Left Temporal Craniotomy Research Articles

Adenosine-induced cardiac standstill in intracranial aneurysm surgery: A case report

Surgical clipping of complex intracranial aneurysms can pose intraoperative challenges due to difficulty in anatomic exposure and uncontrolled intraoperative rupture, leading to significant morbidities or mortalities. This report presents a case of a 61-year-old Asian male with an unruptured saccular basilar tip aneurysm and an unruptured right middle cerebral artery aneurysm. The patient underwent a left temporal craniotomy and clipping of an unruptured basilar tip aneurysm, successfully achieved through adenosine-induced cardiac standstill. This technique reduces perfusion pressure and decreases the turgor of the aneurysm, thereby facilitating clip ligation. Our experience demonstrated that thorough, careful patient selection, optimal anesthetic management, and proper communication between neurosurgeon and anesthesiologist are important for achieving successful surgical outcomes.

Detection of Gnathostoma spinigerum larva in the brain with complete follow-up after surgical treatment of human neurognathostomiasis

Human gnathostomiasis is a food-borne zoonotic helminthic infection widely reported in Latin America, Asia, and Southeast Asia. Consuming raw, or under-cooked fresh-water fish is the leading cause of this helminthic infection, which is clinically characterized by signs of inflammation, itching sensation, or irritation with migratory swelling. Neurological symptoms resulting from neurognathostomiasis vary, and there is scant information due to the rareness of patient brain samples. This study aimed to demonstrate the first evidence of human neurognathostomiasis by the detection of Gnathostoma spinigerum larva in patient's brain during craniotomy, supported by histopathological, immunological and proteomic evidence. Clinical symptoms were obtained from medical history and physical examination with laboratory investigations, including magnetic resonance imaging (MRI), left temporal craniotomy, histopathology of brain tissue, and Western blot analysis, were performed to elucidate the causative pathogens for diagnosis. In addition, the host–parasite interaction of the parasite invading the patient's brain was characterized through proteomics. Histopathology revealed worms with the characteristic cuticular spines of G. spinigerum which were detected and identified. These histopathological findings were consistent with a positive Western blot showing a 24-kDa reactive-band for gnathostomiasis. Proteomic analysis revealed the presence of G. spinigerum serpin and serine protease in the patient's serum. Moreover, the leucine-rich alpha-2-glycoprotein was indicated as a systemic biomarker of early brain injury related to invasion by G. spinigerum. Therefore, our study provides the initial evidence of human neurognathostomiasis due to G. spinigerum larval invasion along with successful craniotomy and proven larval detection including complete follow-up, and the disease prognosis after surgical treatment.

A rare Case of Rhabdomyosarcoma presenting as Gradenigo syndrome in a child

Objective: To study a rare case of Rhabdomyosarcoma. Methods: Observational descriptive study of a case, a 3-year-old female child, presenting to our OPD. She was thoroughly examined and radiological investigations (HRCT Temporal bone and MRI Brain) were done. The Neurosurgery department proceeded with a biopsy of the lesion by left temporal bone craniotomy through subtemporal approach. Results: Histopathology suggested a Rhabdomyosarcoma of anaplastic type. The patient then underwent 6 cycles of Chemoradiation. Conclusion: The awareness that Rhabdomyosarcoma of petrous apex can present as Gradenigo syndrome along with 7th nerve palsy is important for the early diagnosis and its treatment.

Initial Clinical Experience with Thin-Film Polyimide Subdural Electrodes for Seizure Monitoring (P2-1.005)

