Intraparenchymal Cysts Research Articles

Cyst Formation following DBS Electrode Placement: A Rare Complication (P5-11.011)

<h3>Objective:</h3> To present two cases of intraparenchymal cysts, a rare complication of deep brain stimulation (DBS) in patients with movement disorders. <h3>Background:</h3> Formation of an intraparenchymal cyst following DBS electrode placement is a very rare complication. Only a few case reports exist and as a result, there is paucity of knowledge on its etiology, pathogenesis, prevention and treatment. <h3>Design/Methods:</h3> A chart review was done on two cases that had intraparenchymal cyst formation following DBS electrode placement at our medical center. In addition, we reviewed the literature to compare with our cases. <h3>Results:</h3> Patient A is a 79 y.o. male who underwent a left VIM thalamic lead placement and Patient B is a 64 y.o. underwent bilateral VIM lead placement for essential tremor. Both patients had a period of improvement in tremor before starting to experience new neurological deficits about 10 months and 2 months after lead placement, respectively. Patient A experienced right foot weakness, right arm weakness, and subjective decline in cognition while Patient B experienced an acute episode of altered mental status in the emergency department while under cardiac monitoring. Upon imaging, a cyst was found at the tip of the DBS lead in Patient A’s left thalamus and Patient B’s right thalamus. Infectious workup was negative indicating the cysts to be non-infectious. The brain electrodes were removed in both patients with resolution of neurological deficits and cyst regression on repeat imaging. Patient A continued to have tremor suppression for a year despite electrode removal while Patient B had an immediate tremor return to the pre-DBS baseline. <h3>Conclusions:</h3> Electrode explanation resulted in cyst regression with resolution of right hemi-body weakness in Patient A and altered mental status in Patient B. There is a need for reporting this very rare complication of DBS surgery to better understand its etiology, pathogenesis, treatment and prognosis. <b>Disclosure:</b> Ms. Naing has nothing to disclose. Dr. Venkataraman has nothing to disclose. The institution of Dr. Tatter has received research support from Monteris Medical, Inc. The institution of Dr. Tatter has received research support from Arbor Pharmaceuticals. Dr. Tatter has received intellectual property interests from a discovery or technology relating to health care. Adrian Laxton has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Monteris. Adrian Laxton has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Monteris . Dr. Siddiqui has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Boston Scientific Neuromodulation. Dr. Siddiqui has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Abbvie. The institution of Dr. Siddiqui has received research support from Boston Scientific Neuromodulation. The institution of Dr. Siddiqui has received research support from Abbvie. The institution of Dr. Siddiqui has received research support from Biogen. The institution of Dr. Siddiqui has received research support from Neuraly. The institution of Dr. Siddiqui has received research support from Abbvie.

Tumefactive Perivascular Spaces Causing Obstructive Hydrocephalus.

HomeRadiologyVol. 307, No. 1 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyTumefactive Perivascular Spaces Causing Obstructive HydrocephalusDaniel D. L. Loh, Saravana Kumar Swaminathan Daniel D. L. Loh, Saravana Kumar Swaminathan Author AffiliationsFrom the Departments of Neurosurgery (D.D.L.L.) and Neuroradiology (S.K.S.), National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433.Address correspondence to S.K.S. (email: [email protected]).Daniel D. L. LohSaravana Kumar Swaminathan Published Online:Dec 6 2022https://doi.org/10.1148/radiol.221724MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In A 71-year-old woman presented with a 3-week history of intermittent dizziness. Clinical examination was unremarkable. Presentation MRI (Figure) demonstrated a cluster of closely spaced, well-demarcated, variably sized intraparenchymal cysts centered in the midbrain and thalami. No associated solid component, enhancement, or perilesional edema was detected. The cyst contents were isointense to cerebrospinal fluid on all sequences. Associated mass effect resulted in obstructive hydrocephalus from compression of the cerebral aqueduct with lateral and third ventricular dilatation. A diagnosis of tumefactive perivascular spaces was made based on these imaging appearances. The hydrocephalus and dizziness resolved after ventriculoperitoneal shunting.Images in a 71-year-old woman who presented with a 3-week history of intermittent dizziness. (A) Axial MRI T2-weighted and (B) postcontrast T1-weighted scans demonstrate a cluster of well-demarcated, variably sized cysts (short arrows) within the midbrain and thalami that were isointense to cerebrospinal fluids, causing obstructive hydrocephalus (long arrows demonstrate compressed cerebral aqueduct). There was no associated enhancement, restricted diffusion, or calcification. The findings were diagnostic for tumefactive perivascular spaces, causing obstructive hydrocephalus.Download as PowerPointOpen in Image Viewer Perivascular spaces are intraparenchymal, pial-lined, interstitial fluid-filled structures that follow the penetrating arteries but do not directly communicate with the subarachnoid space. When large (>1.5 cm), they exert significant mass effect and are called tumefactive perivascular spaces (1). The mesencephalothalamic region is one of the most common locations of giant (or tumefactive) perivascular spaces (1). While the differential diagnosis includes cystic neoplasms, infarcts, and infections, these other pathologic conditions are all distinct from this entity with MRI (1–3).Disclosures of conflicts of interest: D.D.L.L. No relevant relationships. S.K.S. Patents planned, issued, or pending with National Neuroscience Institute.

