Extra-axial Mass Lesion Research Articles

Expansile neurenteric cyst arising in the frontal lobe associated with status epilepticus: report of a case and discussion of epileptogenesis

The case of a 32-year-old Japanese man with an expansile supratentorial neurenteric cyst is described. The initial MRI revealed a left frontal extraaxial mass lesion 20 mm in diameter that showed marked expansion to 32 mm and change in its signal intensity 13 months later. Fifteen months after his visit, the patient fell into status epilepticus and underwent surgery. The cyst wall was excised, and the cyst content was totally removed. The cytology of the cystic content and pathological findings of the cyst wall were compatible with the diagnosis of neurenteric cyst. Our literature search revealed that in 86% of the patients with this lesion, the lesion was involved in the occurrence of epilepsy during the perioperative period. When a neurenteric cyst is diagnosed, shunt surgery should be avoided to prevent migrating spread of neurenteric cells.

Neurologic Complications of Lymphoma and Leukemia

Lymphoma and leukemia are systemic diseases that affect many end-organs, including the central nervous system. These cancers may directly affect the central or peripheral nervous systems by the production of intraparenchymal or extra-axial mass lesions or by meningeal infiltration. Vascular occlusion may occur as a result of blockage of blood vessels by tumor cells. A variety of paraneoplastic syndromes occur and are most commonly associated with plasma cell tumors. Coagulopathy and metabolic disturbances are direct and indirect effects of these cancers and also are associated with their treatment, resulting in disturbances of consciousness, intracranial hemorrhage, or ischemic stroke. The agents used in the treatment of lymphoma and leukemia are also associated with neurological toxicity. This chapter reviews these neurological manifestations of lymphoma and leukemia and their therapies.

Intracranial capillary hemangioma: case report and review of the literature

Background Capillary hemangiomas are benign vascular lesions that commonly present at birth or in early infancy on the face, scalp, back, or chest. The authors present an exceedingly rare case of an intracranial capillary hemangioma arising in an adult. Only 4 biopsy-proven cases have been reported in the pediatric population previous to this case report. Case Description A 31-year-old pregnant woman presented at 38 weeks of gestation with severe headaches, nausea, and vomiting. Imaging revealed an extra-axial mass lesion arising from the tentorium with both supra- and infratentorial components. The patient underwent a resection of her tumor, which was diagnosed as a capillary hemangioma by histopathologic examination. The patient required 2 further resections after the lesion exhibited a rapid regrowth from residual tumor in the left transverse sinus. The patient has remained free of disease 41 months out from her third surgery. Conclusions Intracranial capillary hemangiomas are exceedingly rare entities, with a capability for rapid growth. When gross total resection cannot be achieved, these patients should be observed closely, and the use of adjuvant radiotherapy should be considered.

Epidermoid cyst of the brain stem symptomatic in childhood

Epidermoid cysts may remain asymptomatic for a long period of time due to their slowly growing pattern corresponding with the normal human skin turnover time and due to soft and light cyst content. They do not cause compression of neural and vascular structures initially that is why almost all of the cases in the literature are diagnosed during adulthood. We report here an epidermoid cyst in childhood, which was located in the medulla oblongata, unusually and atypically with liquefied cyst content. The liquefaction may occur due to an intrauterine or early childhood infection. The reported case also suffered previously a severe respiratory infection. Although the cyst is located in and around a highly eloquent neural area, plasticity of the brain stem prevented neurological deterioration due to this very slow growing extraaxial mass lesion. The ordinary cyst content found in the center of the cyst cavity during the operation suggested that the same ordinary material, which was previously at the periphery, ran to get liquefied in time. We suggest that the symptoms of this present case appeared very early due to liquefaction of the cyst content with compression and displacement of the brain stem caudally. The recent infection process may predispose the pathological condition.

