Intracranial Space-occupying Lesions Research Articles

The Functional Outcome of Spontaneous Hypertensive Supratentorial Intracerebral Haemorrhage after Surgery

This study was to determine the different parameters that affect the outcome and the functional recovery after surgical evacuation of spontaneous hypertensive supratentorial intracerebral haemorrhage. This cross-sectional analytic study was conducted in the Department of Neuro- surgery, Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh during a period of 4 years from January 2016 to December 2019 and total 96 patients were included in this study. Patients with post-traumatic hematomas, intracranial space-occupying lesions with bleeds, haemorrhagic transformation of an ischemic stroke, vascular malformations, aneurysms, and infratentorial haemorrhages were excluded from the study. Decompressive craniotomy and evacuation of clot was performed in most of the cases. The outcome of the patients was categorized according to the Glasgow Outcome Scale. Outcome was classified as “favourable” if the Glasgow Outcome Scale (GOS) score was 5 or 4, and classified as “unfavorable” if GOS score was 3 or less. The mean age of the patients was 57.99±12.74 years with male and female ratio was 1.66. The mean blood volume was 28±19.99 cc and all patients were hypertensive. There was significant difference (p <0.001) in outcome in relation of age and volume of blood. Age > 70 years, GCS < 8 on admission, clot volume above 40 cc, and intraventricular extension remain the most consistent predictors of mortality and poor outcome following surgical evacuation of spontaneous supratentorial intracerebral hematoma. The present study could only assess mortality and the functional outcome. Since a proportion of survivors had an unfavorable outcome, quality of life measures is important and need to be addressed in future studies.

Combining Serum Cystatin C and Urinary N-Acetyl-Beta-D-Glucosaminidase Improves the Precision for Acute Kidney Injury Diagnosis after Resection of Intracranial Space-Occupying Lesions

Background: Postoperative acute kidney injury (AKI) is frequent and associated with adverse outcomes. Unfortunately, the early diagnosis of AKI remains a challenge. Combining functional and tubular damage biomarkers may provide better precision for AKI detection. However, the diagnostic accuracy of this combination for AKI after neurosurgery is unclear. Serum cystatin C (sCysC) and urinary albumin/creatinine ratio (uACR) are considered functional biomarkers, while urinary N-acetyl-β-D-glucosaminidase (uNAG) represents tubular damage. We aimed to assess the performances of these clinical available biomarkers and their combinations for AKI prediction after resection of intracranial space-occupying lesions. Methods: A prospective study was conducted, enrolling adults undergoing resection of intracranial space-occupying lesions and admitted to the neurosurgical intensive care unit. The discriminative abilities of postoperative sCysC, uNAG, uACR, and their combinations in predicting AKI were compared using the area under the receiver operating characteristic curve (AUC-ROC), continuous net reclassification index (cNRI), and incremental discrimination improvement (IDI). Results: Of 605 enrolled patients, AKI occurred in 67 patients. The cutoff values of sCysC, uNAG, and uACR to predict postoperative AKI were 0.72 mg/L, 19.98 U/g creatinine, and 44.21 mg/g creatinine, respectively. For predicting AKI, the composite of sCysC and uNAG (AUC-ROC = 0.785) outperformed either individual biomarkers or the other two panels (uNAG plus uACR or sCysC plus uACR). Adding this panel to the predictive model improved the AUC-ROC to 0.808. Moreover, this combination significantly improved risk reclassification over the clinical model alone, with cNRI (0.633) and IDI (0.076). Superior performance of this panel was further confirmed with bootstrap internal validation. Conclusions: Combination of functional and tubular damage biomarkers improves the predictive accuracy for AKI after resection of intracranial space-occupying lesions.

Diagnostic Value of Diffusion-weighted Magnetic Resonance (MR) Imaging, MR Perfusion, and MR Spectroscopy in Addition to Conventional MR Imaging in Intracranial Space-occupying Lesions.

