Intracerebral Mass Research Articles

Malignant Intracerebral Nerve Sheath Tumors: A Case Report with Review of the Literature

The occurrence of benign nerve sheath tumors within the neuroaxis is uncommon. Even rarer is the finding within brain parenchyma, termed malignant intracerebral nerve sheath tumors (MINST). We present a case of MINST which occurred in the frontal lobe of an 18-year-old male that recurred almost 4 years later. Imaging demonstrated a 4.0 cm lesion with an associated mass effect. He underwent a right fronto-parietal craniotomy for gross total resection. Pathology was inconclusive with a Glioblastoma Multiforme (GBM) as the most likely diagnosis, though gliosarcoma and MINST were also highly considered. Postoperatively, he was treated with chemotherapy and radiation and followed for almost 4 years, when an MRI indicated a recurrence. Resection of the recurrence was highly suggestive of MINST. Surgery was followed by radiation and chemotherapy, but, less than 7 months later, he was readmitted for a surgical-site infection, and, after multiple surgeries, and his family terminated care. Recognizing this unusual tumor in the differential diagnosis of a heterogeneously enhancing intracerebral mass can help surgeons diagnose and treat it. This report also exhaustively reviews the literature and presents diagnostic and treatment strategies.

Efficacy of rituximab plus FAB group C chemotherapy without CNS radiation in CNS-positive pediatric Burkitt lymphoma/leukemia: A report from the Children’s Oncology Group.

9501 Background: Historically, CNS-positive (CNS+) mature B-NHL in children and adolescents has been associated with a dismal outcome (Miles/Cairo, Br J Haematol, 2012). Adding CNS radiation and high-dose MTX and cytarabine to group C therapy for children with CNS+ B-NHL yielded a 77% 5-yr EFS in LMB89 (Patte et al., Blood, 2001). An ensuing FAB/LMB96 trial replaced cranial radiation with further HD-MTX and intrathecal therapy with similar results (75% 4-yr EFS) (Cairo et al., Blood, 2007). Here, patients with marrow and CNS+ disease fared worse than isolated CNS+ (61% vs. 83% 4-yr EFS, p<0.001), with >50% of CNS+ patients who progressed or recurred having systemic, but not CNS, relapse. Rituximab, a chimeric anti-CD20 antibody, improved EFS, PFS, and OS when added to chemotherapy for adults with DLBCL (Coiffier et al., N Engl J Med, 2002; Pfreundschuh et al., Lancet Oncol, 2006). We tested whether adding rituximab to FAB group C chemotherapy in pediatric patients with CNS+ B-NHL was safe and efficacious. Methods: Children and adolescents (<21 yrs.) with CNS+ B-NHL received FAB group C1 therapy (Cairo et al., Blood, 2007). Rituximab (375 mg/m2/dose) was given twice in COPADM courses 1 & 2 and once in CYVE courses (Cairo et al., ASCO, 2010). CSF blasts (>1), cranial nerve palsy (CNP), intra-cerebral mass (ICM), and/or parameningeal extension (PME) defined cases as CNS+. Results: Of 40 eligible Group C patients,15 (38%) were CNS+; all 15 had Burkitt morphology. Eight CNS+ patients were CSF+ [WBC median 35 (range 1-1104)] with 6 cases CNP+, 4 PME+, and 1 ICM+. No adverse events were attributed to rituximab. Fourteen of 15 CNS+ patients (93%) are alive and disease-free. Of 7 BM-/CNS+ patients, 100% are NED. In BM+/CNS+ cases, 7/8 (88%) are NED, with one patient progressing with systemic and CNS disease. Conclusions: Addition of rituximab to group C FAB therapy was well tolerated. Outcomes in this small cohort of 15 children and adolescents with CNS+ BL (93%) suggest that adding rituximab to FAB group C therapy without CNS radiation may reduce systemic relapse. Large randomized studies are warranted to test this hypothesis in this previously high-risk clinical subgroup.

