Subtentorial Region Research Articles

Clinical characteristics of glioblastoma with metastatic spinal dissemination.

Metastatic spinal dissemination (MSD) is a rare phenomenon in glioblastoma (GBM). The study aimed to analyze the clinical characteristics of GBM patients with MSD. Fifteen GBM patients with MSD, who were treated and followed up with at the Department of Oncology, Beijing Shijitan Hospital, Capital Medical University from September 2012 to February 2021, were selected for this study. Clinical data, such as demographic characteristics, clinical manifestation, imaging, cerebrospinal fluid (CSF), treatment and prognosis data, were retrospectively analyzed. The time to MSD and overall survival (OS) were estimated using Kaplan-Meier plotting. A univariate analysis was performed using a logarithmic-rank test, and a multivariate analysis was performed using Cox proportional hazards models. Of the 15 GBM patients with MSD (9 males and 6 females), the primary lesions were located supratentorial region in 12 cases, and subtentorial region in 3 cases. After surgery, the ventricles were open and closed in 7 and 8 cases, respectively. There were 10 cases, 2 cases, 2 cases, and 1 case of MSD in the full spinal cord (FSC), FSC with spinal cord intramedullary infiltration, cervical spinal cord intramedullary infiltration, and cervical/thoracic MSD, respectively. Whole spinal cord magnetic resonance imaging (MRI) showed dotted-line, nodules, and mixed patterns in 3, 2, and 10 cases, respectively. The average CSF protein level during MSD was 2.49 (range, 0.42-6.68) g/L, and the average CSF d-dimer level was 23,718 (range, 4,056-69,000) ng/L. By the end of the follow-up period, all the patients had died. The median OS of all patients, the median time from surgery to diagnosis of MSD, and the median time after MSD to death was 15.0 (range, 8-52), 10.0 (range, 1-49), and 4.0 (range, 1-14) months, respectively. MSD is a rare, metastasized type of GBM. The OS after MSD in GBM patients is very short. Whole spinal cord-enhanced MRI may be the best way to determine the range of MSD.

Stroke and Craniectomy

Neurosurgical involvement in the care of major stroke complications has yielded striking results in the subtentorial region but equivocal outcomes in the supratentorial compartment. Most neurosurgeons want to see some degree of deterioration before proceeding; thus, timing will be debated. Viewpoints have changed over the years regarding surgical or medical intervention, but in many patients the procedure has not produced a definitive change in outcome other than preventing death from terminal brainstem shift. The introduction of craniectomy (and craniotomy) to treat swollen ischemic brain or intracranial hemorrhage has historical interest.

Demographics and Incidence of Histologically Confirmed Intracranial Tumors: A Five-year, Two-center Prospective Study.

IntroductionIntracranial tumors (ICTs) are a diverse group of malignancies that pose an immediate threat to patients' lives, no matter their local or metastatic origin, benign or malignant nature. These lesions have severe clinical courses and need to be diagnosed and treated as soon as possible, with pathological verification being the pivotal moment in the process of determining curative modalities.AimThe aim of this study was to compare the incidence of histologically confirmed ICTs in Eastern Bulgaria, based on their type (primary, metastatic, and non-volume occupying lesions (NVOL)), their respective subtypes, and incidence in a descriptive manner.Materials and MethodsFor a period of five full calendar years (January 1st, 2012 – December 31st, 2016), all histologically confirmed cases of intracranial tumors were prospectively collected from two individual tertiary healthcare institutions. The cases were then statistically analyzed in a descriptive manner, and incidences of primary, metastatic, and NVOL were compared with regards to their specific origins, types, and subtypes. Metastatic tumors were further segregated relative to their intracranial metastatic location.ResultsThe total number of individual ICTs registered in the set timeframe was 822. Primary ICTs represented a total of 66.12% of the histologically confirmed cases, with the most common entries being tumors from a glial and meningeal origin, 30.90% were histologically confirmed as metastatic ICTs, from which the most common entries were of pulmonary origin, and the other 2.94% were NVOL. On behalf of their intracranial metastatic location, metastatic tumors were located predominantly in the supratentorial region, represented as a total of 87.80%, while the other 12.20% were located in the subtentorial region. Based on the descriptive analysis, the annual incidence per 100,000 capita of all ICTs is 9.12, comprised of 6.03 per 100,000 for primary ICTs, 2.82 per 100,000 for metastatic ICTs, and 0.27 per 100,000 for NVOL. The annual incidence of the most commonly diagnosed primary ICTs per 100,000 is 2.36 for meningioma, 2.03 for glioblastoma, and 0.48 for pituitary adenoma. The annual incidence of the most commonly diagnosed metastatic ICTs per 100,000 is 1.32 for lung cancer metastases, 0.28 for gastrointestinal tract (GIT) metastases, 0.22 for melanoma, and 0.17 for breast cancer metastases.ConclusionBased on our results, primary ICTs are operated and biopsied more than two times as much as metastatic ICTs and only a small fraction of neurosurgical interventions are undertaken due to NVOL. Metastatic ICTs are predominantly supratentorial with no evidence of a tumor predominantly metastasizing in the subtentorial region. The demographics reported in the study establish some aspects of age and gender preferences, as well as the annual incidence per 100,000 for the most commonly diagnosed types of ICTs in our population.