Anthelmintics for people with neurocysticercosis.

BackgroundNeurocysticercosis is a parasitic infection of the central nervous system by the larval stage of the pork tapeworm and is a common cause of seizures and epilepsy in endemic areas. Anthelmintics (albendazole or praziquantel) may be given alongside supportive treatment (antiepileptics/analgesia) with the aim of killing these larvae (cysticerci), with or without corticosteroid treatment. However, there are potential adverse effects of these drugs, and the cysticerci may eventually die without directed anthelminthic treatment.ObjectivesTo assess the effects of anthelmintics on people with neurocysticercosis.Search methodsWe searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, the WHO ICTRP, and ClinicalTrials.gov, up to 21 October 2020.Selection criteriaRandomized controlled trials comparing anthelmintics and supportive treatment (+/‐ corticosteroids) with supportive treatment alone (+/‐ corticosteroids) for people with neurocysticercosis.Data collection and analysisTwo review authors independently screened the title and abstract of all articles identified by the search. We obtained full‐text articles to confirm the eligibility of all studies that passed screening. One review author extracted data, which a second review author checked. Two review authors assessed the risk of bias of each trial and performed GRADE assessments. In cases of disagreement at consensus discussion stage between review authors, we consulted a third review author. We calculated risk ratios (RR) for dichotomous variables, with 95% confidence intervals (CIs) for pooled data from studies with similar interventions and outcomes.Main resultsWe included 16 studies in the review. Only two studies investigated praziquantel and did not report data in a format that could contribute to meta‐analysis. Most results in this review are therefore applicable to albendazole versus placebo or no anthelmintic.The aggregate analysis across all participants with neurocysticercosis did not demonstrate a difference between groups in seizure recurrence, but heterogeneity was marked (RR 0.94, 95% CI 0.78 to 1.14; 10 trials, 1054 participants; I2 = 67%; low‐certainty evidence). When stratified by participants with a single cyst or multiple cysts, pooled analysis suggests that albendazole probably improves seizure recurrence for participants with a single cyst (RR 0.61, 95% CI 0.4 to 0.91; 5 trials, 396 participants; moderate‐certainty evidence). All studies contributing to this analysis recruited participants with non‐viable, intraparenchymal cysts only, and most participants were children. We are uncertain whether or not albendazole reduces seizure recurrence in participants with multiple cysts, as the certainty of the evidence is very low, although the direction of effect is towards albendazole causing harm (RR 2.05, 95% CI 1.28 to 3.31; 2 trials, 321 participants; very low‐certainty evidence). This analysis included a large study containing a highly heterogeneous population that received an assessment of unclear risk for multiple 'Risk of bias' domains.Regarding radiological outcomes, albendazole probably slightly improves the complete radiological clearance of lesions (RR 1.22, 95% CI 1.07 to 1.39; 13 trials, 1324 participants; moderate‐certainty evidence) and the evolution of cysts (RR 1.27, 95% CI 1.10 to 1.47; 6 trials, 434 participants; moderate‐certainty evidence).More adverse events appeared to be observed in participants treated with either albendazole or praziquantel compared to those receiving placebo or no anthelmintic. The most commonly reported side effects were headache, abdominal pain, and nausea/vomiting.Authors' conclusionsFor participants with a single cyst, there was less seizure recurrence in the albendazole group compared to the placebo/no anthelmintic group. The studies contributing to this evidence only recruited participants with a non‐viable intraparenchymal cyst. We are uncertain whether albendazole reduces seizure recurrence for participants with multiple cysts. We also found that albendazole probably increases radiological clearance and evolution of lesions. There were very few studies reporting praziquantel outcomes, and these findings apply to albendazole only.