Purpose: Our aim was to determine the diagnostic performance of the combined usage of diffusion-weighted imaging (DWI), magnetic resonance spectroscopy (MRS) and perfusion MR (MRP) imaging for the differential diagnosis of benign and malignant intracranial lesions.Materials and methods: A total of 30 patients with intracranial lesions who were prospectively evaluated with contrast-enhanced magnetic resonance imaging (MRI), DWI, MRS, and MRP were included in this study. The lesions were classified as benign and malignant according to the radiologic findings. All imaging data were compared with the histopathologic results and follow-up of the patients. We used the Pearson chi-square test and Fischer’s exact t-test for statistical analysis.Results: For the differentiation of benign and malignant brain lesions, CBV and choline/creatine (Cho/Cr) ratio at short echo time (TE) had the highest sensitivity (87%-88%), Cho/N‐acetyl aspartate (NAA) at short TE had the highest specificity (86%). DWI predicted 77% sensitivity, 75% specificity; MRP presented 91% sensitivity, 88% specificity; MRS yielded 77% sensitivity, 63% specificity. The combination of either DWI and MRS, MRP and MRS or DWI+MRS+MRP revealed 100% sensitivity, 100% specificity.Conclusion: For the differentiation of benign and malignant brain lesions, the combination of DWI, MRS, and MRP predicted 100% sensitivity. Invasive procedures like transcranial biopsy were not required via the usage of these advanced MRI techniques.

Case Report: A Case of Acquired Symptomatic Arachnoid Cyst in an Elderly Patient

Arachnoid cysts comprise approximately 1% of all intracranial space-occupying lesions and etiologies of its formation are believed to be both congenital and acquired. However, very few cases of symptomatic acquired arachnoid cyst have been reported so far in the elderly. Here we report a case of acquired symptomatic arachnoid cyst in an elderly patient. We present here a case of 75 years-old male presenting with seizure-like episode. He was diagnosed bilateral subdural hygroma and left-sided arachnoid cyst by CT. However, he was performed CT 12 years ago, which showed no arachnoid cyst then. We performed microsurgical cyst excision and fenestration to the subarachnoid space. Postoperatively his condition has been excellent so far, with no cyst recurrence.

Neuroimaging characteristics and long-term prognosis of myxoma-related intracranial diseases.

Myxoma-related intracranial diseases were rarely documented in history. The main purpose of our study is to provide a more comprehensive and detailed understanding of the pathogenesis, imaging features, surgical procedures and pathology of such patients through long-term follow-up. From March 2012 to July 2018, baseline information that included neuroimaging and neuropathology data from 12 cardiac myxoma patients with neurological symptoms were retrospectively analysed, and the treatment options were discussed. Nine patients underwent long-term postoperative follow-up. Twelve cardiac myxoma patients with neurological symptoms were identified, and among them, 10 patients were postoperative patients who had undergone excision of cardiac myxoma, 5 patients had received craniotomy, and the others had received conservative treatment. Positive neuroimaging findings were found in all patients, including cerebral infarction (12/12, 100%), multiple intracranial aneurysms (8/12, 67%), and extravascular metastasis (6/12, 50%). After a long-term average follow-up of 27 months, an increased number of metastatic lesions or an enlargement of the intracranial aneurysms was found in 4 patients. Neuroimaging findings of myxoma-related intracranial lesions were diversed and usually presented as multiple cerebral infarction, aneurysm formation, focal intracranial haemorrhage and space-occupying lesions. Progress is over a long period of time after primary tumour resection. It is necessary for patients to be regularly examined within 2 years after cardiac myxoma resection using MRI+CTA/MRA/DSA in order to be ruled out. Stable and effective chemotherapy drugs are urgently needed.

Primary Cerebral Plasmacytoma: A Rare Case Report with Review of Literature

AbstractSolitary craniocerebral plasmacytoma is the least common form of extramedullary solitary plasmacytoma (SP). Cerebral SP is very rare. The world literature counts only seven intracranial cases. The authors report a case of cerebral tumor of SP in a 52-year-old female who presented to a hospital with headache and difficulty in walking for 6 months. Contrast-enhanced computed tomography (CECT) brain showed left occipital intracranial space occupying lesions (ICSOL) of size 26 mm × 14 mm adjacent to superior sagittal sinus with disproportionate perilesional edema and midline shift toward the right. She underwent gross total tumor excision with left fronto-temporo-parietal decompressive craniectomy. Microscopic sections showed highly cellular tumor infiltrating white matter and gray matter. Histopathology revealed plasmacytoma. These plasma cells were seen infiltrating the adjoining brain parenchyma. Immunohistochemistry study showed the following pattern of antigens: most of the cells were negative to CD138 antibody, and majority of cells were positive (++ to +++) to CD56 antibody, more groups of cells were positive to lambda antibody than KAPPA. Bone marrow biopsy showed only 1% polyclonal plasma cells. Whole body bone scan showed no evidence of any osteoblastic skeletal metastasis. The patient recovered well, and cranioplasty was done after 6 weeks. Conclusion Cerebral SP is rarely found in clinical practice and if diagnosed properly can save patients life. This case report would definitely address many unexplored facts about cerebral SP and set milestone in the field of clinical research.