Clinical characteristics and outcomes of patients with Guillain–Barré and acquired CNS demyelinating overlap syndrome: a cohort study based on a literature review

Background:Some patients with Guillain–Barré syndrome (GBS) also have acquired demyelination of the central nervous system (CNS) (i.e. acquired demyelinating syndrome, ADS). Often, the overlap of GBS and ADS is overlooked. Therefore, we evaluated case reports of GBS/ADS overlap syndrome.Methods:We mainly performed website-based research based on articles in cases presented with GBS/ADS overlap syndrome. A total of 66 cases were included. Clinical and prognosis data were analyzed.Results:A total of 85% of patients with simultaneous or consecutive occurrence of GBS and ADS were identified within 4 weeks of the initial diagnosis. Transverse myelitis (TM) (32%) was the most common ADS found in GBS/ADS. Patients with Miller Fisher syndrome (MFS)/ADS overlap syndrome had greater female predominance, mean age, frequency of onset at the same time period, or within a short period, and percentage of sole involvement of the subtentorial region. The outcome was favorable based on the functional status in 74% of patients. The sensory level (OR = 0·182, 95% CI = 0·055–0·598; P = 0·005) was the best predictor of a poor outcome, while visual deficit (OR = 4·667, 95% CI = 1·187–18·352; P = 0·027) predicted a favorable outcome.Conclusion:The ADS in GBS are diverse, CNS demyelinating may occur at any time, but early in the GBS course (and vice versa). MFS/ADS overlap syndromes is more common. The prognosis is generally good, but patients with sensory level deficit are likely to have a poor prognosis. The features of MFS/other CIS may better reflect involvement of the brainstem in MFS itself, rather than ADS in autoimmune peripheral neuropathies.

Desmoplastic infantile astrocytoma with benign histological phenotype and multiple intracranial localizations at presentation

Desmoplastic infantile astrocytoma (DIA) and desmoplastic infantile ganglioglioma (DIG) are rare intracranial tumors that mostly occur in the first 2 years of life and involve superficial cerebral cortex. Despite the large size of these lesions and some worrisome histological and radiological features, prognosis is generally favorable after gross total resection. We report an original observation of a desmoplastic infantile astrocytoma in a 5-year-old boy with multiple localizations on initial presentation, including the unusual subtentorial region. Magnetic resonance imaging showed a temporal tumor with prepontine and interpeduncular extension, and two other distinct localizations in cisterna magna and left cerebellar hemisphere. Leptomeningeal enhancements were present around the basal cistern. The surgical samples, corresponding exclusively to subtentorial lesions, were devoid of anaplastic features; the temporal lesion was untouched because of the interpeduncular extension. Adjuvant chemotherapy was applied, with shrinkage of lesions. DIA and DIG are more generally unifocal at initial presentation. When the tumor is large, multilobular involvement is common, but multiple location of DIG is, on the contrary, very rare. Previously, only five cases of DIG/DIA located in two or more separate locations have been published. We report the sixth, and first noninfantile, case of DIA/DIG with multifocal initial presentation.

