Marked Mass Effect Research Articles

PATH-14. A CLINICAL CONUNDRUM - INFANTILE POSTERIOR FOSSA EPENDYMOMA WITH YAP1:MAML FUSION?

Abstract BACKGROUND Ependymomas of infancy (0-18months) have been reported to comprise distinct clinical, pathological and genetic entities. Young age is typically associated with posterior fossa group A (PF-A) tumours and therefore a poor prognosis. Treatment of these infants is challenging with limited therapeutic options that have significant long-term sequelae. METHOD We report a single case of a 4-month old baby girl who presented with obstructive hydrocephalus and a presumed posterior fossa mass. RESULTS Imaging demonstrated a large fairly well-defined solid lesion with multiple T1 high and corresponding T2 intermediate signal intensity foci scattered throughout the lesion and marked mass effect on the cerebellum and fourth ventricle. The lesion was inseparable from the pineal gland, habenula and tectum and only mild diffusion restriction. Whilst initially considered to be a posterior fossa tumour, the presence of a claw sign with the tectal plate, favoured a tectal origin. Histological appearances, together with immunohistochemistry findings (GFAP positive and EMA patchy perinuclear dot expression) were consistent with classic ependymoma. Grading was difficult as mitotic activity was relatively low, although focal areas of high ki67 proliferation index were noted suggesting at least focal grade 3 areas. Retained expression of tumour cells for H3K27me3 on immunohistochemistry suggested the likely posterior fossa group B (PF-B) ependymoma. Local SNP chromosome microarray found no acquired clonal abnormality; with no detection of gain chromosome 1q; loss/LOH 6q; Loss/LOH 9p21.3 [CDKN2A, CDKN2B], chromothripsis 11q [ZFTA::RELA], Loss/LOH 17p13 [TP53] or Loss/LOH 22q [NF2]. Additional NGS sequencing identified a YAP1::MAML2 fusion (confirmed with targeted RT-PCR followed by subsequent Sanger sequencing). CONCLUSION This case highlights the challenges with overlapping clinical, pathological and radiological features in an infant with ependymoma, necessitating a molecular diagnosis. After 21months, the patient remains in complete remission following surgery alone.

OTHER-12

Abstract Glomus jugulare tumours are rare but present a treatment challenge due to their anatomy, endocrine and cardiovascular effects. Their care requires a multidisciplinary approach. We present the case of a 62year-old female patient who presented with 4-year history of tinnitus, hearing loss and hypertension. Over a period of 2 weeks she decompensated with bulbar dysfunction and rapid cardiovascular instability. MRI demonstrated a 88 cc right jugulotympanicum para-ganglioma with intracranial, extra-axial extension and encasement of cranial nerves VI to XII, and marked mass effect on the brainstem with compression and left displacement of the medulla. The patient also had hydrocephalus. Clinically she had limited physiological reserve. She underwent partial embolization to reduce the hyperdynamic circulation, a total dose of 54Gy in 30 fractions using IMRT technique and ventriculoperitoneal shunt insertion. She had a prolonged critical care stay .However, she progressively improved over a period of six months with the brainstem oedema resolving. Currently, the patient is living independently with normal cardiovascular status. This case demonstrates the benefit of combining endovascular intervention and radiation therapy in the management of glomus tumours.”

Cholesterol granuloma in the choroid plexus of a cat

BackgroundThis case report describes the clinical presentation, magnetic resonance imaging (MRI) as well as the histopathological findings in an elderly cat with an intracranial cholesterol granuloma.Case presentationAn 11.5-year-old, male neutered cat was presented at the emergency service with deteriorating behavioral changes including aggression, and progressive generalized ataxia. Magnetic resonance imaging (MRI) of the brain revealed a large, well demarcated, inhomogeneous and contrast enhancing mass in the lateral ventricles with marked mass effect. Due to a poor clinical prognosis, the cat was euthanized. Histological examination identified the mass as a bilateral cholesterol granuloma in the choroid plexus of the lateral ventricles.ConclusionsAlthough plexus cholesterol granulomas are rarely seen in cats, they should be considered as a differential diagnosis in elderly patients with neurological signs such as behavioral changes.