<h3>Objective:</h3> NA <h3>Background:</h3> Subdural grid-and-strips are used routinely in pre-surgical evaluations for people with drug-resistant epilepsy (DRE). Thin-film polyimide electrodes (NeuroOne Evo, 0.08mm) which have been approved for clinical use, are thinner and better conform to brain convolutions than current market grids. <h3>Design/Methods:</h3> We present two patients with DRE who underwent intracranial EEG (iEEG) monitoring with thin-film polyimide subdural electrode grid- and-strip electrodes as well as traditional EEG for pre-surgical evaluation. Patient 1 had a prior left mesial temporal lobe ablation with seizure recurrence. They underwent left temporal craniotomy with implantation of two subdural grids, three strips and additional depth electrodes. IEEG demonstrated two habitual seizures arising from anterior temporal subdural strips. Functional mapping identified the basal-temporal and Wernicke’s speech areas. Left anterior temporal lobectomy was performed and he remains seizure free 9 months post-resection. Patient 2 underwent bilateral stereoEEG electrode placement with coverage in the frontal/temporal/insular regions and subdural strip electrodes. IEEG demonstrated seizure onset from the left hippocampus and right hippocampal spikes. Given bilateral findings, they underwent Responsive Neurostimulation System implantation. <h3>Results:</h3> The two patients underwent subdural electrode placements without complications. IEEG recordings were comparable between NeuroOne Evo and traditional electrodes in terms of integrity, artifactual content and signal recording characteristics. The thinner profile of the Evo grid tail facilitated dura closure and reduced mass effect compared to traditional grids. By trimming material from the tip of the subdural strip, the electrode was placed through a burr hole without difficulty. Recording from these grids contributed to presurgical evaluation and led to surgical interventions. <h3>Conclusions:</h3> Our initial experience suggests that thin-film electrodes are a viable option for subdural iEEG that could safely minimize intracranial mass effect/brain shift and improve surgical ease of use. <b>Disclosure:</b> Dr. Reina has nothing to disclose. Dr. Song has received personal compensation in the range of $0-$499 for serving as a Consultant for Clearpoint Neuro. The institution of Dr. Song has received research support from NIH. Dr. Culler has nothing to disclose. Dr. Aronson has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Medtronic.

S2429 A Rare Case of Esophageal Adenocarcinoma Presenting as an Isolated Brain Lesion 6 Years After Treatment

Introduction: Esophageal adenocarcinomas account for ∼1% of all cancers in the U.S. The prevalence of central nervous system (CNS) metastases associated with these cancers is around 1.8%. Response rates to standard of care are poor and prognosis is dismal. Often CNS involvement is associated with widely metastatic disease, herein, we present a case of a solitary brain lesion from esophageal adenocarcinoma at first recurrence. Case Description/Methods: A 72-year-old-male with a 40 pack-year smoking presented with progressive dysphagia in March 2015. Contrast enhanced CT of the chest, abdomen and pelvis revealed a constricting mass at the esophagogastric junction that led to endoscopy guided biopsy revealing esophageal adenocarcinoma. He underwent neoadjuvant chemotherapy (cisplatin/5-fluorouracil) and radiation therapy followed by esophagogastrectomy in July of 2015 where diagnosis of stage IIIBT3N2cM0 esophageal adenocarcinoma was confirmed. Clinical and imaging surveillance for 6 years had not shown any progression of cancer. However, in June of 2021, he presented with altered mental status that led to contrast enhanced brain MRI showing a T2 hyperintense left parietal lobe mass with an 8 mm midline shift and surrounding vasogenic edema (Figure). FDG PET-CT head to toes did not show extracranial recurrence. He underwent left posterior temporal craniotomy for resection of tumor confirming the diagnosis of metastatic esophageal adenocarcinoma. IHC showed positivity of cytokeratin7, CDX2 and SATB2. Whole exome sequencing revealed mutations in ARID1A, FH, and TP53 with variants of unknown significance of ATM and CDH. Tumor displayed proficient mismatch repair protein, a combined positive score of 15 for PD-L1, and negative Her2/Neu. Further sequencing showed tumor mutational burden of 4, no genomic loss of heterozygosity, and stable microsatellite repeats. He received gamma-knife radiation to the solitary left temporal lobe lesion. Patient continues to maintain his quality of life with no evidence of clinical and radiographic recurrence. Discussion: Isolated brain metastasis from esophageal adenocarcinoma is a very rare phenomenon. Limited data suggests that the survival of patients with isolated CNS lesions is < 1 year, however, achieving pathologic complete response after neoadjuvant chemo-radiation therapy has shown to improve survival. These esophageal cancers with isolated CNS metastases may share a unique genomic profile and more research is required to understand their alterations.Figure 1.: MRI of the brain. 1A- Pre-op axial OLEA of L. temporal lobe tumor (06/2021), 1B- Pre-op axial coronal T1 (06/2021), 1C- Follow-up T2 MRI.

