal on ADC map. Dura matter invasion (2 cases) , cerebrospinal fluid spread (2 cases) and intracerebral metastasis were seen. Conclusion There are some relatively specific imaging findings of primary CNS AT/RT that could assist their diagnosis. Key words: Atypical teratoid/rhabdoid tumor; Magnetic resonance imaging; Child

Fluorescence Lifetime Imaging Microscopy, a Novel Diagnostic Tool for Metastatic Cell Detection in the Cerebrospinal Fluid of Children with Medulloblastoma

In pediatric brain tumours, dissemination of malignant cells within the central nervous system confers poor prognosis and determines treatment intensity, but is often undetectable by imaging or cytology. This study describes the use of fluorescence lifetime (FLT) imaging microscopy (FLIM), a novel diagnostic tool, for detection of metastatic spread. The study group included 15 children with medulloblastoma and 2 with atypical teratoid/rhabdoid tumour. Cells extracted from the tumour and the cerebrospinal fluid (CSF) 2 weeks postoperatively and repeatedly during chemo/radiotherapy were subjected to nuclear staining followed by FLT measurement and cytological study. Control CSF samples were collected from patients with infectious/inflammatory disease attending the same hospital. Median FLT was prolonged in tumour cells (4.27 ± 0.28 ns; P < 2.2*10−16) and CSF metastatic cells obtained before chemo/radiotherapy (6.28 ± 0.22 ns; P < 2.2*10−16); normal in inflammatory control cells (2.6 ± 0.04 ns) and cells from children without metastasis before chemo/radiotherapy (2.62 ± 0.23 ns; P = 0.858) and following treatment (2.62 ± 0.21 ns; P = 0.053); and short in CSF metastatic cells obtained after chemo/radiotherapy (2.40 ± 0.2 ns; P < 2.2*10−16). FLIM is a simple test that can potentially identify CSF spread of brain tumours. FLT changes in accordance with treatment, with significant prolonged median values in tumours and metastases. More accurate detection of metastatic cells may guide personalised treatment and improve the therapeutic outcome.

A systematic review of overall survival in pediatric primary glioblastoma multiforme of the spinal cord.

OBJECTIVE The incidence of primary spinal cord glioblastoma multiforme (GBM) in the pediatric age group is very rare. Only a few case series and case reports have been published in the literature; therefore, overall survival (OS) outcome and the as-yet poorly defined management options are not discussed in detail. The authors performed a cumulative survival analysis of all reported cases of pediatric spinal cord GBM to identify the predictive factors related to final survival outcome. METHODS A comprehensive search for relevant articles was performed on PubMed's electronic database MEDLINE for the period from 1950 to 2015 using the search words "malignant spinal cord tumor" and "spinal glioblastoma multiforme." This study was limited to patients younger than 18 years of age. Survival rates for children with various tumor locations and treatments were collected from the published articles and analyzed. RESULTS After an extensive literature search, 29 articles met the study inclusion criteria. From the detailed information in these articles, the authors found 53 children eligible for the survival analysis. The majority (45%) of the children were more than 12 years old. Thirty-four percent of the cases were between 7 and 12 years of age, and 21% were younger than 7 years. In the Kaplan-Meier survival analysis, children younger than 7 years of age had better survival (13 months) than the children older than 7 years (7-12 years: 10 months, > 12 years: 9 months; p = 0.01, log-rank test). Fifty-five percent of the children were female and 45% were male. A cervical tumor location (32%) was the most common, followed by thoracic (28.3%). Cervicothoracic (18.9%) and conus (18.8%) tumor locations shared the same percentage of cases. Cervical tumors had a worse outcome than tumors in other locations (p = 0.003, log-rank test). The most common presenting symptom was limb weakness (53%), followed by sensory disturbances (25%). Median OS was 10 months. The addition of adjuvant therapy (radiotherapy [RT] and/or chemotherapy [CT]) after surgery significantly improved OS (p = 0.01, log-rank test). Children who underwent gross-total resection and RT had better outcomes than those who underwent subtotal resection and RT (p = 0.04, log-rank test). Cerebrospinal fluid spread, hydrocephalus, brain metastasis, and spinal metastasis were not correlated with OS in primary spinal GBM. CONCLUSIONS Adjuvant therapy after surgery had a beneficial effect on overall outcome of spinal GBM in the pediatric age group. Gross-total resection followed by RT produced a better outcome than subtotal resection with RT. Further large-scale prospective study is required to establish the genetic and molecular factors related to OS in primary GBM of the spinal cord in pediatric patients.