MRI features of a presumed noncolloidal intraventricular cyst in a young cat

AbstractA 5‐month‐old, male entire, Abyssinian cat was referred for investigation of 1‐week history of lethargy and suspected neck pain. Neurological examination revealed severe obtunded mentation, intermittent opisthotonic posture, ambulatory tetraparesis, positional vertical nystagmus and neck hyperesthesia. Haematology and biochemistry profile were within normal limits. MRI of the head revealed bilateral ventriculomegaly of the lateral ventricles. The left ventricle was more severely dilated and contained a large intraventricular cyst‐like structure bordered by a thin membrane. The cystic lesion caused a marked mass effect with mild‐line shift, cerebellar compression as well as caudal transtentorial and foramen magnum herniation. A congenital intraventricular cyst was suspected based on MRI findings.

Kyste arachnoïdien temporal gauche et troubles spécifiques des apprentissages associés à un trouble envahissant du développement non spécifié (TED-NoS) : apports d’une approche intégrative neuro-psychomotrice neuropsychologique, psychopathologique et neurochirurgicale à propos d’une observation chez un enfant (le cas François)

Left temporal arachnoid cyst and specific learning disorders associated with pervasive developmental disorders – not otherwise specified (PDD-NOS): contributions of an integrative neuro-psychomotor, neuropsychological, psychopathological and neurosurgical approach about a case report in a child (François). With DSM-IV and DSM-IV-TR, the terminology of pervasive developmental disorders (PDD) covers two main categories of infantile disorders: disorders of “strictly” autistic nature and pervasive developmental disorders – not otherwise specified (PDD-NOS). Under the terminology of multiple complex developmental disorder (MCDD), it is proposed to classify children presenting symptoms approaching the psychotic disharmonies and usually diagnosed as PDD-NOS. Such a category of developmental disorders is now included without nosographic distinction in the autistic spectrum in the Diagnostic and Statistical Manual of mental disorders (DSM-V). Case reportWe are reporting a case report of a 6-year-old boy which shows a PDD-NoS/MCDD complex symptomatology type. This child presents multiple disorders: minor neurological signs (soft signs), neuro-psychomotor disorders, developmental coordination disorder (DCD), communication, thought, and regulation of emotions disorders, attention deficit disorders (ADD); in the presence of a high verbal intellectual potential, which makes it difficult to establish a clear diagnosis. A cerebral magnetic resonance imaging (MRI) was carried out due to the presence of minor neurological signs (soft signs) and of neurodevelopmental multiple disorders. The MRI revealed a voluminous arachnoid temporo-polar left cyst with a marked mass effect on the left temporal lobe. DiscussionA neurosurgical intervention allowed to observe the gradual disappearance of the specific symptomatology (in particular soft signs, neuro-psychomotor functions and autistic symptoms) secondary to the interference of the cyst's pressure with intracranial areas involving neurological and psychopathological abnormalities, underlying at the same time the reversibility of the disorders after decompression as demonstrated in some studies. There are always, with a quantitative and qualitative decrease, an emotional dysregulation, a DCD, an ADD as well as impairments in the executive functions. ConclusionThis clinical case underlines the necessity of an evaluation in a transdisciplinary way and to follow the developmental evolution of the child in order to focus adapted therapeutics. Furthermore, with neurodevelopmental disorders not specified, it is important to examine the presence of soft signs with standardized neuro-psychomotor assessment, and then, to propose an MRI investigation. To our knowledge, this is the first report in the literature with a school age child of an unusual association between a temporal arachnoid cyst associated with PDD-NOS/MCDD.