Spectrum of radiological presentations among the patients of intracranial metastasis

Background: Brain metastasis has been the most common primary intracranial space occupying lesion (ICSOL) in adult patients.The main systemic malignancies presenting with high tendency to invade brain parenchyma are –lung, breast, melanoma, renal and colon cancers etc.
 Aims and Objectives:
 
 To study the various radiological presentations in cases of intracranial metatstasis. 
 To assess the radiological presentations to differentiate metastasis from other differential diagnosis.
 
 Materials and Methods: The present cross sectional study was carried out amongst 32 patients who had been visited tertiary care hospital in Kolkata with radiological features and histopathology suggestive of metastatic lesion.
 Results: The mean age of the subjects was 46.56 years and the maximum number of cases presented in 5th and 6th decades of life. CT Scan showed 75% patient had metastatic lesion appearing hyperdense on plain study and 25% had lesion hypodense on plain CT Scan. On T1 weighted images- In 75% of patient the metastatic lesions were hypointense to brain parenchyma and in 12.5% they were isointense and 12.5% they were hyperintense.T2 weighted images- In 62.5% of patient the metastatic lesions were hyperintense to brain parenchyma and in 25% patients they were isointense and in 12.5% they were hypointense. Contrast Images – 37.5% of patients had homogenous enhancement and 50% had heterogeneous enhancement and 12.5% had ring shaped enhancement. In Biopsy about 75% the metastatic lesion turned out to be metastatic carcinoma.
 Conclusion: A thorough and systematic approach to radiological investigation is crucial for proper identification of intracranial metastatic lesions.

Venture in 101 Cranial Punctures: A Comparative Study between Frame-based versus Frameless Biopsy of 101 Intracranial Space Occupying Lesion.

Background:Presumptive diagnosis based solely on the clinical picture and imaging is not sufficient to provide appropriate treatment with certainty and hence histopathological confirmation of intracranial space occupying lesion (ICSOL) is essential. Needle biopsy via stereotactic frame-based or frameless neuronavigation technique is efficient procedure. The objective of this study is to compare their accuracy and efficacy and safety.Methods:This is a retrospective comparative study conducted among 101 biopsies of ICSOL. Patients data were retrieved from medical record. Data were analyzed in SPSS ver. 20. P value of <0.05 was considered significant.Results:Out of 101 patients, Frame-based stereotactic biopsy was done among 55 patients (54.4%) while 46 patients (45.6%) underwent frameless stealth neuronavigation guided biopsy. Male to female ration was 2.1:1. Age ranged from 5 to 82 years. 54.5% (55 patients) have deeper location of tumor while 45.5% (46 patients) have lobar location of tumor. Frontal (16.8%) and Thalamic (13.8%) were the common site. Mean size of tumor was 3.09±0.85cms. There was statistically significant difference in operative duration among study groups. Overall Diagnostic yield was 89.1%. Glioma was the most common (50.5%) diagnosis. Glioblastoma WHO Grade IV was 37.6% followed by lymphoma (12.8%).Conclusion:Needle biopsy via stereotactic frame-based or neuronavigation frameless technique is a safe and efficient procedure having high diagnostic yield. Reasons for negative biopsy could be missed target or retrieval of gliotic tissue.

Retinal Findings in Young Children With Increased Intracranial Pressure From Nontraumatic Causes.