Primary spinal cord anaplastic oligoastrocytoma presenting with paraplegia

A 43-year-old man presented with progressive bilateral leg weakness of 2 weeks’ duration. He had no trauma history. Neurological examination revealed a muscle power of grade 3/5 in his lower limbs. His lateral spinal radiograph showed no abnormality. Furthermore, spinal magnetic resonance imaging revealed an intramedullary lesion at the T10–T12 level. It appeared isointense on T1-weighted images (Fig. 1, Left) and mildly hyperintense on T2-weighted images (Fig. 1, Middle), and showed heterogeneous enhancement after gadolinium administration (Fig. 1, Right). A T10–T12 laminectomy with intraoperative neuromonitoring was performed. A soft, gray infiltrative tumor with indistinct margins was found (Fig. 2). A histopathological examination confirmed the diagnosis of anaplastic oligoastrocytoma (Fig. 3, Left, Right). Postoperative adjuvant radiotherapy was administered. The magnetic resonance imaging of the patient’s brain revealed no intracranial lesion. The strength of his lower limbs improved moderately at the 6-month follow-up. Oligoastrocytoma is a mixed glioma with distinct oligodendroglial and astrocytic components. It arises preferentially in the cerebral hemispheres [1] and may disseminate through local, hematogenous, or cerebrospinal fluid spread [2–4]. Primary spinal cord oligoastrocytoma is extremely rare, and few cases have been reported [1,5]. The codeletion of the chromosomal arms 1p and 19q in oligoastrocytoma is a favorable genetic marker that predicts better response to treatment and results in a significant survival benefit [6,7].

Risk factors for intraocular involvement in patients with primary central nervous system lymphoma.

To determine the risk factors for intraocular involvement in patients with primary central nervous system lymphoma (PCNSL), a retrospective chart review was performed on 136 patients who were pathologically diagnosed with PCNSL. The patients were investigated for demographics, clinical manifestation, and the profile of immunohistochemical tumor biomarkers, as well as forthe presence of intraocular involvement of lymphoma at diagnosis or during follow-up. The mean age of the entire cohort was 58.6±12.4years, and the mean follow-up period was 31.1±30.8months. Twenty-nine (21%) patients had an intraocular involvement, among which 20 (69%) patients presented with intraocular involvement at diagnosisof PCNSL and 9 (31%) patients developed intraocular involvement after a mean period of 32.4±33.6months. Of the patients with intraocular involvement, 8 (28%) had no visual symptom at the diagnosis of ocular invasion. Between those with and without intraocular involvement, no significant differences were found with respect to the age, sex, and follow-up period as well as cerebrospinal fluid spread and bone marrow involvement. Among the immunohistochemical biomarkers, the Ki-67 proliferation index was significantly higher in patients with intraocular involvement than in patients without (P=0.021), but the other investigated biomarkers did not show a significant difference between the two groups. A Ki-67 level ≥80% was a risk factor for the intraocular involvement in patients with PCNSL (odds ratio, 2.63). Median overall survival was 39.0months in the entire cohort and was not significantly different between those with and without intraocular involvement (P=0.959).

English

Rhabdomyosarcoma (RMS) is an aggressive soft tissue malignancy, not uncommonly seen in adults. The location of this malignancy is quite ubiquitous. However, a parameningeal location is uncommon and accounts for about 16% of all rhabdomyosarcomas. We report an instance where rhabdomyoblasts were seen infiltrating the cerebrospinal fluid (CSF). A 35 year old female patient presented to our hospital with the primary complaints of bilateral nose block and left sided headache since1month. Clinically, a deviated nasal septum was diagnosed which needed a septal surgery. Since the hematological parameters showed a pancytopenia, the surgery was postponed. The patient presented 3 weeks later with additional complaints of worsening headache and significant blurring of vision in her left eye. The MRI scan revealed a midline, dural-based mass. A therapeutic tap of the cerebrospinal fluid sent to the clinical laboratory for analysis which showed large abnormal cells (figure 1). The bone marrow also showed similar cells, with karyomegaly, dense chromatin, and coalescing vacuoles which were Periodic Acid Schiff (PAS) negative. The biopsy from the mass was diagnosed as rhabdomyosarcoma (parameningeal type). Immunohistochemistry showed positivity for Myogenin and Myo-D1. Rhabdomyosarcoma(RMS) is an aggressive soft tissue malignancy, not uncommonly seen in adults.(1)Bone marrow involvement is found in about 29% of RMS patients in clinical stage IV.(2) Parameningeal RMS represent 16% of all sarcomas but less than 10% present with pancytopenia.(3) A simultaneous marrow involvement with CSF spread is an extremely rare phenomenon.(4)The spread portends a poor prognosis. (5)Morphologically; such cases pose serious diagnostic challenges to a hematopathologist. A multidisciplinary approach comprising of histology, IHC on bone marrow biopsy and radiology are crucial to achieve the diagnosis of RMS.