Parasagittal meningioma en plaque with extracranial extension presenting diffuse massive hyperostosis of the skull

Background We describe a case of convexity meningioma en plaque (MEP) invading the skull and scalp with diffuse massive hyperostosis, presenting striking radiological findings. Case description A 48-year-old woman was admitted to our hospital with headache, general fatigue, diplopia, and blurred vision. A skull X-ray film, computed tomography (CT), and 3-dimensional CT demonstrated diffuse significant hyperostosis and sclerosis in the cranial vault. Magnetic resonance (MR) imaging revealed a frontoparietal, well-enhanced extra-axial mass lesion, which is compatible with findings of MEP. The tumor was partially resected. Histological examination revealed massive tumor invasion into the dura mater, hyperostotic skull, and scalp. Conclusion Hyperostosis is frequently observed in MEP, although there has been no report of a case of MEP such as ours demonstrating diffuse tumor extension and diffuse hyperostosis. Analyzing the CT finding of hyperostotic bone is useful for differentiation of MEP from other diseases that include a hyperostotic condition.

Epithelioid haemangioendothelioma of the sphenoid bone

The authors report a case of cranial EH occurred in the left sphenoid bone that was totally excised without transfusion. A 26-year-old woman presented with a 1-year history of progressing exophthalmos in the left eye. A cranial X-ray showed a mixed oste olytic and sclerotic expansile mass lesion in the left sphenoid bone. Neuroradiologic imaging study revealed a left temporosphenoidal extra-axial expansile mass lesion with heterogeneous enhancement after contrast enhancement associated with destruction and erosion of the temporal and sphenoid bones. The cerebral parenchyme and orbital contents were compressed without any sign of infiltration. Bone scan showed hot uptake in the left orbital region. Angiogram demonstrated marked neoplastic angiogenesis f rom the middle meningeal artery and other branches of left external carotid artery, for which preoperative embolisation was tried in vain. Cranio-orbito-zygomatic approach was undergone in two stages because of the patient's religious belief (patient was Jehovah's witness) and profuse bleeding during the first surgery. Two weeks after initial operation, second surgery was carried out with total excision of the residual mass in the left orbital ridge. Histopathological examination revealed typical epithe lioid cell cords or nests in myxoid stroma with a positive immunoreactivity to factor VIII-related antigen. The authors report an unusual case of EH involving sphenoid and temporal bone in a young woman. Preoperative embolisation is thoughtto be absolut ely essential before removal. Because there is no convincing data to advise radiation/chemotherapy, total resection and close follow-up may be reasonable.

Ruptured middle cerebral artery aneurysm and bilateral chronic subdural hematomas

BACKGROUND While rupture of a cerebral aneurysm into the subdural space is rare, aneurysmal subarachnoid hemorrhage in the presence of subdural hematoma(s) is much more uncommon. Such a patient requires changes in routine perioperative management. CASE DESCRIPTION A patient with a ruptured middle cerebral artery bifurcation aneurysm and bilateral subdural hematomas is presented. He underwent successful aneurysm clipping and subdural hematoma evacuations. At the time of surgery, measures commonly used to obtain brain relaxation were avoided. The patient was kept normovolemic, normocarbic, and normotensive. He recovered completely and resumed his prior occupation. CONCLUSIONS Changes in standard techniques for a patient undergoing a pterional craniotomy for a ruptured cerebral aneurysm are required when bilateral extra-axial mass lesions are present.

Head injuries due to falls caused by seizures: a group at high risk for traumatic intracranial hematomas.

This prospective review of adult patients with head injuries examines the incidence of head injuries due to falls caused by seizures, the incidence and severity of intracranial hematomas, and the morbidity and mortality rates in this patient population. A head injury was attributed to a fall caused by a seizure if the seizure was witnessed to have caused the fall, or the patient had a known seizure history, appeared postictal or was found convulsing after the fall, and no other cause for the fall was evident. A total of 1760 adult head-injured patients were consecutively admitted to the authors' service between 1986 and 1993. Five hundred eighty-two head injuries (33.1%) were due to falls and 22 (3.8%) of these were caused by seizures. Based on the prevalence rates for epilepsy in the general population of 0.5 to 2%, these results indicate that epileptics are several times more likely to suffer a head injury due to a fall. Mass lesions were found in 20 (90.9%) of these 22 patients and the remaining two patients suffered mild diffuse head injuries. There was a high incidence of extraaxial mass lesions: 17 (85%) of the 20 intracranial hematomas were either epidural (five cases) or acute subdural (12 cases) hematomas. Eighteen (81.8%) of the 22 patients required evacuation of a hematoma. Both the incidence of intracranial hematomas (90.9% vs. 39.8%, p < 0.001, chi-square analysis) and the rate of hematoma evacuation (81.8% vs. 32.3%; p < 0.001) was significantly greater in patients injured in falls due to seizures (22 cases) than in the group injured in falls from all other causes (560 cases). The higher incidence of hematomas and the need for evacuation were not explained by differences in age, seventy of head injury, or incidence of alcohol intoxication. Despite the greater incidence of mass lesions and the need for operative treatment in patients injured because of seizures, their mortality rate was similar to that of patients injured in falls from other causes. On the basis of their review of patients admitted to a neurosurgical center with complaints of head injury, the authors conclude that patients with head injuries due to a fall caused by a seizure should undergo computerized tomography scanning early in their management. Until a mass lesion has been excluded, any decrease in level of consciousness or focal neurological deficit should not be attributed to the seizure itself.