Increased intracranial pressure (ICP) has been suggested in legal settings as an alternative cause of retinal hemorrhages (RHs) in young children who may have sustained abusive head trauma. We assessed the prevalence and characteristics of RHs in children with increased ICP. We conducted a prospective, multicenter study of children <4 years old with newly diagnosed increased ICP as determined by using direct measurement and/or clinical criteria. Infants who were premature, neonates, and suspected survivors of abusive head trauma were excluded on the basis of nonocular findings. Fundus examinations were performed; extent, number, and type of RH in each of 4 distinct retinal zones were recorded. Fifty-six children (27 boys) were studied (mean age 15.4 months; range 1-43 months). All of the children had elevated ICP that required intervention. One child had papilledema. No child (0%; 95% confidence interval: 0%-6.4%) or eye (0%; 95% confidence interval: 0%-3.3%) was found to have an RH. Causes of increased ICP included hydrocephalus, intraventricular hemorrhage, congenital malformations, malfunctioning shunts, and the presence of intracranial space-occupying lesions. Although acute increased ICP can present in children with a pattern of peripapillary superficial RHs in the presence of papilledema, our study supports the conclusion that RHs rarely occur in the absence of optic disc swelling and do not present beyond the peripapillary area in the entities we have studied.

Diagnosis and treatment of chronic myeloid leukemia with the initial symptoms of intracranial space-occupying lesion

Objective To investigate the clinical characteristics and prognosis of chronic myeloid leukemia(CML) with the initial symptoms of intracranial space-occupying lesion. Methods The clinical features of a 49 years old CML female patient with the initial symptoms of intracranial occupying lesions in the Affiliated Hospital of Southwest Medical University were analyzed.And the literatures were reviewed and summarized. Results The main clinical manifestations of the patient were headache and blurred vision.Cranial CT showed space occupying lesions in the left frontal lobe.The white blood cell counts(WBC) was 360.09×109/L.Bone marrow smear showed 87.0% of granulocyte and 13.5% of primitive granulocytes, and the patient was diagnosed as CML(accelerated phase). The patient was treated with imatinib 600mg qd, and the disease was controlled.Her intracranial mass was disappeared, and achieved long-term disease-free survival.Imatinib on CML intracranial lesions also had certain curative effect. Conclusion Tyrosine kinase inhibitors(TKIs) should also be individualized for different patients.Dasatinib is the first choice for CML with intracranial occupying lesions.However, this case suggests that imatinib also has clinical efficacy.It may be related to the release of intracranial tumor cells into the peripheral blood or imatinib, and also a small amount of penetration through the blood-brain barrier.In the treatment of CML, appropriate TKIs should be chosen according to the patients' condition. Key words: Leukemia, myeloid, accelerated phase; Brain diseases; Case reports

Intracranial Space-occupying Lesion Inducing Intracranial Hypertension Increases the Encephalographic Effects of Isoflurane in a Swine Model.

Patients with a brain tumor are susceptible to the hypnotic effect of anesthetics depending on the tumor's size. We investigated whether intracranial space-occupying lesions (ICSOLs) inducing intracranial hypertension increase isoflurane's effect on electroencephalographic (EEG) results. After anesthetic induction with isoflurane, 11 swine were studied with regard to isoflurane's effect on EEGs at 0.5% to 2.0% inhalational concentration at sequential stages: baseline 1, ICSOL 1, baseline 2, ICSOL 2, baseline 3. At each ICSOL stage, an intracranial epidural balloon catheter was inflated and the intracranial pressure maintained at twice the baseline pressure. The balloon was deflated after each ICSOL stage (baselines 2 and 3). A 95% spectral edge frequency (SEF), which correlates with anesthetic hypnosis, was used to measure isoflurane's effect. Pharmacodynamics was characterized using a sigmoidal inhibitory maximum effect model for the SEF versus end-tidal concentration. ICSOL shifted the relations between SEF and the effect-site concentration (Ce) downward. Baseline and 50% of the maximum spectral edge effect levels significantly decreased during balloon inflation. The Ce that produced SEF=15 was 1.12 (1.04-1.20) (mean [95% confidence interval])% for baseline 1; 0.92 (0.81-1.03) for ICSOL 1; 1.02 (0.94-1.11) for baseline 2; 0.88 (0.82-0.94) for ICSOL 2; 1.05 (0.93-1.17) for baseline 3. Isoflurane's effect on EEGs increased during balloon inflation, with the alteration tending to recover after balloon deflation. ICSOLs inducing intracranial hypertension increase the EEG effect of isoflurane, and external compression from the brain surface enhances the anesthetic hypnosis despite minimum brain injury.