A single institution experience of the incidence of extracranial metastasis in glioma

Glioblastoma multiforme (GBM) is the most common and aggressive subtype of all gliomas. The prognosis is poor but despite the aggressiveness of the tumour, extracranial metastasis of glioma is rare. Most documented cases of extracranial metastases of GBM involve leptomeningeal spread to the spine. In this clinical study we aim to review the incidence and location of extracranial metastasis of glioma from the Brain Tumor Database of the National Neuroscience Institute of Singapore, between September 2004 to October 2009. Four of 148 patients (2.7%) were identified, one of whom had pleomorphic xanthoastrocytoma (PXA) with scalp and spinal metastasis, suggestive of haematogenous rather than cerebrospinal fluid spread that has been described elsewhere. To our knowledge, there has been no published report of PXA with scalp metastasis or vertebral metastasis.

Is CSF cytology a useful diagnostic procedure in staging paediatric CNS tumours?

To evaluate whether there are any factors that predict malignant cells being found in paediatric cerebrospinal fluid (CSF) samples. To determine whether CSF provides useful staging information not provided by magnetic resonance imaging (MRI) in paediatric patients with primary central nervous system (CNS) malignancy. We compared the CSF cytology and spinal MRI staging results in paediatric patients with primary CNS malignancy at a UK tertiary referral centre, over a decade. Of 159 CSF samples, 72 samples were from 72 patients with primary CNS malignancy with spinal MRI available for comparison. Eight of these 72 had positive cytology (seven malignant and one suspicious). All had a high clinical suspicion of tumour at the time of sampling. Of the 72 patients, only two had evidence of CSF spread on MRI spinal staging and CSF cytology; ten had MRI without cytological evidence and six had cytological without MRI evidence. In paediatric patients with primary CNS tumours, CSF cytology provides useful staging information. Spinal MRI alone may miss some patients with CSF spread who would be identified with CSF cytology.

Ectopic ventricular recurrence of an epidermoid cyst in the middle fossa

We present the first case of ectopic ventricular recurrence of an epidermoid cyst in the middle fossa with confirming histological characteristics. A 51-year-old woman presented with an epidermoid cyst in the middle fossa and underwent complete resection. On the 6-month surgical follow-up MRI, a nodular lesion was detected in the frontal horn of the left lateral ventricle without evidence of recurrence at the primary site. The patient underwent transcortial tumor resection. Results of histological studies confirmed that the lesion was an epidermoid cyst similar to the primary lesion. This is a case report of the cerebrospinal fluid spread of an epidermoid cyst, which strengthens the case for special care at the time of surgery to prevent spread of the lesion.

Cerebrospinal Fluid Spread of Anaplastic Glioma

A 35-year-old woman presented with complex partial seizures that progressed to generalized tonic-clonic seizures in March 2002 and was found to have an infiltrating temporal lobe lesion upon receiving magnetic resonance imaging (MRI). Initial concern was for encephalitis or neoplasm. Biopsy of the lesion showed infiltrating glioma with possible neuronal component with a MIB-1 proliferation index focally of 4%. The tumor consisted of a uniformly dense population of mildly pleomorphic nuclei with little visible cytoplasm and no mitotic activity, no vascular cell proliferation, and no necrosis. Subsequent MRIs were stable until the December 2003 scan which showed increased signal on T2-weighted sequences MRI and increased enhancement. A repeat resection was consistent with a fibrillary glioma with anaplastic features— pleomorphic hyperchromatic nuclei with scant cytoplasm, nuclear molding and apoptosis, frequent bizarre multinucleated cells, frequent mitoses, and vascular proliferation with a MIB-1 index of greater than 50%; synaptophysin and pan-keratin stains were negative. The patient underwent treatment with involved field radiation and concurrent temozolomide therapy followed by adjuvant monthly temozolomide for 24 cycles with stable MRIs throughout treatment. After finishing the last cycle in February 2006, the patient developed dizziness and unsteadiness. A repeat brain MRI showed new enhancement in the right temporal resection cavity and also new enhancement surrounding the brainstem and cerebellar folia concerning for leptomeningeal gliomatosis (Figs 1A, 1B, and 1C; postcontrast T1-weighted, arrows). Pre-contrast (Fig 2 thoracic spine; A-T1-weighted; B-T2-weighted) and postcontrast (Fig 2 thoracic spine; C-T1-weighted) images of spine MRI showed marked, diffuse enhancement of subarachnoid space with nodular deposits of tumor (Fig 2C; arrow) nearly resembling a T2-weighted scan. A lumbar puncture for cerebrospinal fluid (CSF) was obtained and showed protein of 1,958, glucose of 66, WBC 333 (71% lymphocytes), and RBC (280,000). Cytology was positive for sheets of malignant cells with pleomorphic nuclei with high cytoplasmic to nuclear ratio consistent with glial origin (Fig 3). This constellation of findings is consistent with leptomeningeal seeding of glioma. The patient underwent an Ommaya reservoir placement and received intrathecal chemotherapy in addition to systemic chemotherapy. Despite several chemotherapy regimens, the leptomeningeal gliomatosis progressed on imaging and CSF cytology and the patient died 5 months later. CSF spread is recognized as a terminal pattern of progression in high-grade glioma patients. As new treatments improve local tumor control (24 months in this case), leptomeningeal seeding of gliomas appears to be increasingly evident. CNS parenchymal and blood-brain-barrier penetrating drugs, such as temozolomide, have improved the outcome of high-grade gliomas, but the penetration and distribution throughout the whole CSF system is an important issue that has yet to be addressed, especially with novel targeted agents. This issue was recently highlighted in a report of epidermal growth factor receptor inhibitor (gefitinib) for non– small-cell lung cancer with leptomeningeal metastases. Furthermore, the biologic underpinnings of this pattern should be investigated as they may provide insight into why such tumors are refractory to current treatments.