English

The differential diagnosis of the cystic lung disease is extensive, ranging from an isolated incidental lung cyst to multiple diffuse lung cysts with other varied associated lung abnormalities. High resolution computed tomography (HRCT) thorax is the imaging modality of choice in the evaluation of these diseases, by improving the characterisation of the lung cysts (number, size, shape, distribution, wall thickness and regularity), and associated pulmonary and extrapulmonary abnormalities (like ground glass densities, nodules, interstitial fibrosis, mediastinal lymphadenopathy). After differentiating from the common cyst mimickers (cavity, centrilobular emphysema and cystic bronchiectasis), they should be grouped by location into subpleural cysts (paraseptal emphysema, bulla and honeycombing) and intraparenchymal cysts. Intraparenchymal cysts are in turn categorised into solitary / localised cysts (incidental cyst, congenital pulmonary airway malformations, intrapulmonary bronchogenic cyst and hydatid cyst) and multiple diffuse cysts. The next step will be the categorisation of these multiple diffuse cysts into those without other lung abnormalities (lymphangioleiomyomatosis and Birt-Hogg-Dube syndrome) and those with other lung abnormalities such as predominant ground glass densities (Pneumocystis jirovecii pneumonia, desquamative interstitial pneumonia, lymphoid interstitial pneumonia, subacute hypersensitivity pneumonitis and pneumatoceles) or predominant nodules (pulmonary Langerhans cell histiocytosis, amyloidosis, light chain deposition disease, follicular bronchiolitis, recurrent respiratory papillomatosis, cystic tuberculosis, cystic lung metastasis, sarcoidosis, and pulmonary mesenchymal cystic hamartomas). We conclude that this orderly radiologic approach in a given HRCT chest study of a cystic lung disease (in addition to correlation with clinical and laboratory findings), can lead us to a specific diagnosis in majority of instances, thereby optimising their treatment management, without the need of an invasive biopsy. KEY WORDS HRCT Thorax, Lung Cysts, Ground Glass Densities, Lung Nodules

Surgical treatment and outcome of sterile prostatic cysts in dogs.

ObjectiveTo describe the surgical treatment and outcome of a large cohort of dogs with sterile prostatic cysts (PCs).Study DesignRetrospective study.AnimalsForty‐four client‐owned dogs.MethodsDogs with sterile PCs with at least 6 months of follow‐up were included. Clinical variables, type of surgery, complications, recurrences, and outcomes (telephonic interviews or rechecks) were recorded.ResultsExtra‐ and intraparenchymal cysts were diagnosed in 29 and 11 dogs, respectively. Four dogs had both types. Extraparenchymal cysts were treated by partial resection and omentalization (n = 22) and complete resection (n = 7). Drainage and intracapsular omentalization were performed in all dogs with intraparenchymal cysts. The four dogs with both types of cyst were treated by omentalization. Resolution was documented in 39/44 dogs (88.6%). Intraoperative complications occurred in one dog (urethral tear). Major complications resulting in death occurred in three dogs (oliguric kidney injury, cardiac arrhythmia, and persisting urinary tract obstruction). Minor complications (n = 10) consisted of temporary urinary incontinence (n = 2), permanent urinary incontinence (n = 5), urinary retention (n = 2), and dysuria (n = 1). Recurrence occurred in two dogs with extraparenchymal cysts. Median long‐term follow‐up was 528 days (range, 250–730 days). Thirty‐nine dogs had no signs associated with prostatic disease at long‐term follow‐up.ConclusionPartial or complete resection and/or omentalization of sterile PCs led to resolution of clinical signs in most dogs, although postoperative urinary incontinence was frequent.ImpactThis study is the largest case series relative to canine sterile PCs treated surgically and provides evidence on the prognosis and rate of complications.

Micro-computed tomography utility for estimation of intraparenchymal spinal cord cystic lesions in small animals.