Ocular manifestations in patients with intracranial space-occupying lesions

Aim: This study aims to study the ocular manifestations in patients with intracranial space-occupying lesions (ICSOLs). Materials and Methods: Cross-sectional hospital-based study. Minimum of 70 patients diagnosed and undiagnosed with ICSOL coming to ophthalmology OPD, neurosurgery OPD, and admitted patients to any ward of Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha, Maharashtra, were selected. Selected patients underwent detailed clinical history, neurological and ocular examination depending on presenting ocular complaints. Results: The study included 36 males and 34 females. 68.57% of ICSOLs were found in the supratentorial compartment of the brain. The most common ocular symptom was diminution of vision followed by doubling of vision, loss of vision, drooping of eyelids, and protrusion of the eyeball. Commonly seen ocular sign was papilledema followed by visual field defect. Glioma (18.57%) and meningioma (18.57%) were encountered to be the most common ICSOLs followed by vestibular schwannoma (17.14%). Other ICSOLs were pituitary adenoma (11.43%), chronic subdural hemorrhage (8.57%), craniopharyngioma, epidermoid cyst, etc. It was observed that symptoms and signs correlated with the location of ICSOL. Conclusion: Ophthalmologists play important role in intracranial localization of ICSOLs depending on ocular symptoms and signs; thus, early diagnosis and referral to neurosurgeon promote early treatment.

Ophthalmic manifestations of tuberous sclerosis: A diagnostic clue

A 22-year-old female with severe headache was referred to eye outpatient department for fundus examination with a possibility of intracranial space-occupying lesion. On fundus examination, we found bilateral disc edema with creamy white elevated lesion in the left eye suggestive of retinal astrocytoma which was confirmed by spectral-domain optical coherence tomography. Hence, the patient underwent magnetic resonance imaging brain, ultrasonography abdomen, and dermatological workup which confirmed it to be the case of tuberous sclerosis. This case report exemplifies the systemic manifestations of tuberous sclerosis complex and its specific expression in the eye. Hence, in turn, to establish an appropriate diagnosis, retinal manifestations of the disorder must not be overlooked.

Characterization of In-Vivo Proton Magnetic Resonance Spectroscopic Patterns of Intracranial Space-Occupying Lesions: A 1-Year Observational Study

Characterization of In-Vivo Proton Magnetic Resonance Spectroscopic Patterns of Intracranial Space-Occupying Lesions: A 1-Year Observational Study

Radiation therapy for intracranial tumours in cats with neurological signs.

The aim of this study was to evaluate the outcome of cats with intracranial tumours presenting with neurological signs treated with radiation therapy. This study comprised a retrospective multicentre case series. Medical records of a total of 22 cats with intracranial space-occupying lesions, presenting with neurological signs and/or epileptic seizures and treated with external beam radiation therapy, were reviewed. In the treated cats, patient-, tumour- and treatment-related variables were investigated, including age, sex, tumour location, tumour volume, total radiation dose, equivalent dose in 2 Gy fractions (EQD2), corticosteroid dose, overall treatment time and institution for influence on local tumour control and survival. Based on advanced imaging characteristics, the 22 treated cats presented with meningioma (n = 11), pituitary tumour (n = 8), choroid plexus tumour (n = 2) or glioma (n = 1). Allocated to the neuraxis, 11 lesions were extra-axial, three were intra-axial and eight were located in the pituitary region. At diagnosis, 21 cats exhibited altered neurological status. One cat presented with epileptic seizures and another cat had both seizures and altered neurological status. The mean total physical dose of radiation was 41.63 Gy (± 4.33), range 24-45 Gy. In all but one cat (95.5%), neurological signs improved after radiation therapy. The median progression-free survival was 510 days (95% confidence interval [CI]: 51-969). The proportion free of progression at 1 year was 55.7% (95% CI: 33-78). Fourteen cats died (only in five cases was death related to the intracranial tumour) and eight cats were still alive or lost to follow-up. The median overall survival time was 515 days (95% CI: 66-964). None of the tested variables influenced outcome. Radiation therapy seems to represent a viable treatment option in cats with intracranial tumours, relieving neurological signs and improving local tumour control. Radiation therapy may be considered for cats with tumours in complicated/inoperable localisations or for cases with a high peri- and postoperative risk.