Intracranial Mesenchymal Chondrosarcoma: A Case Report

Primary intracranial mesenchymal chondrosarcoma is an extremely rare tumor. We present a case of primary intracranial mesenchymal chondrosarcoma in a young female who presented with headache, loss of vision, and one episode of convulsions associated with nausea and vomiting. MRI brain revealed a large, well-marginated, lobulated, partially calcified, intensely enhancing lesion with a broad dural base in bilateral frontal regions with marked mass effect suggestive of meningioma. Bilateral frontal craniotomy with gross tumor excision was performed. Histopathology revealed mesenchymal chondrosarcoma. Adjuvant radiotherapy was delivered and patient is currently on follow-up. We emphasize that intracranial mesenchymal chondrosarcoma is a rare neoplasm and should be considered in the differential diagnoses of intracranial mass along with meningioma. Treatment of choice is surgery followed by adjuvant radiotherapy. We review the relevant literature and discuss the characteristics of this rare tumor.

Intradural Intraneural Hemorrhagic Cyst Resulting in Progressive Cauda Equina Syndrome After Anticoagulation Therapy

Case report. To report a case of lumbar intraneural hemorrhagic cyst after anticoagulation therapy that caused progressive radiculopathy and cauda equina syndrome. The possible pathogenic mechanism, associated diseases, and treatment options are discussed. Various pathological processes can cause progressive cauda equina syndrome. However, there have been no reports of progressive cauda equina syndrome due to compression from an intraneural hemorrhagic cyst after anticoagulation therapy. A case of lumbar intradural intraneural hemorrhagic cyst with progressive cauda equina syndrome after anticoagulation therapy is presented. A 42-year-old-female patient complained at presentation of progressive bilateral lower extremity radiating pain, numbness, and urinary difficulty during the previous 2 months. Lumbar magnetic resonance imaging revealed an L1 cystic lesion with marked mass effect on the surrounding nerve roots. Complete drainage and excision of the lesion was performed, which resulted in excellent postoperative symptoms relief. Pathological examination revealed no definite neoplastic process except some nerve fibers with hemosiderin stain along the cyst wall. On the basis of a combination of intraoperative findings and pathology, an intradural intraneural hemorrhagic cyst that developed after systemic anticoagulation therapy was diagnosed. This is the first report of an intradural intraneural hemorrhagic cyst causing progressive cauda equina syndrome due to anticoagulation therapy. Surgical excision of the cyst is the definite treatment of choice. N/A.

A systematic approach to diagnosis of cystic brain lesions

Brain metastasis is the most common intracranial tumor in adults. The incidence of brain metastasis is rising with the increase in survival of cancer patients. Magnetic resonance imaging with contrast enhancement is the imaging procedure of choice to diagnose and characterize brain metastases. Multiple lesions with marked vasogenic edema and mass effect are typically seen in patients with brain metastases. The classical appearance of a metastasis is a solid enhancing mass with well-defined margins and extensive edema. Occasionally, central necrosis produces a ring enhancing mass. Here, we report a case of Non Small Cell Lung Cancer with multiple ring enhancing lesions in brain, and the approach to diagnosis of such patients.

Prenatal diagnosis of ‘isolated’ Dandy–Walker malformation: imaging findings and prenatal counselling

