Surrounding Brain Edema Research Articles

Preoperative Prediction of Intracranial Meningioma Grade Using Conventional CT and MRI.

ObjectivePreoperative diagnosis of tumor grade can assist in treatment-related decision-making for patients with intracranial meningioma. This study aimed to distinguish between high-grade and low-grade meningiomas using conventional CT and MRI.MethodologyWe retrospectively analyzed 173 consecutive patients with intracranial meningioma (149 low-grade and 24 high-grade tumors) who were treated surgically at the National Hospital Organization Kyushu Medical Center from 2008 to 2020. Clinical and radiological features, including tumor doubling time (Td) and relative growth rate (RGR), were compared between low-grade and high-grade meningiomas.ResultsMultivariate logistic regression analysis showed that symptomatic tumor (p=0.001), non-skull base location (p=0.006), irregular tumor shape (p=0.043), tumor heterogeneity (p=0.025), and peritumoral brain edema (p=0.003) were independent predictors of high-grade meningioma. In 53 patients who underwent surgery because of tumor progression, progression to symptoms (p=0.027), intratumoral heterogeneity (p<0.001), peritumoral brain edema (p=0.001), larger tumor volume (p=0.005), shorter Td (p<0.001), and higher RGR (P<0.001) were significantly associated with high-grade meningioma. Receiver operating characteristics (ROC) curve analysis showed that the optimal Td and annual RGR cut-off values to distinguish high-grade from low-grade meningioma were 460.5 days and 73.2%, respectively (100% sensitivity and 78.6% specificity).ConclusionBased on our findings, conventional CT and MRI are useful methods to predict meningioma grades before surgery. High-grade lesions are associated with non-skull base location, irregular tumor shape, intratumoral heterogeneity, and peritumoral brain edema. High-grade meningioma should be suspected in tumors that exhibit Td <460.5 days or annual RGR >73.2% or those that develop intratumoral heterogeneity or surrounding brain edema on surveillance imaging.

A practical predictor of the growth potential of benign meningiomas: Hypointensity of surface layer in T2-weighted magnetic resonance imaging

BackgroundAccurate evaluation of proliferative potential is particularly important in the clinical management of individual patients with meningiomas. We introduce a new feature in the parenchyma of meningioma, namely, hypointensity of the surface layer (HSL), on T2-weighted MR images and compare it with a cellular proliferation index and growth speed. Materials and methodsWe retrospectively analyzed the records of consecutive patients with WHO grade I meningiomas in two institutes: an operated group with 124 meningiomas resected in one institute, and an observed group with 89 meningiomas monitored without surgery in the other. Proliferative potential was evaluated using the MIB-1 labeling index (MIB-1 LI) for the operated group and using the relative growth rate on serial MR images for the observed group. ResultsIn the operated group, 60 (48.4%) meningiomas exhibited HSL. HSL-positive meningiomas were significantly smaller in size and more often calcified than HSL-negative ones. Univariate analysis showed that HSL negativity, large size, no calcification, and surrounding brain edema were significantly associated with high MIB-1 LI (p < 0.05). Multivariate analysis demonstrated that only HSL was significantly related to MIB-1 LI (p = 0.001). HSL did not correlate with tumor recurrence after resection. In the observed group, 43 (48.3%) meningiomas exhibited HSL and they presented a significantly slow relative growth rate. ConclusionsHSL is a simple and new radiological feature indicative of low proliferative potential and a low risk of enlargement of meningiomas. The presence or absence of HSL may serve as a key parameter for the selection of aggressive treatment or active observation.