Precise assessment of spinal cord cystic lesions is crucial to formulate effective therapeutic strategies, yet histological assessment of the lesion remains the primary method despite numerous studies showing inconsistent results regarding estimation of lesion size via histology. On the other hand, despite numerous advances in micro-computed tomography (micro-CT) imaging and analysis that have allowed precise measurements of lesion size, there is not enough published data on its application to estimate intraspinal lesion size in laboratory animal models. This work attempts to show that micro-CT can be valuable for spinal cord injury research by demonstrating accurate estimation of syrinx size and compares between micro-CT and traditional histological analysis. We used a post-traumatic syringomyelia rat model to compare micro-CT analysis to conventional histological analysis. The study showed that micro-CT can detect lesions within the spinal cord very similar to histology. Importantly, micro-CT appears to provide more accurate estimates of the lesions with more measures (e.g., surface area), can detect compounds within the cord, and can be done with the tissue of interest (spinal cord) intact. In summary, the experimental work presented here provides one of the first investigations of the use of micro-CT for estimating the size of intraparenchymal cysts and detecting materials within the spinal cord. All animal procedures were approved by the University of Akron Institutional Animal Care and Use Committee (IACUC) (protocol # LRE 16-05-09 approved on May 14, 2016).

Delayed presentation of primary parenchymal arachnoid cyst in adult population: a rare location of a common cyst\u2014case report and review of the literature

BackgroundArachnoid cysts account for about 1% of all intracranial mass lesions. Intraparenchymal arachnoid cysts are an uncommon entity. Only a few reports are available in adults with the intraparenchymal arachnoid cyst.Case presentationWe present a 40-year-old lady with right-side progressive hemiparesis, and radiology revealed a cystic mass located in the left posterior frontal area. She underwent craniotomy and excision of the cyst. In the postoperative period, she recovered well. Immunohistochemistry stains confirm arachnoid cyst.ConclusionThis was a case of a pure frontal arachnoid cyst with delayed clinical presentation without any communication with sub-arachnoid space or ventricle.

New insights in radiation-induced leukoencephalopathy: a prospective cross-sectional study.

Radiation-induced leukoencephalopathy (RIL) is the most threatening delayed complication of cerebral radiotherapy (RT) and remains roughly defined by cognitive dysfunction associated with diffuse FLAIR MRI white matter hyperintensities after brain irradiation. We documented clinical, neuropsychological, and radiological aspects of RI in order to refine diagnostic criteria. Patients referred to our center for deterioration in cognitive complaint at least 6months after completing a focal or whole brain RT underwent a systematic cross-sectional assessment including clinical examination, neuropsychological tests, and a standardized MRI protocol. Patients with progressive tumor were excluded. Forty patients were prospectively enrolled. Of these, 26 had received a focal RT, median dose of 53Gy (range 50 to 60), and 14 had received a whole brain RT, median dose of 30Gy. Cognitive complaints, gait apraxia, and urinary troubles were reported in 100, 67, and 38% of cases, respectively. On neuropsychological examination, patients displayed a global and severe cognitive decline through a subcortical frontal mode. The cognitive changes observed were not hippocampic, but related to executive dysfunction. On MRI, 68% of the patients had extensive FLAIR hyperintensities with anterior predominance, 87% had brain atrophy, and 21% had intraparenchymal cysts. T2*-weighted MRI showed small asignal areas in 53% of the patients. These abnormalities are evocative of cerebral small vessel disease. Fractional anisotropy in the corpus callosum correlated with the cognitive evaluation. No differentiation in terms of cognitive and MRI features could be made between patients treated with focal brain RT (glioma) and patients treated with WBRT (for brain metastases or PCNSL). RIL can be defined by clinical symptoms (subcortical frontal decline, gait apraxia, urinary incontinence) and MRI criteria (cortico-subcortical atrophy, spread FLAIR HI, T2* asignals). This condition mimics a diffuse progressive cerebral small vessel disease triggered by RT, independent of RT protocol.

Intraparenchymal Cysts Following Deep Brain Stimulation: Variable Presentations and Clinical Courses.

The development of cysts at the electrode lead is a rare complication of deep brain stimulation (DBS), with only 3 cases reported in the literature. A better understanding of the variable clinical presentations and courses of these cysts may help increase awareness of this potentially life-threatening complication. To review the clinical presentation of patients with intraparenchymal cysts following DBS implantations. We report 3 patients who developed a cyst along the course of the DBS lead. These patients received DBS for different indications and in different brain locations. Clinical courses differed considerably with 1 asymptomatic patient followed conservatively, 1 mildly symptomatic patient who had the DBS hardware removed for insidious worsening over months, and 1 who had it emergently removed for acute development of hydrocephalus. Serial imaging revealed spontaneous reduction in cyst size over time in the asymptomatic patient, and following removal in 1 of the symptomatic patients. This report highlights the variable clinical presentation and course of patients who develop cysts along the DBS lead. It suggests that some cases can be followed clinically without removal of hardware but that ongoing vigilance is required given the potential for serious adverse events.