The purpose of this article is to improve prenatal imaging diagnosis and counselling for cases of 'isolated' Dandy-Walker malformation (DWM) in the light of recent literature, which has demonstrated a potential good clinical and intellectual outcome of fetuses presenting with DWM characterised by partial vermian agenesis (identification of two fissures and three lobes) and absence of associated anatomical anomalies. This is a retrospective observational study of six consecutive prenatal cystic posterior fossa malformations, diagnosed as DWM, encountered in a national reference centre for posterior fossa malformations over a 2-year period. In all cases, DWM was diagnosed as isolated (without any associated central nervous system or extra-central nervous system malformations and normal standard karyotype). Despite good-quality imaging, including fetal magnetic resonance imaging (MRI), prenatal analysis of the vermis was impossible because of limited identification of fissuration and lobulation. In three cases, a cytogenetic anomaly was found, including 6p subtelomeric deletion (n = 2) and partial 4 qter deletion associated with partial 7p trisomy (n = 1). One fetus with 6p deletion was terminated. In four of the five postnatal cases, MRI confirmed the diagnosis of DWM but provided only limited information for vermian analysis. In one case, postnatal MRI showed a large Blake's pouch cyst with rotated but complete vermis associated with a marked mass effect on the distal part of the tentorium. Of the four babies born with postnatal diagnosis of DWM, all required ventriculoperitoneal shunting because of early postnatal hydrocephalus. When fetal MRI is necessary to exclude additional cerebral lesions in the diagnosis of DWM, we highlight the inaccuracy of magnetic resonance for anatomical analysis of the vermis. We also emphasise the potential high incidence of subtelomeric anomalies in isolated DWM, especially 6p deletion. In the postnatal period, paediatricians should look for postnatal hydrocephalus even if the ventricular size is normal or slightly dilated on prenatal imaging.

Microcystic meningioma presenting as a cystic lesion with an enhancing mural nodule in elderly women: report of three cases

Cystic meningioma with an enhancing mural nodule is uncommon and can present as a radiologic and clinical dilemma with wide differential. We report a series of rare and unique presentation of microcystic meningioma in three elderly women aged 76 (case 1), 72 (case 2), and 76 (case 3)years, respectively. The first patient presented with a 3-year history of vertigo and past history of carotid artery stenosis, hypertension, and hypothyroidism. The second patient presented with headache and an acute episode of weakness in her legs. The third patient presented with headache, vomiting, and confusion. Magnetic resonance imaging for these three cases showed a cystic lesion with an enhancing mural nodule in the right frontal lobe. The preoperative differential diagnoses included hemangioblastoma and well-circumscribed gliomas for the first two cases. Glioblastoma and metastatic tumor were the working diagnoses for the third case because of vasogenic brain edema and marked mass effect. The final pathological diagnosis was microcystic meningioma for all three cases. Case reports are mainly of fibrous or meningothelial meningiomas with cystic formation. Male predominance and young age are most commonly reported. Our series is unique because of the rare and unusual clinical-radiologic presentation of microcystic meningioma in elderly women.

Atypical teratoid/rhaboid tumour arising in association with a pleomorphic xanthoastrocytoma: a case report

Atypical teratoid rhabdoid tumour (AT/RT) is a rare, highly malignant embryonal tumour most often occurring in the posterior fossa in children under 3 years of age. We report a case of a supratentorial AT/RT arising in association with a pleomorphic xanthoastrocytoma (PXA). A 6-year-old girl presented with a 1 month history of headache and vomiting. An MRI showed a heterogeneously enhancing mass involving the posterior left frontal lobe associated with marked local mass effect. Following a subtotal resection of the tumour she commenced treatment with chemoradiation. Histological sections showed a tumour with two distinct but focally intermixed morphological appearances, a high grade component with cellular morphology typical of an AT/RT and a low grade component with features of a PXA. The diagnosis was confirmed by demonstrating immunohistochemical loss of INI1 expression, restricted to the rhabdoid areas. In addition, a significantly higher proportion of the rhabdoid cells showed loss of a chromosome 22 marker by fluorescent in situ hybridisation. To our knowledge this is the second reported case of an atypical teratoid rhabdoid tumour arising in the setting of a pleomorphic xanthoastrocytoma. We postulate that the AT/RT arose through secondary genetic events in the PXA, including INI1 inactivation.