Fetal Intracerebral Mass With Major Perinatal Implications

A 27-year-old G3A2L0 woman is referred to the Maternal Fetal Medicine clinic after a routine third-trimester ultrasound in a community setting shows an intracerebral mass at 30 weeks’ gestational age (GA). The mother is healthy other than being a chronic carrier of hepatitis B. She is blood type B positive with a negative antibody screen. She previously had two first-trimester therapeutic abortions, and this is her first pregnancy with her current partner. The pregnancy was uneventful with a negative integrated prenatal screen and ultrasounds with normal results at 14 and 20 weeks’ GA. Mild maternal thrombocytopenia was detected throughout the pregnancy (lowest platelet count 97 × 109/L) with reported increased bruising. There is no family history of bleeding disorders in either her or her partner's family. The findings on physical examination are normal with no signs of bleeding, bruising, or petechiae. A complete blood cell count shows a hemoglobin level of 11.3 g/dL (113 g/L) and a platelet count of 124 × 103/μL (124 × 109/L). A repeat ultrasound confirms a large complex intracerebral mass with hypoechoic areas suggestive of cysts as well as echogenic portions that were felt to be either solid or to represent bleeding with clots. The composition of the mass is clarified by maternal MRI at 31 weeks’ GA, which shows a large cystic complex lesion measuring 5.0 × 3.8 × 4.5 cm (Fig 1). There is a solid component that shows blooming on the susceptibility-weighted imaging sequence, suggestive of blood products, clot, or calcification, but an underlying neoplastic process or vascular anomaly cannot be excluded. Figure 1. MRI of the maternal pelvis at 31 weeks’ GA without gadolinium. Large complex cystic lesion (arrow) in the frontoparietal region of the left cerebral hemisphere of the fetus with characteristics suggestive of blood products. …

Intracerebral mass lesion diagnosed as cryptococcoma in a patient with sarcoidosis, a rare opportunistic manifestation induced by immunosuppression with corticosteroids

Cryptococcal infection of the central nervous system (CNS) typically affects patients with HIV infection. In addition, opportunistic infections can also occur during immunosuppressive therapies. Some patients develop cryptococcal meningitis. Cryptococcomas, however, are rarely observed. A 42-year-old patient with sarcoidosis known for 2½ years presented with a cerebral mass lesion primarily thought to be CNS sarcoidosis. Stereotactic biopsy and extensive micro- and macrobiological investigations revealed a cryptococcoma which had emerged from cryptococcal meningitis despite 3 months of treatment. Differential diagnosis of cerebral cryptococcoma is difficult due to the unspecific findings in the CSF analysis if C. neoformans fails to be detected using Indian ink staining or PCR studies. In this case, stereotactic biopsy and pathohistological examination revealed C. neoformans causing intracerebral mass lesion. Intensive treatment with antifungal drugs was followed by remission of all symptoms. In conclusion, cryptococcoma of the CNS represents a very important indication of mass lesions in patients suffering from sarcoidosis and treated with corticosteroids.

5-Aminolevulinic acid (5-ALA)-induced fluorescence in intracerebral metastases: a retrospective study

Microsurgical, circumferential stripping of intracerebral metastases often proves to be insufficient to prevent local tumor recurrence. We were interested in the potential impact of 5-aminolevulinic acid (5-ALA)-induced-fluorescence (5-AIF) as a diagnostic tool for the resection of intracerebral metastases. A retrospective analysis was performed for 52 patients who underwent 5-AIF-guided resection for intracerebral mass lesions that histologically corresponded to metastases from tumors outside the central nervous system. The presence of ALA fluorescence in the tumor was determined in each patient. In 42 patients, fluorescence of the resection cavity after tumor removal was additionally recorded. Data were correlated with neuropathological findings in tissue specimens. A total of 32 of the 52 metastases (62%) exhibited 5-AIF in tumor parts. All 5-AIF-positive metastases exhibited an inhomogeneous fluorescence pattern. 5-AIF was neither associated with the histological type nor with the site of origin of the metastases. Residual fluorescence of the resection cavity was detected after macroscopically complete white light resection in 24 patients with 5-AIF positive metastases. Residual tumor tissue was histologically confirmed in 6 of 18 patients with available tissue specimens from such 5-AIF positive areas (33%). The majority of metastases (62%) were 5-AIF positive, suggesting a potential impact of 5-AIF for improved visualization of metastatic tumor tissue within the brain. However, residual 5-AIF after macroscopically complete resection of a metastasis needs to be interpreted with caution because of the limited specificity for detection of residual tumor tissue.