Neuroendoscopic Approach to Intracranial Ependymal Cysts

Intraparenchymal cysts without communication to the ventricles or the subarachnoid space are named ependymal or epithelial cysts. The estimated ratio of their incidence compared with arachnoid cysts is 1:10. Neurologic deficit can occur when the cyst exerts mass effect on its surroundings. We evaluated the success rate of endoscopic fenestration of intracranial ependymal cysts. Our prospectively maintained endoscopy database was screened for all cases of ependymal cysts. The charts were retrospectively reviewed for symptoms, surgery, postoperative course, and complications. Magnetic resonance imaging scans performed before and after surgery were analyzed. We identified 6 patients harboring an intracranial ependymal cyst. The cyst location was frontoparietal, parietal, occipital, or mesencephalic. Patients presented with several symptoms according to the location of the cyst (i.e., epilepsy, hemiparesis, diplopia, hemianopsia). All patients were treated by navigation-guided endoscopic fenestration of the cyst to the ventricular system. Two complications occurred: a cerebrospinal fluid leak, which was managed surgically by wound revision without the need for cerebrospinal fluid shunting, and a chronic subdural hematoma, which occurred 6 weeks after surgery and required burr hole evacuation. Follow-up period ranged from 6 months to 9 years. Magnetic resonance imaging revealed that all cysts decreased in size. Symptoms improved in all patients. Endoscopic fenestration of ependymal cysts to an adjacent ventricular cavity is a treatment option with excellent long-term results and minimal morbidity. It should be considered as the therapy of choice to avoid craniotomy and shunt dependence.

Persistent Brain Herniation after Decompressive Hemicraniectomy: Role of Lumbar Drainage for Cranioplasty. Case Report

Hydrocephalus and ex-vacuo ventricular dilatations which cause persistent brain herniation with impossibility to perform cranioplasty, are well known late complications after decompressive hemicraniectomy; concerning the physiopathologic mechanism leading to these complications, there are several theories. We report the particular case of a patient suffering from persistent brain herniation after decompressive hemicraniectomy, due to development of subdural hygroma, intraparenchymal multiple liquoral cysts and only mild enlargement of frontal horn of right lateral ventricle. A fifty-five years old male patient was treated with decompressive right hemicraniectomy for acute hemispheric swelling consequent to right internal carotid artery dissecation. After several months, evaluating the patient for cranioplasty, brain herniation was clinically evident and brain MRI confirmed it due to subdural hygroma, intraparenchymal multiple liquoral cysts and mild enlargement of frontal horn of right lateral ventricle. According to several reported theories, communication between right frontal horn of lateral ventricle, intraparenchymal liquoral cysts and subdural hygroma was supposed, and CSF lumbar drainage was placed. Regression of brain herniation was achieved and cranioplasty was possible; after few days lumbar drainage was removed: neither operative, nor short and long follow-up period complications were observed. Temporary CSF lumbar drainage resulted effective to obtain regression of a particular case of persistent brain herniation developed after decompressive hemicraniectomy; moreover this safe procedure, not previously described to forerun cranioplasty surgery to our knowledge, allowed performing cranioplasty in absence of complications and avoiding temporary or permanent ventricular shunts which present a major rate of risks and possible complications.

MRI findings in Fukuyama-type congenital muscular dystrophy of Chinese

Objective To investigate the MRI features of Fukuyama-type congenital muscular dystrophy(FCMD) in Chinese. Methods The MRI and clinical data of 3 patients with FCMD which had been diagnosed by gene analysis were retrospectively analyzed.Two females and one male were included in this study, and they underwent MR examination at 0.5,2.3,5.0 years old respectively. The main clinical manifestations were muscular hypotonia and severe developmental delay. Abnormalities on MR images were analyzed and recorded by two experienced radiologists. Results Unlayerdpoly microgyria involved in frontal lobes, numerous intraparenchymal cysts at the peripheral hemispheres and prolonged T1 and T2 signal in the white matter were found in all the 3 cases. Disorganized cerebellar folia, lissencephaly of cerebral cortices, flattened pons were detected in 2 cases. Cystic region of white matter incerebral cortices and enlarged fourth ventricle could be seen in one case. Conclusion There are typical MR imaging featuresof FCMD, and preliminary diagnosis can be made by the combination with clinical symptoms and biochemical analysis. Key words: Muscular dystrophies; Brain; Magnetic resonance imaging