Delayed HSV-1 Encephalitis Relapse After Epilepsy Surgery: A Case Report

BACKGROUND AND IMPORTANCE: Herpes simplex virus 1 encephalitis (HSVE) can be a rare postoperative complication after neurosurgery. We present the case of a patient with postoperative, twice recurrent HSVE after 20 years, the longest latency period reported after neurosurgery. CLINICAL PRESENTATION: A 21-year-old man with a history of HSVE at 13 months and intractable epilepsy presented for surgical resection of seizure focus. The patient underwent left temporal craniotomy and resection of left temporal encephalomalacia. Five days after discharge, the patient presented with fever and headache and was found to have herpes simplex virus 1 (HSV-1)–positive cerebral spinal fluid. The infection was treated with acyclovir, with subsequent symptomatic improvement. Six weeks later the patient represented with recurrent symptoms and HSV-1–positive cerebral spinal fluid. This recurrence was treated with a prolonged course of acyclovir, followed by suppressive valacyclovir therapy, resulting in symptomatic improvement. CONCLUSION: HSV-1 encephalitis is a rare but previously reported complication after neurosurgery procedures. In patients with relapse of HSVE, the latency period can range from weeks to years after primary infection, and multiple relapses are rare. We present the case of a patient with twice recurrent, postoperative HSV-1 encephalitis 20 years after initial infection. We aim to emphasize that HSV status should be considered during treatment planning in patients with a history of HSVE being treated for HSV-related illnesses, and HSVE should remain on the differential in these patients when presenting with fever and neurological symptoms after surgery, regardless of time since initial infection.

An unusual temporal lobe lesion: A case report

We present a case of a 42-year-old African female with a past medical history of hypertension and hepatitis B carrier, who developed sudden generalised clonic seizures. MRI brain revealed a thickening insular cortex on the left side suggestive of a low grade glial tumour with a differential of progressive multifocal leukoencephalopathy. She proceeded to a left temporal craniotomy and tumour excision. Unfortunately after the procedure the patient had a right side embolic stroke and is in continuing care and rehabilitation.

Abstract 1122‐000117: Transcranial Arterial Embolization of an dAVF: A Case Report

Introduction : We detail the management of a woman with a posterior fossa dAVF (dural arteriovenous fistula) that was unable to be treated by standard transarterial or transvenous embolization or microsurgical ligation. She underwent craniotomy for surgical exposure and direct access of her left middle meningeal artery followed by microcatheter embolization with favorable results. Methods : This is a case report, which describes a case of a difficult to access dAVF. Results : A 72 year‐old woman presented with vertigo, nausea, and vomiting one week following a fall. CT head disclosed cerebellar vermis intraparenchymal hematoma and CT head angiography was suspicious for underlying vascular malformation. Diagnostic cerebral angiogram demonstrated extensive tentorial and suboccipital dural arteriovenous fistula (dAVF) fed by branches of both middle meningeal and occipital arteries with direct cortical venous drainage and venous aneurysmal ectasia directly adjacent to the vermian hemorrhage (ruptured Cognard grade 4). Left vertebral artery angiogram demonstrated excessive tortuosity of vertebral enlarged posterior meningeal artery, which was unable to be catheterized sufficiently beyond its origin despite different microwires and microcatheters due to tortuosity. Transfemoral venous approach was also attempted, however, this was also unsuccessful and decision was made to proceed with microsurgical treatment. The following day a suboccipital craniotomy was performed, but was ultimately aborted due to nearly uncontrollable bleeding from bony exposure and dural access secondary to severe venous hypertension. The next day percutaneous endovascular treatment was attempted a second time. A small right middle meningeal artery (MMA) contribution to the fistula was embolized with liquid embolic but, again because of excessive tortuosity and insufficient microcatheter access, right MMA occlusion occurred without embolic agent reaching the fistula. Similar access related difficulties due to tortuosity were encountered in accessing the left middle meningeal and occipital arteries contributing to the fistula. Repeat transvenous access was also attempted from the occipital and right transverse sinuses, but microcatheter access to the fistula was unable to be established beyond the venous outflow from the aneurysm, and, given the risks of hemorrhage related to embolization of the venous outflow without occluding arterial inflow into the ruptured aneurysm, transvenous embolization was not performed. A few days later, after the patient was given time to recover from the prior procedures, the patient underwent left temporal craniotomy in a hybrid operating room/interventional radiology suite for direct cannulation of the left MMA. Localization of the craniotomy site over the left MMA access point was planned by transfemoral cerebral angiogram and a transcarotid/peripheral access kit was used to catheterize the left MMA directly following surgical exposure. An .017 microcatheter was advanced close to the fistula point using standard biplanar roadmap fluoroscopy, and Onyx embolization of the fistula was performed to complete occlusion, without complication. Conclusions : For cerebrovascular disorders that are inaccessible by traditional endovascular and surgical means, a hybrid approach should be considered.

