Extracranial Localization Research Articles

Extracranial Nasosinusal Meningioma: A Case Report of a Rare Entity

Meningiomas are the most common neoformations of the central nervous system, and represent the 33% of all intracranial neoplasms. The nasosinusal tract is involved in 24% of cases of extracranial localization. The aim of our paper is to present the case of a patient with an ethmoidal sinus meningioma.

Rare Schwannomas of Head and Neck and Review of Literature.

Benign schwannoma is a slow growing encapsulated tumor arising from the sheath of Schwann, The majority had extra-cranial localization. We report in this review three cases of a rare extra cranial localization of benign schwannoma in the trachea, frontal sinus and intraparotid facial nerve. The first case diagnosed in a 10-years-old boy, presented with a painless, slow growing mass evolving for three years in the left parotidic region, total conservative parotidectomy was done. The second case concerned a 38-years-old, was admitted to the emergency department with acute inspiratory dyspnea, endoscopic exploration revealed a polylobed tracheal tumor, complete tumor excision was done endoscopically. The third case was about a 33years old patient, presented a gradually enlarging frontal swelling associated with headache and left nasal obstruction, the endoscopic examination revealed a gray pinkish, smooth and firm soft tissue mass occupying the entire left nasal cavity, CT scan and MRI were requested to assess the characteristics and extent of the tumor, The surgical intervention combined two approaches: trans facial through a mid-frontal incision, and endonasal one. Histopathological examination confirmed the diagnosis of benign schwannoma in all these cases.

A SNAPSHOT FROM AN EASTERN EUROPEAN REGISTRY ON FIBROMUSCULAR DYSPLASIA

Objective: To evaluate the specific characteristics of patients with fibromuscular dysplasia (FMD) with various localizations and clinical manifestations (or without). The diagnosis is made with angiography. Design and method: This is a case series of 27 consecutive patients with FMD, who were diagnosed in the Cardiology clinic of UMHAT “Alexandrovska” for a period oof 4 years. The diagnosis is based on angiographic criteria, but in several cases an intravascular ultrasound (IVUS) was needed for confirmation, because of discrepancies with the universal understanding for the angiographic image and localization of lesions. Results: The mean age at the time of diagnosis was about 58 years; males were 6 (22%). Renal localization had 17 (63%); extracranial localization – 7 (26%); intracranial – 2 (7.4%); other (3.7%). The age at diagnosis was relatively high. Nine (33%) of the patients underwent interventional treatment in accordance with the contemporary guidelines. Both groups intervened/non-intervened should be routinely followed (at least with ultrasound) in order to properly assess their cardiovascular risk. Conclusions: All the cases were scheduled for angiography for a variety of symptoms: neurological, cardio-vascular, or for embolization of a renal cell carcinoma. Although there are clear criteria for the diagnosis of FMD, in several cases an IVUS was needed for confirmation and exclusion of the differential diagnoses. In the future, clear IVUS criteria may be reasonable to be included in the diagnostic process, especially in cases with borderline angiographic morphology or in those without any typical clinical manifestation.

Neck pain and headache as the only manifestation of cervical artery dissection

To analyze clinical and neuroimaging data in patients with neck pain and headache as the only manifestation of the internal carotid artery (ICA) dissection (ICAD) and vertebral artery (VA) dissection (VAD). One hundred and sixty-one patients (mean age - 37.4±4,99 years, 84 women, 52%) with cervical artery dissection (CAD) verified by magnetic resonance imaging (MRI) were enrolled. Neck pain and headache were the only CAD manifestation in 33 patients (mean age 37,3±7,4 yars, 28 women, 85%). The localization of the dissections in these patients was the following: one VA (15 patients), two VA (9), one ICA (7), two ICA (1), one ICA + two VA (1). The whole number of dissected arteries was 45: extracranial localization - 38, extra-intracranial - 6, intracranial - 1. Dissection led to stenosis of the arterial lumen in 41 arteries, to occlusion - in 2 and to dual lumen in 2 arteries. Small aneurism was found in 4 arteries. Combination of headache and the neck pain was observed in 26 out of 33 patients (79%), the only headache in 4 patients, the only neck pain in 3 patients. Along with this, 9 out of 24 VAD patients had the shoulder and/or arm pain. Headache in VAD patients was located more often in the occipital region (18 out of 24) that had never been observed in ICAD patients (p=0.0009). Fronto-temporal pain was observed more often in ICAD patients (5 out of 8 patients) than in VAD (2 out of 24 patients) (p=0.003). Neck pain in all VAD patients in comparison with 3 out ofI8 [CAD patients had posterior localization (p=0,007). Anterolateral neck pain was observed in 4 out ofI8 ICAD patients and in no patients with VAD (p=0.0009). The pain appearance was abrupt in all ICAD patients and most of the VAD patients. In 8 VAD patients the pain has been increasing during several hours. The pain intensity was severe in 19 patients, moderate in 12 and mild in 2. The characteristics of the pain were as following: constrictive/dull (26 patients), throbbing (1 patient) or combined (6 patients). Pain was increasing in a stepwise manner during the first days in 14 out of 24 VAD patients and in no one of ICAD patients (p=0.008). The mean pain duration period was 31 8 ± 15,7 days. Pain relief drugs were ineffective or had a short effect in 97% of patient. Isolated pain is more characteristic for women with VAD. Usually pain is presented as a combination of headache and neck pain. Pain localization, mode of appearance and the course are different in VAD and ICAD. The rarity of occlusion among patients with <<pain-only>> manifestation let to suggest that the intramural hematoma in this group of patients spreads to the adventitia that can reflect media weakness. Arterial wall changes underlying its weakness seem to be sex-hormone dependent taking into consideration the high predominace of women in cad manifested by isolated pain.