Report of two cases of chordoid meningioma in patients with Castleman syndrome

We read with great interest the article by Lin et al. on the evidence and specific profile of chordoid meningioma in adult patients [1]. They reported a comprehensive clinicopathologic study of 11 adult patients suffering from this uncommon tumor, adding useful information regarding the existence of such tumors in all ages. Interestingly, of their 11 patients who had a mean age of 60.8 years at first surgery, none of them presented any systemic manifestations of Castleman syndrome such as iron-refractory hypochromic/microcytic anemia and dysgamaglobulinemia [1]. For this reason, they arrive at their main observation that ‘‘chordoid meningiomas (CMs) are not always associated with Castleman’s Syndrome’’. They further speculate that ‘‘CMs in young patients are mainly formed by B cells due to the association with the Castleman syndrome, while a predominance of T cells is observed in adult cases’’. However, the mechanism through which these tumors are associated with the Castleman syndrome needs to be further discussed. In presenting our observations of two adult patients with chordoid meningioma associated with systemic manifestations, we hope to add some useful information to this controversial relationship. The first patient, a 48-year-old woman, presented with a long history of iron-refractory hypochromic anemia. Peripheral blood cell examination confirmed the presence of an inflammatory syndrome with hypochromic anemia (HGB = 9.61 g/dl), elevated erythrocytes sedimentation (ERS = 29 mm/h), moderate leucocytosis (WBC = 16,000), and thrombocytosis (PLT = 707,000). Cerebral CT and MRI revealed a right cerebellar mass with homogenous contrast enhancement and marked perifocal edema (Fig. 1). She underwent a total surgical removal of the tumor, histological examination of which revealed the presence of nest and cords of epithelioid cells embedded in basophilic extracellular material producing the chordoid meningioma pattern (Fig. 2). In the early post-operative course, refractory anemia and inflammatory syndrome disappeared (HGB = 13.1 g/dl, ERS = 14 mm/h, WBC = 11,100). Cerebral MRI 39 months after the surgery confirmed the absence of any recurrence. The blood picture was within normal ranges. The second patient, a 47-year-old man, presented with a 2-month history of headaches. Peripheral blood cell examination revealed the presence of hypochromic and microcytic anemia (HGB = 9.6 g/dl), elevated erythrocytes sedimentation (ERS = 28 mm/h), moderate leucocytosis (WBC = 16,000), and thrombocytosis (PLT = 707,000). Cerebral CT scan showed a right temporal lesion with homogenous contrast enhancement exerting a marked mass effect on median structures (Fig. 3). Histopathological examination of the totally removed lesion confirmed the presence of a meningothelial neoplasm with whorl formation and composed of cells with intranuclear inclusions. Neoplastic cells are embedded in a mucoid matrix (Fig. 2). The surrounding tissue consisted of marked lymphoplasmacytic inflammatory infiltrate and siderophages. Proliferation index (Ki-67) was 2%. The tumor showed diffuse positive immunoreactivity with vimentin and EMA. In the G. Kaloshi (&) G. Vreto A. Lame I. Kerri T. Bushati A. Rroji M. Petrela Department of Neurosurgery, Tirana School of Medicine, University Hospital Center ‘‘Mother Theresa’’, 327 Rr e Dibres, Tirana, Albania e-mail: g_kaloshi@yahoo.com