Papillary glioneuronal tumors: Distinctive cytological characteristics and cyto-histologic correlation

Intraoperative cytological examination and cyto-histologic correlation of papillary glioneuronal tumors have rarely been described in detail in the literature. A 23-year-old female presented at our institution with seizure-like activity, and a 3.0 cm left temporal lobe hypoattenuating lesion. She was accurately diagnosed with papillary glioneuronal tumor on Intraoperative cytology. The patient subsequently proceeded to stealth-guided awake left temporal craniotomy, confirming the diagnosis. In this article, we present a detailed report of papillary glioneuronal tumor (extremely rare central nervous system neoplasm) describing the cytologic and histologic morphologic features, its differential diagnosis with review of the literature.

Brain Abscess with Situs Inversus and Dextrocardia: A Case Report

Background: Brain abscess is a neurosurgical emergency. It has to be evacuated without any delay. Though these patients may have congenital heart diseases with ASD and VSD, presence of situs inversus and dextrocardia are relatively uncommon in neurosurgical practice.&#x0D; Objective: The aim was to present the case with multiple episodes of convulsions and gradual deterioration of consciousness without history of fever.&#x0D; Methods: The case was carefully evaluated with taking history and examining the patient. Diagnosis was confirmed with a MRI of the brain. It had shown a large ring enhancing lesion in the left temporal lobe which was diagnosed as brain abscess.&#x0D; Results: The patient underwent left temporal craniotomy and the abscess was totally removed along with the capsule. He made an uneventful recovery.&#x0D; Conclusion: Dextrocardia and cardiac congenital anomalies are serious conditions especially when they are accompanied with brain abscess. But prompt surgery and careful intraoperative and postoperative care can help the patient to recover early without any adverse event.&#x0D; Bangladesh Med Res Counc Bull 2020; 46(1): 61-63

Spontaneous hemispheric ventricular collapse and subarachnoid haemorrhages in a dog with congenital hydrocephalus internus

BackgroundOverdrainage and collapse of the hemispheres is a potential severe complication after surgical treatment of internal hydrocephalus using ventriculoperitoneal shunts. Here we describe a case of a spontaneous hemispheric ventricular collapse in an untreated dog with congenital hydrocephalus internus.Case presentationA twelve-week-old, male, intact Golden Retriever was presented with a history of peracute obtundation, impaired vision, and progressive gait abnormalities of all limbs for three days. Neurological examination revealed a dome shaped skull, a broad-based stance and a moderate cerebellar ataxia. The postural responses were markedly delayed in all limbs. Moderate ventro-lateral strabismus, vertical nystagmus and absent menace response were observed bilaterally. Clinical signs indicated multifocal localisation (forebrain, cerebellum). Magnetic resonance imaging (MRI) showed dilation of all cerebral ventricles, irregular thinning of the periventricular white and grey matter, consistent with internal hydrocephalus. In addition, the hemispheres were collapsed at the right temporal and left frontal lobe with haemorrhage filling the adjacent subarachnoid space. The dog underwent left frontal and right temporal craniotomy for removal of the haemorrhage. The dog improved on all neurological signs and was discharged after seven days. A repeat MRI three months postsurgical intervention showed reexpansion of the cerebral hemispheres. Subarachnoid haemorrhages were markedly reduced.ConclusionsCollapse of the hemispheres can occur spontaneously in dogs with hydrocephalus internus. Removal of the haemorrhage can improve clinical signs.