Cervico‐medullary desmoplastic infantile ganglioglioma: An unusual case with diffuse leptomeningeal dissemination at diagnosis

Desmoplastic infantile ganglioglioma (DIG) is a rare intracranial tumor affecting newborns and infants, and generally arising in the supratentorial region. We report a case of an unusual DIG, arising at the cervico-medullary junction, with diffuse leptomeningeal seeding at diagnosis that was treated with chemotherapy (CT) and delayed partial surgery. The case we describe demonstrates that DIG can occur in the subtentorial region and can show leptomeningeal dissemination like other low-grade gliomas.

Effects of hyperosmolality on the central nervous system and intracranial hemorrhage

The relationship between hyperosmolality and intracranial hemorrhage as well as brain dysfunction was studied. Hyperosmolality was induced by continuous infusion of hyperosmotic solutions, such as 7% sodium bicarbonate (1,666 mOsm/1), 4.64% sodium chloride (1,666 mOsm/1), 20% glucose (about 1,200 mOsm/1), 20% mannitol (about 1,200 mOsm/1), and 10% glycerol with 0.9% sodium chloride and 5% fructose (about 2,000 mOsm/1). 1) Intracranial hemorrhage was observed without exception after the rabbits had died of hyperosmolality due to the infusion of these agents. The intracranial hemorrhage was mostly subdural hemorrhage in the subtentorial region. 2) The plasma osmolality just before death varied according to the agents administered and was lowest in the case of 7% sodium bicarbonate with a level of 441 mOsm/1. 3) The plasma osmolality in the case of 10% glycerol was higher than the case of 20% mannitol at the death. 4) The arousal reaction was suppressed by hyperosmotic solutions which contain sodium ions, and when the plasma osmolality surpassed 320 mOsm/1, dysfunction of the CNS began to appear. 5) The evoked muscular discharges caused by stimulation of the midbrain reticular formation were suppressed only by the administration of 7% sodium bicarbonate, so this result is related to alkalosis.

Visualization of the fourth ventricle in A-scan and B-scan echoencephalography

123 neuropediatric children were examined ultrasonically by A- and B-scan in the sagittal plane to visualize echoes from the subtentorial space. The ultrasonic beam was directed from the anterior part of the vertex to just above the sella into the subtentorial region. An echo from an interface corresponding very well with the location of the caudal part of the roof of the fourth ventricle was found in 97.6% of the cases. The origin of the echo was validated by 26 PEG examinations, both in normal and in pathological cases, and additionally in cases returning to normal after a successful shunt operation. In 20 cases with a normal sized fourth ventricle the ultrasonic finding was confirmed by a normal CT scan. The method allows a reliable determination of the fourth ventricular size both in normal cases, in cases of hydrocephalus and in cerebellar atrophies with otherwise normal ventricular systems. When the size of the fourth ventricle is compared with the other ventricles, measured ultrasonically, conclusions about the patency of the aqueduct can be drawn. It is not possible with this technique to diagnose a dilation of the cisterna magna.

Intracranial hemorrhage following administration of sodium bicarbonate in rabbits

Studies on the correlation between hyperosmolality and brain damage, especially intracranial hemorrhage, were carried out on young and newborn rabbits following infusion with 7% sodium bicarbonate. 1) All the young rabbits injected with 7% sodium bicarbonate died of hyperosmolality at over 380 mOsm/L (the mean was 462 mOsm/L) after drip infusion at the rate of 20-60 ml/kg/hr. Young rabbits under a 10% hypoxic environment died even at the 350 mOsm/L level (the mean was 392 mOsm/L) during infusion of 7% sodium bicarbonate. Half of the case of newborn rabbits injected with 7% sodium bicarbonate at 10 ml/kg, intraperitoneally, had intracranial hemorrhage at 335 mOsm/L. When the hyperosmolality reached 392 mOsm/L (50 ml/kg), intracranial hemorrhage was observed in all cases. 2) The main cause of death in young and newborn rabbits was subdural hemorrhage in the subtentorial region. Intraventricular hemorrhage was observed in about 40% of the cases of young and newborn rabbits. 3) The blood pH was elevated by the drip infusion, but when the hyperosmolality reached about 400 mOsm/L, the blood pH began to fall. At the same osmolality, pCO2 showed a marked elevation. It is likely that the decrease of the blood pH was caused by the elevation of pCO2 and the outflow of H+ from intracellular compartments resulting from the hyperosmolality. These results apparently indicate that fatal intracranial hemorrhage was induced by hyperosmolality and was enhanced by the combination of hypoxia and immaturity.