Rare extracranial localizations of the head and neck schwannomas

Schwannomas are tumors of neurogenic origin, that arise from Schwann cells which surround peripheral, cranial and autonomic nerves. Schwannomas account for only 5% of all benign soft tissue tumors, and 25-45% of extracranial schwannomas are present in the head and neck region. They are usually classified according to the nerve of origin and the site within the head and neck. We presented extremely rare extracranial localizations of schwannomas and discussed about diagnosis and management of these tumors. Schwannomas are slow-growing tumors and late symptoms appearance may cause a delay in diagnosis and treatment of patients with these tumors. An appropriate diagnostic protocol is indispensable tool in performing a differential diagnosis of malignant from benign lesions. Choice of surgical approach depends on schwannomas localization.

A CYLINDRICAL EXTRACRANIAL CRANIAL BASE NEURINOMA OF THE HYPOGLOSSAL NERVE

Neurinomas of the hypoglossal nerve are very rare. They are mostly located intracranially or combined intra- and extracranially, resulting in the so-called dumbbell shape. The isolated extracranial localization of the neurinoma of the hypoglossal nerve adjacent to the cranial base as described in this case report is extremely rare. The 23-year-old patient presented with recurring headaches. She had right-sided hypoglossal nerve palsy for approximately 5 to 6 years. Magnetic resonance imaging revealed an extracranial tumor with contact to the cranial base originating from the hypoglossal nerve. The tumor was extirpated surgically and verified histologically as a schwannoma of the hypoglossal nerve. Pathologies of the hypoglossal nerve as such are very rare within the clinical landscape. When a tumor occurs, its shape and location must be analyzed to establish whether, or by which approach, surgical removal is feasible. Although very unusual, the mere extracranial occurrence of a hypoglossal neurinoma at the cranial base should be considered a differential diagnosis.

Rare extracranial localization of primary intracranial neoplasm

Meningioma, craniopharyngeoma and glioma are mainly intracranial lesions. Nevertheless, in rare cases these entities may occur solely as extracranial lesions that may present as intranasal/sinusoidal masses, with headaches and nasal obstruction. We present three cases of common intracranial tumors, with purely extracranial extension. The three described cases demonstrate, that preoperative MRI and CT imaging is important for differential diagnosis to exclude intracranial connections of the tumors. A definitive diagnosis requires specialized immunohistochemical examinations. In all cases of intranasal or pharyngeal neoplasm the diagnosis of meningioma, craniopharyngeoma and glioma should be considered as differential diagnosis to optimize the surgical procedure.

Rare Extracranial Localization of Primary Intracranial Neoplasm

Meningioma, craniopharyngioma, and glioma are mainly intracranial lesions. Nevertheless, in rare cases these entities may occur solely as extracranial lesions that may present as intranasal or sinusoidal masses, with vision disturbances, headaches, and nasal obstruction. Diagnosis is usually confirmed histologically. We present three cases of common intracranial tumors, with purely extracranial extension. We report a case of a 60-year-old woman with an extracranial meningioma located in the left frontal sinus. Extracranial meningiomas are rare tumors comprising 1 to 2% of all meningiomas, whereas intracranial meningiomas are the most common adult benign intracranial neoplasm. The second case is a 26-year-old woman with a sphenoid sinus craniopharyngioma involving the clivus simulating a chordoma prior to surgery. The bony skull base and the dura were not affected. Craniopharyngiomas are most commonly located in the intradural suprasellar region. An infrasellar location for these tumors is extremely rare and has only been described in 14 case reports.