IVth ventricular neurocysticercal cyst

An 11-year-old boy presented with acute-onset projectile vomiting, bifrontal headache, and altered sensorium. Contrast-enhanced MRI brain was suggestive of intraparenchymal and intraventricular neurocysticercosis, with an intraparenchymal ring-enhancing lesion with central scolex in the left cingulate gyrus and a large cyst enlarging the IVth ventricle, with obstructive hydrocephalus (figure).1 Intraventricular cysticerci with acute hydrocephalus are rare.1 In contrast to intraparenchymal cysts, intraventricular cysts are large and typically lack an identifiable scolex.2 Confirmation of cysticerci is based upon identification of scolex in the intraparenchymal lesion or use of high-resolution T2 MRI sequences, which are superior in identifying scolex in intraventricular cysts.3

Cysticercal encephalitis

A 10-year-old boy was brought to our emergency room with generalized tonic-clonic seizures that had started one hour before. There was a three-year history of seizures treated with phenytoin (5 mg per kg twice daily) and headache associated with fever. The patient went into cardiopulmonary arrest (RR 5 per min, HR 40 per min, SBP 50 mmHg, weak pulse, capillary refill >15 sec). On examination, he was unconscious (GCS: 3/15), with both pupils dilated and unresponsive. Cardiopulmonary resuscitation was done, but vital signs did not return; the patient was declared dead. In postmortem analysis, a coronal section of the brain showed bilateral ventricular cavities collapsed, and generalized cerebral oedema with cortical and subcortical distribution of numerous intraparenchymal cysts of various sizes, some with visible larvae (figure). Microscopically, the cysts contained the larvae preserved (figure) or in degrees of decomposition (figure). Interstitial deposits, fibrosis, gliosis, and necrosis were also found. A 10-year-old boy was brought to our emergency room with generalized tonic-clonic seizures that had started one hour before. There was a three-year history of seizures treated with phenytoin (5 mg per kg twice daily) and headache associated with fever. The patient went into cardiopulmonary arrest (RR 5 per min, HR 40 per min, SBP 50 mmHg, weak pulse, capillary refill >15 sec). On examination, he was unconscious (GCS: 3/15), with both pupils dilated and unresponsive. Cardiopulmonary resuscitation was done, but vital signs did not return; the patient was declared dead. In postmortem analysis, a coronal section of the brain showed bilateral ventricular cavities collapsed, and generalized cerebral oedema with cortical and subcortical distribution of numerous intraparenchymal cysts of various sizes, some with visible larvae (figure). Microscopically, the cysts contained the larvae preserved (figure) or in degrees of decomposition (figure). Interstitial deposits, fibrosis, gliosis, and necrosis were also found.

Delayed cerebral vasospasm and systemic inflammatory response syndrome following intraoperative rupture of cerebral hydatid cyst

Dear Editor, Treatment for symptomatic cerebral hydatid cyst is usually surgical excision. Surgery for cerebral hydatid cyst remains tricky, as inadvertent rupture may cause dissemination and occasionally allergic shock [3]. We report an unusual complication of delayed cerebral vasospasm and systemic inflammatory response syndrome (SIRS) following intraoperative rupture of hydatid cyst. A twenty-two-year old male presented with bifrontal headache for 5 years that worsened over the last 4 months, along with vomiting and left brachio-facial weakness in the last 1 month. Radiology revealed multiloculated large cystic lesion in the right temporal lobe, with the cyst walls partly enhancing (Fig. 1a–d). The lesion was approached through middle temporal gyrus, and multiple white translucent cysts were encountered, adhered to the medial temporal lobe and tentorium. Though the cysts were excised completely, there was some spillage of fluid from the inadvertent rupture (due to adhesions) of the first cyst into the cisternal spaces. Thereafter, 10 % betadine-soaked gauze was put over the operative cavity for 30 min, followed by thorough saline lavage. The cyst fluid showed scolices of echinococcus granulosus with several protoscolices and hooklets. The immediate pos operative period was uneventful. Twenty-four hours later, the patient became drowsy and developed left grade 3/5 hemiparesis with low grade fever. Blood examination showed marked leucocytosis. CT scan of the head showed diffuse brain edema with no infarcts (Fig. 1e– g). In view of new focal neurological deficit after a day, vasospasm was suspected. Cerebral digital subtraction angiography (DSA) revealed diffuse vasospasm of bilateral vertebral, basilar posterior cerebral arteries and focal vasospasm of the right posterior communicating artery. Intraarterial nimodipine was infused in bilateral vertebral and internal carotid arteries that showed radiological improvement of vasospasm (Fig. 1i–l). However, there was no clinical improvement. Diagnostic lumbar puncture and cerebrospinal fluid (CSF) examination revealed cell count of 170/dl (55 % neutrophils) and normal sugar. CSF culture was sterile. His sensorium worsened over the next 2 days, alongwithworsening of hemiparesis to left hemiplegia. High grade fever had set in and leucocytosis persisted. Blood, urine and tracheal aspirate culture did not show any growth. Steroids were administered. On the fourth post-operative day, the patient became hemodynamically unstable. Haematological workup showed pancytopenia. He expired a day later. Repeat CT head showed no new findings (Fig. 1h). Unfortunately, an autopsy was not performed. Cerebral hydatidosis is often encountered in developing countries [3]. The intraparenchymal cysts are usually unilocular cysts and tend to occur in the middle cerebral artery territory. These are non-enhancing spherical cystic lesions without perilesional edema. With progressive neurological deficits and raised intracranial pressure (ICP), surgical excision remains the treatment of choice. A high index of suspicion is necessary as intraoperative cyst rupture is not desirable. The preoperative diagnosis, however, may be missed in case of multiple loculations and wall enhancement as in the index case. Besides, despite all attempts to avoid cyst Not presented at any conference.