Cavernous sinus syndrome, an atypical presentation of tertiary syphilis: Case report and review of the literature

Cavernous sinus syndrome is rarely caused by tertiary syphilitic infection. To our knowledge only two other cases of cavernous sinus syndrome caused by syphilis have been reported in the literature. We report a case of a 62-year-old female who presented with a mass in the cavernous sinus, which was initially diagnosed as a meningioma radiologically, necessitating a biopsy for diagnostic confirmation. Clinical features of syphilitic aortitis and subsequent positive neurosyphilis laboratory results lead to the suspicion of a gumma infiltrating the cavernous sinus. Empirical treatment with penicillin in an attempt to defer the need for biopsy led to both significant clinical improvement and radiological resolution. This confirmed the diagnosis of a syphilitic gumma in the cavernous sinus. In this paper we emphasize the rarity of cavernous sinus syndrome as a result of syphilitic infection, highlight the diagnostic difficulties using current serological and radiological measures, and propose treating intracerebral mass lesions in serum positive cases empirically prior to more invasive measures.

Decompressive Craniectomy for Acute Disseminated Encephalomyelitis

Acute disseminated encephalomyelitis (ADEM) is a rare, acute demyelinating condition. Although it usually presents in an acute or subacute manner over days, its clinical course may be rapid with symptoms and signs of severe intracerebral mass effect secondary to cerebral oedema. Case report and literature review. We report a case of a patient presenting with a hyperacute course manifested by rapid loss of consciousness and focal neurological signs. Management with emergency hemicraniectomy and steroids resulted in rapid neurological improvement and minimal long-term deficit. We believe that only surgical decompression is likely to be life saving in similar cases of hyperacute cerebral oedema due to ADEM. The wide decompression performed was concordant with that indicated for traumatic brain swelling. Such aggressive management is vindicated by the rapid recovery shown by our patient within days of surgery and the finding of minimal neurological sequelae at 3 months.

Intrazerebrale Blutung als Tumor verkannt

Report of a 33-year-old woman who had sudden vision problems and homonymous hemianopia on the left. A cranial computed tomography (CCT) was carried out in a radiologic practice. A native homogeneous, smooth-edged hyperdense intracerebral mass of about 5.5 cm diameter on the right parietooccipital region with density values of +50 HU was found. Only a small proportion of about 2 cm diameter was more hyperdense with density values of +65 HU. Following intravenous administration of contrast medium, a patchy increase in density of about 1 cm was seen. The mass had only a thin hypodense rim. The patient was informed that she had a tumor. Three days later, magnetic resonance imaging was to be done for further evaluation. After the patient had returned home, she had headaches, nausea and vomiting in the evening. At night, she was admitted to a hospital as emergency case. With further increase of intracranial pressure, a craniotomy was done and a hemorrhage was removed. Histologically, a bleeding of a cavernous hemangioma was found. The patient appealed to the fact-finding board for medical liability questions because she had not been admitted to a hospital immediately after the CCT. Therefore, surgery was done delayed. The board found that the behavior of the radiologist was wrong. However, it cannot be proven that this medical malpractice is of importance for the existing postoperative complaints.

Intracerebral mass bleeding in a term neonate: Manifestation of hereditary Protein S deficiency with a new mutation in the PROS1 Gene

Intracerebral mass bleeding in a term neonate: Manifestation of hereditary Protein S deficiency with a new mutation in the PROS1 Gene

Is there a place for FET PET in the initial evaluation of brain lesions with unknown significance?

The aim of this study was to evaluate the clinical value of the use of O-(2-[(18)F]fluoroethyl)-L: -tyrosine (FET) positron emission tomography (PET)/computed tomography (CT) in patients of a neurological clinic for evaluation of brain lesions newly diagnosed by magnetic resonance imaging (MRI). We evaluated 88 patients (44 women and 44 men) with a mean age of 50 +/- 19 years who were sent consecutively for evaluation of an intracerebral mass or lesion observed by MRI from 2006 to 2008. Hospitalization was necessary due to neurological clinical symptoms. Images were obtained by PET/CT 30 min after i.v. injection of 185 MBq FET. Coregistration with MRI was done by HERMES workstation. FET uptake above the cortical level was observed in 60 patients. Neurosurgery was performed in 60 patients (51 with FET-positive imaging); 36 high-grade and 19 low-grade tumours were verified histologically. The sensitivity of FET PET for high-grade tumours (WHO III-IV) was 94% in this setting. Among the low-grade brain tumours (WHO I-II) 13 of 19 were FET positive, which indicates a sensitivity of 68%. Five of ten (50%) astrocytomas I and II could not be visualized by FET. Histological data were not provided for 28 of 88 patients, so the diagnostic approach is based upon longitudinal observation. Radiological and/or clinical control was done at a median of 7 months later. Three patients (all FET positive) died a few months after the examination because of rapid progression of the malignant brain tumour. A malignant entity could be excluded in the other 25 patients. Considering the whole cohort of 88 patients, 43 patients with malignant tumour could be identified, including high-grade glioma, intracerebral lymphoma (n = 1) and metastasis (n = 3). The sensitivity of FET PET for detecting a malignant tumour entity was 93%. We observed two false-positive cases with postischaemic lesions. Remarkably, the two patients with cerebral gliomatosis were false-negative on FET PET imaging. The negative predictive value for a malignant entity was calculated to be 89%. Our results indicate a high sensitivity of FET PET for detecting high-grade glioma in patients with neurological symptoms and recently observed brain lesions by MRI. In the setting of evaluating new brain lesions of unknown significance via FET PET a negative image can encourage a wait and see strategy-of course in accordance with the clinical picture and morphological imaging.