Myelopathy Due to Thickened Ligamenta Flava and Abnormal Fibrous Tissue of the Cervicothoracic Junction

A 49-year-old female with subacute myelopathic symptoms due to thickened cervicothoracic yellow ligament and abnormal epidural fibrous tissue is reported. Myelography showed a complete block at the Th3 level. Magnetic resonance imaging demonstrated an extra-axial mass lesion in the spinal canal at the cervicothoracic junction causing the spinal cord compression. Laminectomy with resection of the lesion resulted in good neurological recovery. Histological examination revealed a thickened ligamenta flava and abnormal epidural fibrous tissue without calcification foci.

Intraoperative ultrasound imaging of the entire brain through unilateral exploratory burr holes after severe head injury: technical note

A portable ultrasound unit with a 3.5-MHz probe allows accurate imaging of both cerebral hemispheres and partial imaging of the posterior fossa through unilateral exploratory burr holes or a craniotomy. In patients with clinical signs of transtentorial herniation after severe head injury, this unilateral technique can detect extraaxial and intraparenchymal mass lesions more accurately than is possible with bilateral exploratory burr holes.

Vacuolated (Microcystic) Meningioma

Two patients with extensively vacuolated meningiomas are described. The first, a 51-year-old female who had had several convulsive seizures within a 3-month period, was found on a plain computed tomography (CT) to have a diffuse, hypodense lesion in the frontoparietotemporal region. Contrast enhancement was slight. Neuroradiological examination suggested an extra-axial mass lesion. Histopathological examination of the surgical specimen showed extensive vacuolation and meningothelial cell nests, and a diagnosis of meningioma was established. No lipids were demonstrated in the vacuolated component. Electron microscopy of a formalin-fixed specimen showed interdigitations of cytoplasmic processes and desmosomes. Cytoplasmic processes also delimitated intercellular spaces of variable size. The second patient, a 68-year-old female, had had several right facial spasms within 6 months before admission. Plain CT revealed a hypodense lesion in the left frontotemporal region. Enhanced CT showed a well defined mass lesion. Light microscopy of the tumor specimen showed an area of mixed vacuolated and angiomatous components. It is important to note that the CT appearance of such hypodense meningiomas may mimic that of intra-axial tumors, such as filial tumors. The low density is considered to be due to extensive, diffuse vacuolation. Electron microscopic findings suggest that one of the causes of vacuolation in vacuolated meningioma is recapitulation of the subarachnoid structure.

Intracranial perineural metastasis of adenoid cystic carcinoma of head and neck

Three cases of intracranial perineural metastasis from adenoid cystic carcinoma of the head and neck are presented. The metastases presented more than 1 year (14 months to 5.5 years) after the primary tumor had been successfully treated without any evidence of local recurrence. Computed tomography of the intracranial metastasis demonstrated well-demarcated, hyperdense, enhancing extraaxial masses indistinguishable from meningioma. An intracranial extraaxial mass lesion with the appearance of a meningioma in a patient with known adenoid cystic carcinoma of the head and neck, regardless of the presence or absence of local recurrence, should be considered as metastasis until proved otherwise.

Positive contrast evaluation of the posterior cranial fossa.

Positive contrast posterior fossa cisternography has been performed in more than 100 patients with suspected extra-axial mass lesions of the posterior cranial fossa. Sufficient contrast medium is required to demonstrate the vascular anatomy of this region as well as the relationship of the mass to adjacent portions of the central nervous system. Compression of the pontine cistern by a mass lesion of the brainstem or cerebellum or by an Arnold-Chiari malformation can be recognized at fluoroscopy and confirmed by a cross-table lateral radiograph.