Clinical characteristics and anesthesia management of intracranial space-occupying lesions during pregnancy: a retrospective analysis

Objective To analyze and summarize the clinical features and anesthesia management of patients with intracranial mass lesion during pregnancy. Methods We retrospectively collected 34 cases of intracranial mass lesions during pregnancy in our hospital from 2010 to 2017, and analyzed the characteristics, treatment, choice of anesthesia, and outcomes of the patients. Results A total of 34 cases of pregnant women suffered from intracranial mass lesions were enrolled in this study, and include 3 cases of pituitary adenoma, 2 cases of schwannoma, 5 cases of hemangioblastoma, 5 cases of hemangioma, 1 case of aneurysm, 1 case of dermoid cyst, 2 cases of meningioma, 1 case of neuroglial and neuronal mixed tumor, 12 cases of glioma, 1 case of medulloblastoma, and 1 case of choriocarcinoma. Regarding pregnant stages, 7 cases were in the early trimester, 13 cases in middle trimester, and 14 cases in late trimester of pregnancy. Twenty eight out of 34 cases were admitted into the hospital as emergency. As for the treatment, 9 cases received emergency neurosurgery, 3 cases received caesarean section and neurosurgery, 12 cases received emergency neurosurgery after caesarean section, 7 cases received conservative treatment, and 3 cases withdrew treatment after caesarean section. In neurosurgery treatment, 19 cases received brain mass lesion resection, 3 cases received hematoma clearance or decompression, 2 cases respectively received ventricular-peritoneal shunt and endovascular treatment. For obstetric management, 27 cases terminated pregnancy and 7 cases were expected to delivery. Twenty six out of 27 cases in the middle and late trimester of pregancy underwent caesarean section, and among them, 16 and 10 cases respectively received epidural and general anesthesia. The Observer′s Assessment of Alertness/Sedation(OAA/S) in patients received general anesthesia was lower than those received epidural anesthesia (P<0.05). MAP decreased more rapidly after delivery in patients under epidural anesthesia during surgery. There were 4 cases of maternal death and 2 cases of fetal death. Conclusions Intracranial mass lesion during pregnancy increased the risk of maternal and fetal death. The appropriate treatment requires comprehensive diagnosis involving obstetrician, anesthesiologists and neurosurgeons to fully evaluate patient′s intracranial tumor, gestational age and fetal maturity to timely terminate pregnancy and carry out appropriate neurosurgical treatment to ensure the safety of mother and fetus. Key words: Pregnancy; Intracranial mass lesion; Anesthesia; Neurosurgery

Examining the relationship between sepsis and oropharyngeal dysphagia in hospitalised elderly patients: a retrospective cohort study

IntroductionElderly people are recognised to be at increased risk of oropharyngeal dysphagia (OPD), the causes of which are multifactorial. Our aim was to identify if sepsis is associated with OPD...