Pure Intracerebral Mass Lesion of Adult T-Cell Leukemia/Lymphoma -Case Report-

A 48-year-old female presented with a rare case of adult T-cell leukemia/lymphoma (ATL) occurring as only intracerebral mass lesion manifesting as progressively worsening headaches, transient mild weakness of the left lower extremity, bilateral papilledema, and left homonymous hemianopsia. Laboratory examination showed transient leukocytosis (15900/microl) without febrile episode or elevation of C-reactive protein. Neuroimaging revealed a solitary enhanced mass lesion in the right occipital lobe adjacent to the choroid plexus with prominent perifocal edema. The patient underwent gross total removal, and the histological diagnosis was intracerebral ATL. She underwent radiation therapy and chemotherapy after local recurrence and metastasis to an optic nerve. The lesions had disappeared on magnetic resonance imaging with contrast medium 10 months after onset and no recurrence was detected even 5 years later. Intracerebral ATL should be considered in the differential diagnosis of intracerebral mass without leukemia or systemic lymphoma.

Experience with a Therapeutic Platelet Transfusion Strategy in Acute Myeloid Leukemia: Preliminary Results of a Randomized Multicenter Study After Enrolment of 175 Patients.

Abstract 20 IntroductionWe have shown in a monocenter study (ASH 2005, abstract # 428) that routine prophylactic platelet (plt) transfusions are not necessary in patients (pts) with acute myeloid leukemia (AML). Therefore, we started a multicenter randomized study comparing the routine prophylactic (morning trigger: plts ≤ 10/nl, arm P) with a therapeutic platelet transfusion strategy (arm T). MethodsDiagnosis of AML and feasability of intensive chemotherapy within standard protocols was required (M3 only in CR). In arm T transfusions were given only when clinically relevant bleeding (more than petechiae) happened regardless of the morning plt count. For safety reasons prophalyctic plts were transfused in case of invasive aspergillosis, sepsis syndrom and repeated or continous headache. In case of headache pts in arm T received a ct-scan. The experimental transfusion strategy startet at day 8 of induction and at day 1 of consolidation. Primary endpoint was the reduction of plt transfusions by 20%; secondary endpoints were bleeding complications, red blood cell transfusions, side effects, duration of thrombocytopenia and hospital stay. ResultsUntil July 2009 175 pts have been randomized. Full data were evaluable for 161 pts (79 arm P and 82 arm T). Median age was 52 years (20-78). We registered 251 induction and 112 consolidation cycles. Mean duration of thrombocytopenia (<20/nl or <10/nl) was 17 and 8 days, respectively. Duration of thrombocytopenia was significantly longer in arm T. Depite the longer duration, the number of platelet transfusions in arm T was significantly reduced, by about 25% (p <0.001). Number of red blood cell transfusions were not different (p = 0.95). Days in hospital and side effects were not different in both groups. Bleeding complications (more than petechial) were significantly increased in arm T showing a 2.3 times higher risk compared to arm P. This is clearly correlated with bleeding being the trigger for plt transfusion in arm T. Majority of hemorrhages were of minor or moderate significance that could all be treated effectively by plt transfusion. Most important was the observation that we registered 5 minor and 2 major cerebral hemorrhages in arm T and none in arm P. Minor cerebral hemorrhages with headache were not registered in arm P since we did not perform ct-scans routinely in arm P in case of headache. Minor cerebral complications were 2 sub-/epidural bleedings after vasovagal collapses of pts at plt counts of 53 and 96/nl, respectively, and 3 spontanuous minor subarachnidal/ intracerebral hemorrhages at plt counts of between 15 and <5/nl. All 5 minor cerebral complications were detected by ct-scan performed due to headache. All pts recovered after plt transfusion without any sequelae.The two other pts died following fatal cerebral bleeding. One pt. had repeated headache since several days. At a plt count of 11/nl fatal bleeding happened. A ct-scan revealed intracerebral mass bleeding. The pt was randomized to the experimental strategy but even following standard transfusion strategy the pt would not have been transfused prophylactically. The only fatal cerebral bleeding that must be clearly attributed to the therapeutic strategy was a female pt with a pulmonary fungal infection that improved under antifungal treatment. She had a morning platelet count of <5/nl. During the following night she woke up with severe headache. Despite timely platelet transfusions she died of progressive mass bleeding. Unfortunately, we could not perform an autopsy to see whether the patient had fungal involvement of the brain. 1-2 % of fatal cerebral bleedings are reported in AML trials despite a prophylactic strategy. Whether these two complications happened by chance in arm T or were the consequence of the experimental strategy cannot be answered by our study. To give proof of this important question one would need about 2000 pts in both arms for statistical reasons. Conclusions A therapeutic platelet transfusion strategy according to our protocol is feasible in AML pts during intensive chemotherapy and can reduce the number of platelet transfusions significantly. An increased risk of fatal cerebral bleeding cannot be excluded by this study. An international collaboration would be necessary to set up a study large enough to determine the final safety. Disclosures:No relevant conflicts of interest to declare.