A Unique, Histopathologic Lesion in a Subset of Patients With Spontaneous Pneumothorax

Spontaneous pneumothorax can be idiopathic (primary), or it can occur in association with an underlying predisposing condition (secondary). Spontaneous pneumothorax may be a harbinger of an undiagnosed clinical condition, which may be associated with serious systemic abnormalities, making early recognition and diagnosis important. The pulmonary pathology of some of these disorders has not been fully elucidated. To review cases of pneumothorax in the hope of identifying pathologic features that might correlate to specific clinical syndromes. The pathology computer files at 3 hospitals were searched for all cases of spontaneous pneumothorax, primary and secondary, regardless of etiology during a 11-year period. Ninety-two cases were retrieved. Each of the cases was evaluated for reactive eosinophilic pleuritis, elastosis, pleural fibrosis, emphysema, intra-alveolar macrophages, cholesterol clefts, vasculopathy, and intraparenchymal or intrapleural cysts. Clinical information regarding asthma and smoking history, site of the pneumothorax, family history, radiographic findings, predisposing conditions, recurrence, age, and sex were extracted from the medical records. In 11 patients (12% of all the patients with spontaneous pneumothorax), a distinctive pattern of pleural fibrosis with islands of fibroblastic foci within a myxoid stroma was noted at the pleural-parenchymal interface or leading edge. These lesions correlated with a select subset of patients, consisting predominantly of young men. Our review identified a distinct pattern of pneumothorax-associated fibroblastic lesions in a subset of cases of spontaneous pneumothorax. Whether this is related to the pathogenesis of the pneumothorax remains to be elucidated.

Prenatal Neurologic Anomalies

The low prevalence of fetal CNS anomalies results in a restricted level of exposure to, and limited experience for most obstetricians involved in, prenatal ultrasound. Sonographic guidelines for screening the fetal brain in a systematic way may increase the detection rate of fetal CNS anomalies, thus promoting correct referral to tertiary care centers offering patients a multidisciplinary approach to the condition. The aim of this review is to elaborate on the prenatal sonographic diagnosis and outcome of various CNS malformations. Detailed neurosonographic investigation has become available through high-resolution vaginal ultrasound probes and the development of a variety of 3-dimensional (3D) ultrasound modalities, such as ultrasound tomographic imaging. In addition, fetal magnetic resonance imaging is particularly helpful in the detection of gyration and neurulation anomalies, and disorders of the gray and white matter. Isolated mild ventriculomegaly is a rather common finding with good overall outcome. With an increasing diameter of the atria, however, and especially with the presence of associated malformations, long-term neurodevelopmental and behavioral outcome is disturbed in about 15% or more of cases. In view of recent developments in fetal therapy for neural tube defects, there is a clear need for a high level of ultrasound screening, work-up and counseling in tertiary care centers to identify those cases that might benefit from in utero intervention. The failure of prosencephalic midline induction and development results in midline defects ranging from alobar holoprosencephaly to isolated corpus callosum defects. The detection of callosal abnormaties is enhanced by 3D ultrasound, but counseling on neurodevelopmental outcome remains challenging. The Dandy-Walker spectrum includes isolated megacisterna magna, Blake's pouch cyst, hypoplasia of the vermis and Dandy-Walker malformation. Except for complete agenesis of the vermis associated with fourth ventricle cyst formation, data on long-term outcomes for the various conditions is largely lacking. Congenital cytomegalovirus (CMV) results in the highest incidence of children born with, or developing, long-term neurologic conditions. If proof of fetal infection has been delivered, microcephaly, cortical malformations, and intraparenchymal cysts show a strong correlation with poor outcome. Fetuses with CMV-related ultrasound abnormalities might benefit from maternal transplacental treatment. The aneurysm of the vein of Galen, a vascular malformation of the brain, often results in high cardiac output failure. After neonatal arterial embolization, survival is about 50% with normal neurologic development in 36% of cases. Over 50% of intracranial tumors are teratomata, presenting as fast-growing heterogeneous solid-cystic masses with calcifications. Most intracranial hemorrhages are related to the ventricular system, and prognosis is often poor, particularly in cases involving parenchymal and subdural bleeding. Proliferation disorders of the brain are often characterized by microcephaly. Their etiology is heterogeneous and prenatal diagnosis is often made late in gestation.