Gastrointestinal stromal tumor with intracranial metastasis: case presentation and systematic review of literature

BackgroundIntracranial metastasis of Gastrointestinal Stromal Tumors (GISTs) is rare but presents unique treatment challenges. We present a case of intracranial metastasis of GIST with a systematic review of the literature. A literature search using key terms “‘gastrointestinal stromal tumor’ AND brain AND metastasis”” was conducted through May 2019 via Embase and Pubmed according to PRISMA guidelines. Only cases describing intradural metastases rather than calvarial or intraorbital metastases were included.Case presentationA 57-year-old woman with history of GIST metastatic to the liver presented with a six-week history of left facial weakness, left hearing loss, and left facial numbness, and a one-week history of headaches, gait disturbance, and dizziness. MRI revealed a contrast-enhancing dural-based left middle cranial fossa mass measuring 2.9 cm × 3.1 cm × 3.4 cm with extension into the internal auditory canal and cerebral edema. A left temporal craniotomy was performed to excise the lesion, and the patient was discharged to a rehabilitation facility at her preoperative baseline. Intraoperative pathology revealed a spindle cell neoplasm, postoperative MRI demonstrated gross total resection of the lesion, and microscopic analysis demonstrated sheets of spindled tumor cells with short ovoid, irregular, hyperchromatic nuclei and scattered large atypical nuclei without extensive necrosis. Immunohistochemical staining was positive for KIT proto-oncogene (CD117, c-KIT), and the patient was put on imatinib (400 mg/day).ConclusionsOf the 18 cases analyzed and our present case, metastasis typically involved the cerebrum with only one in infratentorial elements. The tumors in seven of the cases involved the dura, and one case metastasized to the pituitary. Eight patients died following treatment. Surgery remains the mainstay of intracranial metastatic GIST, however there are many reports of good responses to radiation or chemotherapy alone. More investigation is required to determine the best treatment course for these patients.

Multidisciplinary Approach to Malignant Peripheral Nerve Sheath Tumor of the Trigeminal Nerve: 2-Dimensional Operative Video.

Malignant peripheral nerve sheath tumors (MPNSTs) of the trigeminal nerve are uncommon lesions that pose a surgical challenge to neurosurgeons. The case described in this video involved a 67-yr-old man who presented with a 2-yr history of left-sided facial numbness spreading from his chin along the left mandible to the preauricular area. He also reported left-sided tongue numbness and decreased taste on the left side of the tongue. On examination, he had left-sided facial numbness along the V3 distribution to pinprick and light touch. Magnetic resonance imaging (MRI) revealed an enhancing left V3 lesion extending from Meckel's cave to the angle of the mandible. The patient underwent a left temporal craniotomy for biopsy of the lesion, formalizing the diagnosis of a MPNST of the left trigeminal nerve. A multidisciplinary resection of his lesion was performed. Left infratemporal fossa approach with neck dissection, mandibulectomy, and frontotemporal craniotomy were performed. Additionally, a frontal external ventricular drain was placed for 3 d to aid in CSF diversion to avoid CSF leak, and free-flap reconstruction was undertaken. The patient tolerated the procedure well. Postoperatively, he retained his facial numbness, dysphagia, and dysarthria. The patient was discharged to inpatient rehabilitation on postoperative day 12. Postoperative computed tomography and MRI depicted complete resection of the left trigeminal nerve MPNST. At his last follow-up appointment, 3 mo after surgery, the patient reported significant improvement in his symptoms. Neuroimaging demonstrated no residual tumor and adjuvant radiotherapy was recommended. The patient provided consent for publication.

Left temporal craniotomy and direct microcatheterization of the middle meningeal artery for treatment of a complex temporal dural arteriovenous fistula.

The preferred method for treating complex dural arteriovenous fistulae of the transverse and sigmoid sinuses is via endovascular, transarterial embolization using liquid embolysate. However, this treatment approach mandates access to distal dural feeding arteries that can be technically challenging by standard endovascular approaches. This video describes a left temporal craniotomy for direct stick microcatheterization of an endovascularly inaccessible distal posterior division of the middle meningeal artery for embolization of a complex left temporal dural arteriovenous fistula. The case was performed in the hybrid operative suite with biplane intraoperative angiography. Technical considerations, operative nuances, and outcomes are reviewed.The video can be found here: https://youtu.be/Dnd4yHgaKcQ.