Rare Extracranial Localization of Primary Intracranial Neoplasm

Meningioma, craniopharyngioma, and glioma are mainly intracranial lesions. Nevertheless, in rare cases these entities may occur solely as extracranial lesions that may present as intranasal or sinusoidal masses, with vision disturbances, headaches, and nasal obstruction. Diagnosis is usually confirmed histologically. We present three cases of common intracranial tumors, with purely extracranial extension. We report a case of a 60-year-old woman with an extracranial meningioma located in the left frontal sinus. Extracranial meningiomas are rare tumors comprising 1 to 2% of all meningiomas, whereas intracranial meningiomas are the most common adult benign intracranial neoplasm. The second case is a 26-year-old woman with a sphenoid sinus craniopharyngioma involving the clivus simulating a chordoma prior to surgery. The bony skull base and the dura were not affected. Craniopharyngiomas are most commonly located in the intradural suprasellar region. An infrasellar location for these tumors is extremely rare and has only been described in 14 case reports.

Acetylsalicylic Acid and Microembolic Events Detected by Transcranial Doppler in Symptomatic Arterial Stenoses

Background: In patients with symptomatic carotid artery stenosis, high-intensity transient signals detected by transcranial Doppler (TCD) have been related to particulate microemboli originating at the stenotic lesion. The occurrence of these microembolic events within the Doppler spectrum should be influenced by antithrombotic agents of proven efficacy in these patients mainly by reducing cerebral embolism. Methods: Seventy-four of 192 consecutive patients with symptomatic arterial stenosis in the anterior circulation and clinical symptoms within the last 30 days underwent 1-hour bilateral TCD monitoring. Patients were selected, if they presented temporal bone windows enabling transcranial insonation, revealed normal Doppler CO₂ test excluding hemodynamic impairment, had not received antithrombotic therapy other than acetylsalicylic acid (ASA) before sonographic examination, and gave informed consent to 1-hour monitoring which could be performed immediately on admission/presentation of the patient at the Department of Neurology. Results: Microembolic events were detected in 38 patients (51%). The proportion of patients with events among 26 patients without antithrombotic medication was 73% as compared with 40% in 48 patients receiving ASA at the time of TCD monitoring (p = 0.023). Multivariate analysis including time from ischemia to TCD, presence and start of ASA prevention, degree and localization of stenosis, and presence of a single or recurrent ischemia revealed that absence of an ASA prevention (odds ratio OR 7.1, 95% confidence interval CI 1.6–31.4, p = 0.010), recurrent ischemic events (OR 7.1, 95% CI 1.6–32.7, p = 0.011), and extracranial localization of the stenosis (OR 3.8, 95% CI 1.1–13.2, p = 0.038) were independent predictors for microembolic events. Conclusion: In patients with symptomatic arterial stenosis, the absence of an ASA medication is associated with the occurrence of TCD-detected microembolic events, suggesting a relation between these events and ASA-sensitive microemboli from the stenotic lesion.

Extracranial localization of intracranial interictal epileptiform activity using LORETA (low resolution electromagnetic tomography)

Besides the standard clinical methods of EEG waveshape analysis, mathematical models for reconstruction of dipolar sources from the digitized surface EEG have been introduced in epilepsy research. Although useful for localizing focal sources, these methods are inadequate for analyzing widespread epileptiform activity. A recently introduced alternative method called LORETA (low resolution electromagnetic tomography, Pascual-Marqui et al., 1994), directly computes the current distribution throughout the full brain volume, assuming that neighboring neuronal populations are simultaneously and synchronously activated. In mathematical terms the method selects the smoothest of all possible 3-dimensional current distributions, inherently introducing a certain amount of dispersion. In 7 patients, undergoing simultaneous EEG recording from 10 intracranial (subdural) and 22 extracranial electrodes, 111 subdural discharges (61 subtemporal and 50 lateral temporal) were identified. The exact time point of maximal intracranial activity was automatically identified, and the LORETA solution at that timepoint was computed from the surface EEG. Statistical comparison revealed significantly higher LORETA current density in the area corresponding to the subdurally recorded spike compared to other areas, and a more anterior and more medial LORETA location for subtemporal compared to lateral temporal spikes. This study indicates that the LORETA technique may become a useful method to localize electrical activity in the brain.

M103 Extracranial localization of intracranial interictal epileptiform activity using LORETA (Low Resolution Electromagnetic Tomography)

M103 Extracranial localization of intracranial interictal epileptiform activity using LORETA (Low Resolution Electromagnetic Tomography)