Different Strokes for Different Folks - Football

HISTORY: 22-year-old D1 University Football Long Snapper presents to the training room for migraines. He’s had migraines for 6-7 years and 4 concussions since HS. The night prior he had a migraine in the temporal region associated with transient left-sided vision loss & left arm numbness for 30-40 minutes. A diffuse headache lasting for 4-5 hours followed. Sumatriptan relieved the pain. He’s had increased migraine frequency for the past 6 months. Episodes were described to his neurologist. MRI of the Brain & Cervical Spine were ordered. PHYSICAL EXAMINATION: AF VSS. NAD, well appearing. PERRLA, EOMI, NCAT Cranial nerves intact, no nystagmus, normal face symmetry, tongue & palate midline Sensation intact Strength/tone normal bilaterally Reflexes 2+ Coordination and gait intact DIFFERENTIAL DIAGNOSIS: Migraine (hemiplegic/retinal) with brainstem aura Transient Ischemic Attack or Cerebrovascular Accident Cerebral Aneurysm Intracranial space-occupying lesion Dissection Syndrome TESTS & RESULTS: MRI Brain w/o contrast: small subacute infarct in the right cerebellum. No mass effect or ICH. MRI C-Spine: mild degenerative changes. No canal stenosis Admitted to the hospital further work up. Labwork negative. US LE w/ doppler - No DVT CTA head/neck: Normal vessels. No dissection MRA Neck: Common and internal carotid arteries w/ normal caliber and contour. Normal vertebral arteries. Left vertebral a. is dominant. No flow-limiting stenosis. TTE: Small right to left shunt on agitated saline contrast study suggestive of a patent foramen ovale. Transcranial Doppler US Bubble Study: Right to left shunting, showering bubbles FINAL / WORKING DIAGNOSIS: Cryptogenic subacute right cerebellar infarct secondary to a PFO TREATMENT AND OUTCOMES: Aspirin & Clopidogrel started inpatient. Discharged after workup. PFO closure and transseptal left heart catheterization completed with Cardiovascular Surgery. Continue ASA and Clopidogrel for 6 months post-op; ASA lifelong. Retired from the football team. Repeat TTE: well seated closure device. Cardiac rehabilitation for first 2 months post-op. 4 months post-op: running about 1 mile daily, 6 days/week. Endurance and circuit training with low weights. He’s been migraine free since 2 months post-op. He takes Indomethacin as needed. Follow up scheduled for 6 months post-operation.

Clinical features and prognosis of 18 cases of primary lymphocytic hypophysitis

Objective: To analyze clinical features, prognosis and treatment of lymphocytic hypophysitis (LYH). Methods: The clinical data, treatments and outcomes of 18 cases diagnosed as LYH at Chinese PLA General Hospital between January 2001 and July 2017 was respectively reviewed. Results: Eighteen patients with histology-proven LYH (13 females and 5 males ) were identified. All lymphocytic adenohypophysitis (LAH) were females(n=6), two of whom were associated with pregnancy. Eleven patients (6 females and 5 males) had lymphocytic panhypophysitis (LPH) and one(female) had hypothalamitis. Pre-treatment evaluation revealed that 11 patients presented with symptoms of intracranial space-occupying lesions, 12 patients had symptoms of anterior pituitary hormone deficiencies, and 12 patients had central diabetes insipidus (CDI). All patients had space-occupying lesions on magnetic resonance imaging (MRI), which were symmetrically enlarged and homogenously enhanced with or without pituitary stalk thickening. Before or after surgery, 11 patients received immunosuppressant therapy or radiotherapy to alleviate space-occupying effect. After 4-204 months follow-up, 5 patients had a relapse and received immunosuppressants, radiotherapy or surgery to achieve remission. Full recovery (both symptomatic and radiographic) was seen in 6 patients, and 11 patients maintained stable replacement therapy. Conclusions: LYH presents with acute space-occupying effects such as headache, visual disturbances, hypopituitarism, CDI and mild hyperprolactinemia, especially with characteristic radiographic manifestations. Usually, surgery reliably establishes diagnosis, and immunosuppressant therapy is a necessity. On the whole, LYH has a good prognosis.

Retrospective analysis of intracranial and intraspinal space-occupying lesions at a tertiary care center: A 5-Year study

Background: Incidence of central nervous system (CNS) tumors is 2% of all malignancies. Low-grade tumors progress to high-grade tumors. CNS is a common site for metastasis from other organs. Aims: The aim is to study the incidence of various lesions in light of the World Health Organization (WHO) classification of tumors of the CNS, 2016, and to study relevant statistics. Objectives: The objective of this study is to provide an overview of intracranial and intraspinal space-occupying lesions at a single tertiary care referral center. Materials and Methods: A total of 124 cases were studied. Intraoperative diagnosis was desired in 70 cases. The final diagnoses in all the cases were made by routine histopathology. Results: Neoplastic lesions comprised 83.88%, including metastatic tumors, while 16.12% were nonneoplastic. Classification and grading of CNS tumors was done according to the WHO, 2016. Astrocytic tumors constituted the largest category. Incidence was more in females than males and in the fifth and sixth decades of life. Conclusion: This study highlights histological diversity of CNS tumors in adults and children. The most common destructive but nonneoplastic lesions such as infections/abscesses, infarcts, and cysts can be diagnosed, by crush cytology and frozen section for the definitive management.