Distinctive multicystic hemispheric lesions suggesting a novel variant of infantile astrocytoma

Two unrelated female infants presented at 9 days and 2 months, respectively, with apneic episodes in the former and gaze preference in the latter. MRI revealed enlargement of almost the entire right hemisphere, apparently smooth cortex, simplification of the gyral pattern, and expanded white matter with abnormal signal intensity containing multiple intraparenchymal cysts. Histologic examination of both cases revealed white matter infiltration by a hypocellular lesion composed of uniform, fibrillary astrocytes in a microcystic background. Multilocular tumor cysts were prominent, but Rosenthal fibers and eosinophilic granular bodies were absent. Very rare mitoses were seen in the absence of necrosis or vascular change. There was no convincing cortical infiltration, but the subpial zone was diffusely expanded by a band of astrocytes set in a dense fibrillar feltwork which opened out into numerous cystic spaces. No desmoplastic changes or associated atypical ganglion cells were identified. There was no evidence for a BRAFKIAA1549 fusion or BRAF mutation in one case tested. In conclusion, both lesions are not desmoplastic infantile astrocytoma/ganglioglioma, fibrillary astrocytoma, or typical for pilocytic astrocytoma. Such extreme subpial spread with cysts is most unusual and may suggest a novel variant of infantile astrocytoma.

Cystic Lesions of the Thorax

Traditional management of cystic lesions involving the mediastinum or lung parenchyma consists of surgical resection. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been reported to successfully treat bronchogenic cysts. We present 2 cases in which EBUS-TBNA was performed to aid in making the diagnosis. Endobronchial ultrasound imaging and TBNA were successful in both cases. The mediastinal cyst was therapeutically managed with complete aspiration in one case, whereas in the other an intraparenchymal cyst was found to be multiloculated and could only be partially aspirated and required surgical excision. EBUS-guided real-time aspiration of intrathoracic cysts can be both diagnostic and therapeutic in simple mediastinal bronchogenic cysts that can be fully aspirated. However, surgical resection may be required for multiloculated intraparenchymal cysts that cannot be aspirated completely. EBUS guidance helps to identify multiloculation and completeness of the aspiration.

Diagnosis of Neurocysticercosis by Detection ofTaenia soliumDNA Using a Global DNA Screening Platform

Neurocysticercosis is caused by Taenia solium infection of the brain. Diagnosis is most often made by visualization of the parasitic scolex by magnetic resonance imaging of the brain or by characteristic neuroimaging findings with serologic test results positive for T. solium. A patient who presents with a solitary brain lesion usually poses a diagnostic dilemma, because the differential diagnosis often includes neurocysticercosis and other infections or neoplasm. Although the sensitivity of serologic testing for T. solium approaches 100% in patients with multiple intraparenchymal cysts, the sensitivity of testing for patients with solitary cysts is <50%, which makes serologic testing a less useful diagnostic tool for patients with solitary central nervous system (CNS) lesions. We describe 2 patients with solitary CNS lesions who received a neurocysticercosis diagnosis after identification of T. solium DNA in brain biopsy tissue with use of a global DNA screening platform. Global screening is a promising tool for the diagnosis of CNS infection, especially when traditional diagnostic tools are insensitive.