An Analysis of Possible Mechanisms of Unexpected Death Occurring in Hydatid Disease (Echinococcosis)

Most cases of hydatid disease in human populations are due to Echinococcus granulosus. The hydatid life cycle involves passage between definitive hosts such as dogs and intermediate hosts such as sheep. Humans become accidental intermediate hosts following ingestion of food or water contaminated with eggs or by contact with infected dogs. Although hydatid disease may remain asymptomatic, occasional cases of sudden and unexpected death present to autopsy. Causes of rapid clinical decline involve a wide range of mechanisms including anaphylaxis (with or without cyst rupture), cardiac outflow obstruction or conduction tract disturbance, pulmonary and cerebral embolism, pericarditis, cardiac tamponade, myocardial ischemia, pulmonary hypertension, peritonitis, hollow organ perforation, intracerebral mass effect, obstructive hydrocephalus, seizures, cerebral ischemia/infarction, and pregnancy complications. The autopsy assessment of cases therefore requires careful examination of all organ systems for characteristic cystic lesions, as multiorgan involvement is common, with integration of findings so that possible mechanisms of death can be determined. Measurement of serum tryptase and specific IgE levels should be undertaken for possible anaphylaxis.

Dural plasmacytoma mimicking meningioma in a young patient with multiple myeloma

Intracranial involvement in multiple myeloma (MM) is rarely found, especially with dural involvement. There are only a few cases found concerning MM with intracranial involvement. MM usually involves an older group of patients. Cases involving young patients are very rare. The differential diagnosis of a dural plasmacytoma includes meningioma, metastasis, lymphoma and sarcoma of the dura mater. We present a young patient, 33 years old, with MM presenting an intracerebral mass mimicking meningioma on MRI. MM was diagnosed the previous year. The patient presented with headache, balance disturbance and back pain. MRI revealed an occipital extra-axial mass with a dural tail. Histopathological examination after excision showed MM. Published literatures on intracranial involvement of MM are also discussed. Plasmacytoma should be considered in the differential diagnosis of a solitary dural mass, particularly in a patient with MM.

Ventriculitis: a rare case of primary cerebral toxoplasmosis in AIDS patient and literature review

Cerebral toxoplasmosis remains the most important neurological opportunistic infection and the most common cause of intracerebral mass lesion in patients with acquired immunodeficiency syndrome (AIDS). We report a case of an adult AIDS patient with an atypical pattern of toxoplasma encephalitis, presenting with ventriculitis and obstructive hydrocephalus without any focal parenchymal lesion.

Neonatal Macrocephaly: Cerebral Primitive Neuroectodermal Tumor or Neuroblastoma as an Infrequent Cause-A Case Report and Review of the Literature

We report a male term newborn presenting with a congenital macrocephaly 3.5 standard deviations above the median, with a wide and tense anterior fontanel, splayed calvarial sutures, and muscular hypotonia. Antenatal head circumferences were repeatedly below the median. A postnatal head ultrasound showed a large right intracerebral mass with right lateral ventricle compression, right temporal horn dilation, and right frontal horn enlargement with lateral displacement. Additional imaging by computed tomography scan and magnetic resonance imaging was performed. A decompression was performed and histology, immunohistochemistry, and molecular biology supported the diagnosis of a primitive neuroectodermal tumor. A MYCN gene amplification assay remained negative. The incidence of neonatal brain tumors is between 1.4 and 4.1/100,000 live births. Their most common presentation is macrocephaly, hydrocephalus, stillbirth, or diagnosis by pre- or postnatal imaging. Although hydrocephaly and intra- or extracranial hemorrhage are the most frequent causes of congenital macrocephaly, this should be initially investigated by head ultrasound. A suspected malignancy will be confirmed by histopathology, immunohistochemistry, and molecular biology.