Traumatic Subdural Hygromas: Proposed Pathogenesis Based Classification

Traumatic subdural hygroma (TSHy) is an accumulation of cerebrospinal fluid (CSF) in the subdural space after head injury. It appears to be relatively common, but its onset time and natural history are not well defined. Considered a benign epiphenomenon of trauma, the pathogenesis of TSHy is still unclear and many questions remain unanswered. This study adds to the information on TSHy, and proposes a classification based on pathogenesis. Thirty-four consecutive adult patients with TSHy were analyzed for clinical evolution and serial CT scan, during a period of several months. TSHy diagnosis was based on published CT scan criteria of hypodense subdural collection after trauma, without enhancement and neomembrane, with a minimum distance of 3 mm between the skull and brain. Ventricle size was analyzed by calculating the bicaudate index (BCI). For comparison, the BCI was measured from CT scan at three moments: admission, at time of TSHy diagnosis, and from last CT scan. There were 34 patients, aged between 16 and 85 years (mean 40), half of them were below 40 years. Road traffic crashes were the main cause of head injury. The mean time for hygroma diagnosis was 9 days. Twenty-one patients (61.8%) underwent conservative treatment for TSHy and 13 (38.2%), surgical treatment. TSHy are early lesions and can be detected in the first 24 hours after trauma, usually as small subdural effusion (SSEff). Based on clinical and CT scan findings, we divided the 34 patients into 3 groups, (Ia and Ib) without evident mass effect and (II) with evident mass effect. Group Ia includes patients without ventricle dilation; Ib, patients with associated ventricle dilations. SSEff detected in the first 24 hours posttrauma in our series evolved into TSHy suggesting that this is an early lesion; all THSy were divided in three groups according to the pathophysiologic mechanism. These three groups probably represent a continuum of CSF absorption impairment. Group Ia represents what most authors consider a simple hygroma, with no impairment on CSF absorption. Group Ib represent the external hydrocephalus form with various degrees of CSF imbalance, and group II were the cases presenting marked mass effect.

Arachnoid cyst in a patient with psychosis: Case report

BackgroundThe aetiology of a psychotic disturbance can be due to a functional or organic condition. Organic aetiologies are diverse and encompass organ failures, infections, nutritional deficiencies and space-occupying lesions. Arachnoid cysts are rare, benign space-occupying lesions formed by an arachnoid membrane containing cerebrospinal fluid (CSF). In most cases they are diagnosed by accident. Until recently, the coexistence of arachnoid cysts with psychiatric disturbances had not been closely covered in the literature. However, the appearance of some references that focus on a possible link between arachnoid cysts and psychotic symptoms has increased the interest in this subject and raised questions about the etiopathogeny and the therapeutic approach involved.Clinical presentationWe present the clinical report of a 21-year-old man, characterised by the insidious development of psychotic symptoms of varying intensity, delusional ideas with hypochondriac content, complex auditory/verbal hallucinations in the second and third persons, and aggressive behaviour. The neuroimaging studies revealed a voluminous arachnoid cyst at the level of the left sylvian fissure, with a marked mass effect on the left temporal and frontal lobes and the left lateral ventricle, as well as evidence of hypoplasia of the left temporal lobe. Despite the symptoms and the size of the cyst, the neurosurgical department opted against surgical intervention. The patient began antipsychotic therapy and was discharged having shown improvement (behavioural component), but without a complete remission of the psychotic symptoms.ConclusionIt is difficult to be absolutely certain whether the lesion had influence on the patient's psychiatric symptoms or not.However, given the anatomical and neuropsychological changes, one cannot exclude the possibility that the lesion played a significant role in this psychiatric presentation. This raises substantial problems when it comes to choosing a therapeutic strategy.

Atypical Imaging Findings in a Near-Fatal Case of Posterior Reversible Encephalopathy Syndrome in a Child

1Both authors: Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710. Address correspondence to H. F. Keyserling. he term “posterior reversible encephalopathy syndrome” (PRES) refers to a complex of symptoms usually manifested by headache, confusion, seizures, visual disturbances, or a combination of these symptoms. PRES usually occurs in the setting of an acute rise in blood pressure, and in recent years, PRES has been recognized as a complication of immunosuppressive and chemotherapeutic agents including cyclosporine A and L-asparaginase [1, 2]. Imaging findings are characteristic and consist of typically unenhancing lesions that predominate in the white matter of the posterior brain regions, seen as hypodense regions on CT and hyperintense areas on T2-weighted MR images. We report an unusual case in which a child with PRES developed contrastenhancing lesions with marked mass effect in the posterior fossa that resulted in cerebellar tonsillar herniation and cardiac arrest.