Classic and unusual appearances of hydatid disease in children.

In endemic regions, hydatid disease is commoner in children than in adults. The hydatid cysts may have classic appearances, but unusual sites and appearances may cause diagnostic difficulties. To assess the classic and unusual appearances of hydatid disease in children. A 3-year retrospective review of available imaging of proven hydatid disease at a tertiary paediatric institution. RESULTS. Review of imaging of 21 children (9 boys, 12 girls), with a mean age of 8 years and 1 month, demonstrated cysts in the liver ( n=9), lung ( n=8), brain ( n=7), spleen ( n=2), heart ( n=1), orbit ( n=1) and soft tissues ( n=1). Multi-organ involvement occurred in eight cases with two cases that did not involve the liver. Complicated cysts were found in 13 cases and usually involved the liver ( n=8) and lung ( n=5). An unusual case of spontaneous cerebrospinal fluid (CSF) spread was also documented. Hydatid disease in children classically involves the liver, lung and brain but can involve almost any organ and numerous organs simultaneously. Whether hydatid disease is discovered incidentally or by intentional imaging, extended imaging is recommended to identify multifocal disease which may also display complicated cysts that may assist in the diagnostic process. All patients with one known site should undergo a minimum of an abdominal US and CT scan of the chest and brain. CT may be used instead of US of the abdomen, and MRI may be used to replace CT of the brain. Over 50% of cases in our study showed complicated cysts. Unique findings of this study include multi-organ involvement without liver cysts. Multiplicity and complications of cysts can assist diagnosis. Intraventricular and intrathecal CSF spread of a spontaneously ruptured intracerebral cyst has not, to our knowledge, been previously reported.

Specific matrix metalloproteinase profiles in the cerebrospinal fluid correlated with the presence of malignant astrocytomas, brain metastases, and carcinomatous meningitis.

Detection in tumor tissue of specific matrix metalloproteinases (MMPs), particularly gelatinases A and B, correlates with the grade and aggressiveness of primary and metastatic brain tumors. The ability to detect these enzymes in the cerebrospinal fluid (CSF) would be a minimally invasive method of evaluating brain tumors. CSF from 66 patients with white blood cell counts of < or = 5 microL were analyzed for the presence of gelatinolytic activity by zymography. Twenty-nine patients had malignant astrocytomas, 10 had brain metastases from systemic malignancies, 4 had systemic cancer not involving the central nervous system, 4 had nonmalignant neurologic diseases, and 19 were healthy controls. Fifteen CSF samples had positive cytologies. The zymographic results were retrospectively correlated with clinical information and CSF cytologic data. CSF from all patients with malignant astrocytomas or brain metastases contained precursor gelatinase A (pMMP2) and precursor gelatinase B (pMMP9), whereas control CSF contained only pMMP2. All patients with positive CSF cytologies had activated MMP2. A similar correlation was observed between the presence of activated MMP9 and positive CSF cytology. The precursor and activated forms of gelatinases A and B can be detected in the CSF of patients with primary and metastatic brain tumors. The distribution of gelatinase activity in CSF distinguishes patients with malignant gliomas or brain metastases from those without brain tumors, and distinguishes patients with meningeal carcinomatosis from those without CSF spread of tumor, regardless of their brain tumor status. Analysis of MMPs in the CSF may be a sensitive technique for diagnosing CNS tumors and provide an early indication of tumor recurrence. This technique may also provide longitudinal information that would be useful in evaluating ongoing treatment and predicting tumor behavior.