Supratentorielle Tumoren

Magnetic resonance imaging is a routine diagnostic measure for a suspected intracerebral mass. Computed tomography is usually also indicated. Further diagnostic procedures as well as the interpretation of the findings vary depending on the tumor location. This contribution discusses the symptoms and diagnostics for supratentorial tumors separated in relation to their intra- or extracranial location. Supratentorial tumors include astrocytoma, differentiated by their circumscribed and diffuse growth, ganglioglioma, ependyoma, neurocytoma, primitive neuroectodermal tumors (PNET), oligodendroglioma, dysem-bryoplastic neuroepithelial tumors (DNET), meningoangiomatosis, pineal tumors, hamatoma, lymphoma, craniopharyngeoma and metastases. The supratentorial extracranial tumors include the choroid plexus, colloid cysts, meningeoma, infantile myofibromatosis and lipoma. The most common sub-forms, especially of astrocytoma, will also be presented.

Fast improvement of verbal memory function after left temporal tumour resection

A 7-y-old, right-handed girl presented at our clinic with complex partial seizures, behavioural problems and word-finding difficulties. Clinical examination was normal, but electroencephalogram revealed bilateral epileptic discharges in the temporal and paracentral leads. Magnetic resonance imaging showed an intracerebral mass in the left mesial temporal lobe in the areas of the gyrus temporooccipitalis medialis and gyrus parahippocampalis. Neuropsychological testing brought to light an above-average general intelligence, but the girl performed below average in verbal memory tests and average in figural memory tests. The tumour was completely removed by surgery. Neuropsychological testing 3 and 11 wk after tumour resection demonstrated above-average verbal learning and memory abilities and improved visual memory. The emotional disturbances, seizures and electroencephalogram abnormalities disappeared completely during the postoperative follow-up. After resection of a left temporal brain tumour, the patient was free of seizures, and neuropsychological functions recovered completely within weeks.

Dural plasmacytoma mimicking meningioma in a patient with multiple myeloma

Apart from calvarial infiltration, intracranial involvement in multiple myeloma is uncommon. Diffuse leptomeningeal invasion with or without parenchymal involvement is most common. Dural infiltration without involvement of the parenchyma, leptomeninges or skull is rare. The differential diagnosis of a dural plasmacytoma includes meningioma, which has a similar MRI appearance, metastasis, lymphoma and sarcoma of the dura mater. We present a patient with multiple myeloma presenting with an intracerebral mass mimicking a meningioma on MRI. Multiple myeloma had been diagnosed seven years previously. The patient presented with headache and speech disturbance 12 months after autologous peripheral stem cell transplantation for recurrence of multiple myeloma. MRI revealed a left temporal extra-axial mass with a dural tail mimicking meningioma. Histopathological examination of the mass after excision showed multiple myeloma immunopositive for IgG, kappa light chain and CD38. There was no recurrence after postoperative radiotherapy. Plasmacytoma should be considered in the differential diagnosis of a solitary dural mass, particularly in a patient with multiple myeloma.

Hypotension and Transient Renal Impairment Induced by Lumbar Puncture

Raised intracranial pressure (ICP) may induce hypertension through sympathetic mechanisms. Case report. A 55-year-old man was admitted with a symptomatic intracerebral mass and new refractory arterial hypertension. Several antihypertensive medications were necessary to control his blood pressure. A lumbar puncture was performed for diagnostic purposes and raised opening pressure (42 cm H2O) denoted raised ICP. After cerebrospinal fluid extraction, the closing pressure dropped to normal level. Shortly after the lumbar puncture, a sudden and pronounced drop in blood pressure was noted. Over the next day, the patient's serum creatinine rose from 0.9 to 1.9 mg/dL. Blood pressure normalized after discontinuation of all antihypertensive drugs and administration of intravenous fluids. Renal function also completely recovered within 2 days. The patient remained spontaneously normotensive thereafter. Sudden hypotension may occur after lumbar puncture in patients with raised ICP receiving treatment for arterial hypertension.