Expressive aphasia caused by &lt;em&gt;Streptococcus intermedius &lt;/em&gt;brain abscess in an immunocompetent patient

BackgroundBrain abscess is an uncommon but life-threatening infection. It involves a focal, intracerebral infection that begins in a localized area of cerebritis and develops into a collection of pus, surrounded by a well-vascularized capsule. Brain abscess still poses a significant problem in developing countries but rarely in developed countries. Predisposing factors vary in different parts of the world. With the introduction of antibiotics and imaging studies, the mortality rate has decreased between 5% and 15%. If left untreated it may lead to serious neurologic sequelae. The temporal lobe abscess can be caused by conditions like sinusitis, otitis media, dental infections, and mastoiditis if left untreated or partially treated. Additionally, in neurosurgical procedures like craniotomy, the external ventricular drain can get infected, leading to abscess formation.Case presentationWe present the case study of an elderly female patient who presented with expressive aphasia caused by brain abscess, secondary to Streptococcus intermedius infection. The 72-year-old female with a medical history of hypertension came to hospital for evaluation with word-finding difficulty, an expressive aphasia that began a few days prior to presentation. Computed tomography of the head showed a left temporal lobe mass-like lesion, with surrounding vasogenic edema. The patient was empirically started on courses of antibiotics. The next day, she was subjected to magnetic resonance imaging of the brain, which showed a left temporal lobe septated rim-enhancing mass lesion, with bright restricted diffusion and diffuse surrounding vasogenic edema consistent with abscess. The patient was also seen by the neurosurgery department and underwent stereotactic, left temporal craniotomy, with drainage, and resection of abscess. Tissue culture grew S. intermedius sensitive to ampicillin sulbactam. Subsequently her expressive aphasia improved.ConclusionBrain abscess has a high mortality, however a significant proportion of patients with appropriately treated abscess recover completely and can survive without significant neurologic damage. Advanced imaging modalities may yield more accurate methods of differentiation of mass lesions in the brain. Biopsy of brain lesion with early initiation of appropriate antibiotics will change the outcome.

Enigmatic intracranial cyst causing diplopia and trigeminal neuralgia

Chronic compression by intracranial cystic lesions can cause cranial nerve palsies and bony changes. With the advent of imaging techniques, grossly accurate diagnosis is possible. However, few cases do surprise the clinicians both intra, and postoperatively. A 27-year-old male presented to us with complaints of double vision for 4 months followed by sharp, shooting pain in the left V1 and V2 distribution for 1-month duration, on examination, he had left lateral palsy and decreased pin prick and temperature sensation in V1 distribution. On computed tomography scan, a cystic lesion noted which is isodense in the middle cranial fossa with erosion of the underlying bone. On magnetic resonance imaging lesion was iso to hyperintense on T1-Weighted and hyperintense on T2-Weighted, brilliantly enhancing on contrast administration. Provisional diagnosis was trigeminal schwannoma, left temporal craniotomy and total excision of the cyst done. Histopathological examination showed cyst wall lined with collagen. Postoperatively patient neuralgic pain subsided with persisting sixth nerve palsy.

Multicentric Low-Grade Gliomas

Multicentric low-grade gliomas are rare entities that occur in disparate regions of the brain. They can present with distinct pathologic and imaging findings and may harbor a worse prognosis. We present a case of multicentric low-grade gliomas and highlight their pathogenesis, imaging characteristics, and molecular signatures, with implications for clinical management. A 49-year-old man presented with left-sided headaches for 3 months. Magnetic resonance imaging revealed concurrent non-enhancing lesions in the left medial temporal lobe and superior cerebellum. Increased size and the development of contrast enhancement in the temporal lesion promoted a left temporal craniotomy. Pathology revealing a grade II ganglioglioma. Three months later, the cerebellar lesion also acquired new contrast enhancement and was found to be a grade II astrocytoma following a supracerebellar infratentorial approach for resection. At 2 years follow-up, the patient remains clinically stable, receiving adjuvant chemotherapy for new non-enhancing, unresectable pontine lesion. Tumor growth rate, detailed pathologic findings, imaging characteristics, and molecular signatures influence the clinical course of multicentric low-grade gliomas. PDGFRA amplifications and IDH1 wild-type status may act in a concerted fashion to produce an accelerated course of radiologic changes and tumor recurrence, as noted in our case. Additional research is needed to stratify the risk of transformation in patients with multicentric low-grade glioma and to guide management strategies.