Acute Subdural Hematoma After Intro-arterial Thrombolysis for Acute Ischemic Stroke-Case Report-

A 79-year-old man with a cardiac pacemaker for bradycardia fell down and presented with sudden onset of right hemiplegia and aphasia. Initial computed tomography (CT) showed no cerebral infarction but angiography revealed occlusion of the left middle cerebral artery (MCA). Local intra-arterial thrombolysis with tissue plasminogen activator (tPA; tisokinase, 1,600,000 units) was performed 3 hours after the onset, and the MCA was partially recanalized. Further administration of tPA was suspended because of nosebleed. However, the patient's neurological findings did not improve. His consciousness gradually deteriorated to coma and quadriplegia with dilation of the left pupil 2.5 hours after thrombolysis. CT disclosed marked mass effect with a left acute subdural hematoma and a small intracerebral hematoma in the left frontal lobe. He underwent urgent craniotomy and removal of the subdural hematoma. The subdural hematoma originated in a frontal cerebral contusion. He died of severe brain edema 2 days after surgery. Acute subdural hematoma is a very rare complication of intra-arterial thrombolysis. Presumably he had suffered head trauma at the first onset. Evidence of head trauma should be considered a contraindication for the use of thrombolytic agents in a patient with acute stroke.

Calcified Chronic Subdural Hematoma — Case Report

Calcified or ossified chronic subdural hematoma is a rare entity that usually presents as a space-occupying lesion over the cerebral convexity. We report a case of calcified and ossified chronic subdural hematoma in an unusual location that has not been previously reported. A 24-year-old man with a history of tonic-clonic convulsions since 7 months of age was admitted because of increasing frequency and duration of seizures. Computed tomography and magnetic resonance imaging demonstrated a fusiform extra-axial lesion just above the tentorium and adjacent to the cerebral falx. A calcified and ossified chronic subdural hematoma was noted and was almost completely removed by craniotomy. Better seizure control was achieved by removal of the calcified chronic subdural hematoma. Calcified subdural hematoma, calcified epidural hematoma, calcified empyema, meningioma, calcified arachnoid cyst, and calcified convexity of the dura mater with acute epidural hematoma should be considered for the differential diagnosis of an extra-axial calcified lesion.

Resolución espontánea de un hematoma subdural agudo

Acute postraumatic subdural hematoma is known to have bad prognosis. Traditionally, its treatment consisted in urgent surgical evacuation. Rapid spontaneous resolution of the hematoma has been infrequently observed. We report a case of a patient with an acute traumatic subdural hematoma which disappeared without surgery. CT-scan showed a left-sided subdural hematoma with marked mass effect. A low density layer, which implied involvement of CSF in the subdural space, was observed between the hematoma and the inner wall of the skull. We think that the spontaneous resolution of the hematoma was due to the dilution and washing-out by the CSF through an arachnoid tear. Another suggested mechanism in the literature is blood redistribution in the subdural space. Selected patients with an acute subdural hematoma can be managed with conservative treatment.

Transcranial color Doppler sonography in the emergency diagnosis of middle cerebral artery occlusion in a patient after head injury: Case report

The purpose of this report is to highlight the utility of transcranial color Doppler sonography (TCCDS) in the emergency diagnosis of an ischemic stroke in a 64-year-old patient after head injury. An emergency CT identified a subdural hematoma, subarachnoid hemorrhage, a brain contusion and edema. The patient's status deteriorated after admission, and a second CT revealed an intracerebral hematoma and marked mass effect. Transcranial color sonography revealed no flow in the ipsilateral middle and anterior cerebral arteries, which was consistent with ischemic stroke. This case demonstrates that transcranial color Doppler sonography performed early after head injury may be useful in detecting associated occlusion of cerebral vessels.

Atypical MRI findings in treatment-related leukoencephalopathy: case report

A patient with acute myeloblastic leukaemia showed atypical findings on MRI following combination therapy including intrathecal methotrexate and radiation. MRI findings not previously been reported are ring as well as patchy enhancement, marked mass effect and lesions extending to the putamen and corpus callosum.