CN-13 * RECURRENT ASEPTIC MENINGITIS IN PATIENTS WITH METASTATIC BRAIN TUMORS; A NOVEL PERSPECTIVE

Meningitis due to infectious or neoplastic infiltration is a commonly considered differential diagnosis in metastatic brain tumor patients presenting with altered mentation. However, aseptic meningitis, a disease marked by CSF pleocytosis, elevated protein, sterile cultures and negative cytology is rarely encountered. Aseptic meningitis has been described in benign CNS neoplasms that occur in the vicinity of ventricles, such as dermoid and epidermoid cysts. It has been postulated that rupture of a cystic CNS tumor nearby ventricles leads to leakage of neoplastic content into the CSF resulting in aseptic meningitis. A similar process has not been described in metastatic brain tumor patients. Here, we present a case of recurrent aseptic meningitis due to leakage of necrotic and neoplastic content into CSF in a patient with brain metastasis. 62 year old male presented with progressive aphasia 6 months after diagnosis of squamous cell lung cancer. Imaging revealed a left temporal lobe brain metastasis. Radiation therapy provided minimal improvement. Upon symptom progression, imaging favored radiation necrosis and bevacizumab was initiated with no improvement. On further deterioration, his CSF profile was consistent with aseptic meningitis with further spontaneous clinical improvement. He later presented with worsening symptoms and his repeat imaging showed enlargement of the previously noted left temporal mass with communication with the posterior temporal ventricle. A repeat CSF was consistent with recurrent aseptic meningitis. The patient underwent a left temporal craniotomy. The surgeon encountered liquid necrotic material at a depth of 5 mm and wide-open ventricles with easily discernable choroid plexus. Pathologic examination revealed mostly necrosis with some cancerous tissue. The patient continued to decline without recurrence of the meningitis and expired. This case signifies the importance of considering the leakage of necrotic tissue into subarachnoid space as the cause of recurrent aseptic meningitis in patients with cranial tumors close to the ventricles.

Glioblastoma mimicking a cerebral contusion: A case report

A 61-year-old male presented with a rare case of glioblastoma mimicking a cerebral contusion subsequent to collapsing. The patient had been medicated for hypertension for seven years and diabetes for eight years prior to hospitalization. Brain computed tomography (CT) revealed a cerebral contusion and intracerebral hemorrhage (ICH) in the left temporal region. The patient was initially administered intravenous drugs to reduce the intracranial pressure following the diagnosis of a cerebral contusion. Serial CT revealed ICH resorption. However, the patient was again admitted due to a headache and vomiting two months later. Magnetic resonance imaging (MRI) demonstrated an enhanced ring-shaped mass around the cyst cavity within the left temporal region, with surrounding edema. The patient underwent cyst puncture drainage in the temporal region. No tumor cells were identified in the cyst fluid and the culture was also negative. The patient was admitted for a headache and vomiting for the third time one month after being discharged. A cyst, tumor and meningoencephalitis were suspected following an MRI scan. The patient was treated with a left temporal craniotomy for a mass resection and biopsy. The histological diagnosis of the biopsy specimen was that of a glioblastoma. Two months later, MRI revealed a recurrence of the glioblastoma. In the present case, a brain tumor should have initially been suspected as the cause of the ICH, despite the history of craniocerebral trauma and hypertension. Early awareness of this potential cause of ICH may facilitate a more prompt diagnosis and treatment.

Freiburg Neuropathology Case Conference: Widespread Mass Lesions After Resection of a Glioblastoma Multiforme

an 80-year-old male patient presented with intermittent aphasia, focal seizures with speech arrest and gait disturbance. Magnetic resonance imaging (MRi) revealed a contrast-enhancing lesion in the left temporal lobe (Fig. 1). a left temporal craniotomy was performed and a complete microsurgical resection of the lesion was achieved as demonstrated by early postoperative MRi (not shown). neuropathological analysis revealed a glioblastoma multiforme WHO grade iV. The neurological symptoms resolved completely. The patient was treated with external beam radiation therapy (60 Gy). Four months after surgery, he presented with fatigue and reduced general condition. MRi revealed a contrast-enhancing rim around the resection cavity and a subdural hygroma with compression of the sulci of the left hemisphere (Fig. 2). He was treated with a subdural drainage for 3 days. although the symptoms improved, computed tomography (CT) showed no resolution of the subdural effusion. The patient received four cycles of standard temozolomide chemotherapy (200 mg/m2, 5/28 pattern). eight months after the surgery, the follow-up MRi revealed multiple intraand extraaxial contrast-enhancing mass lesions located supraand infratentorially (Fig. 3). Meanwhile, the patient had developed a right-sided facial paresis and hearing loss, dysmetria and severe ataxia. Open biopsy was performed and an intradural, extracerebral lesion in the right parietal area was excised. The patient was transferred into palliative care.