Primary Central Nervous System Vasculitis Mimicking Brain Tumor

Primary central nervous system vasculitis (PCNSV) is a rare disease with a nonspecific and expansive spectrum of clinical manifestations. A 40-year-old woman presented with acute onset of severe headache associated with nausea. Computed tomography of the brain showed 1 solitary hypodense parenchymal lesion over the left temporal lobe with an internal fluid level. A brain magnetic resonance imaging showed the presence of 1 isointense parenchymal lesion on T1-weighted and T2-weighed images, with surrounding brain edema. The patient accepted craniotomy for excision of lesion under the preoperative impression of brain tumor with hemorrhagic transformation. The pathologic report was extensive vasculitis with hemorrhagic infarction. The diagnosis of PCNSV was made after exclusion of secondary causes–related vasculitis and hereditary hypercoagulant status. This report highlights that PCNSV could appear as a hemorrhagic tumor-like lesion on neuroimaging. Considering PCNSV in the differential diagnosis is important in patients suspected with cerebral hemorrhage, cerebral thrombosis, or brain tumor.

Atypical Teratoid Rhabdoid Tumor in a Child: Case Report

Atypical teratoid/rhabdoid tumor (ATRT) is a rare and aggressive type of embryonal tumor of the central nervous system (CNS) occurring in childhood. The present study aims to describe the case of a 16-year-old girl who presented with an occipital mass lesion that was diagnosed as ATRT. We present a brief review of the current knowledge of the treatment of this rare neoplasm. A previously healthy 16-year-old girl was referred after two episodes of partial complex seizure 2 weeks before admission. MRI showed a right parieto-occipital lesion with homogeneous contrast-enhancing and significant surrounding brain edema. The patient underwent uneventful surgical resection of the lesion and was discharged home on the fifth postoperative day. Pathologic examination revealed it to be ATRT. The patient was referred to chemotherapy and radiotherapy. After 6 months of follow-up, the patient remains free of seizure and disease progression. ATRT is a rare and aggressive disease. Therefore, early diagnosis and treatment may improve the patient's prognosis and quality of life.

Intracranial hypertension associated with obstructive sleep apnea: A discussion of potential etiologic factors

Obstructive sleep apnea has been shown to increase intracranial pressure, and to be a secondary cause of intracranial hypertension. There are a few theories that attempt to explain this relationship, however there is little data, and even less recognition among physicians that this actually occurs. This paper discusses multiple pieces of data, from anatomical correlates to biochemical information involving neuro-excitotoxicity, as well as hematologic factors and issues surrounding brain edema and blood–brain barrier dysfunction. A complex paradigm for how obstructive sleep apnea may lead to increased intracranial pressure is thus proposed. In addition, suggestions are made for how obstructive sleep apnea must as a result be managed differently in the setting of idiopathic intracranial hypertension.

Intracerebral foreign body granuloma caused by a resorbable plate with passive intraosseous translocation after cranioplasty

Numerous reports have demonstrated the usefulness of bioresorbable materials, but few have described severe complications caused by delayed degradation. The authors present the case of an intracranial foreign body granuloma caused by plates made of unsintered hydroxyapatite (uHA) particles and poly-l-lactide (PLLA; Super Fixsorb MX, Takiron) after cranioplasty. This 1-month-old boy presented to the authors' department with Pfeiffer syndrome. He had multiple-suture synostosis causing turribrachycephaly, Chiari malformation Type 1, and obstructive sleep apnea syndrome. At 6 months old, the child was treated with multidirectional cranial distraction osteogenesis. The uHA-PLLA plates were applied as base stones to reinforce the pins. After 16 days of distraction and 3 weeks of consolidation, the pins were removed. Seventeen months postoperatively, the plate on the right temporal bone showed passive intraosseous translocation (PIT), and by 2 years postoperatively, the plate was completely left behind in the cerebrum. At 3.5 years postoperatively, MRI disclosed a contrast-enhanced mass with surrounding brain edema at the site of the plate. The lesion was resected. The clinical history and histological specimens led to a diagnosis of foreign body granuloma surrounding the nonabsorbed resorbable plate in the dura mater. Resorbable plates are clearly useful resources in cases in which delayed absorption will not prove problematic, but careful application and follow-up is required when dealing with the growing skull given the possibility of intracranial displacement after PIT.

Rapid progression of rhabdoid components of a composite high-grade glioma and rhabdoid tumor in the occipital lobe of an adult

We report a very unusual case of a composite high-grade glioma and rhabdoid tumor in an adult. A 22-year-old woman presented with scintillating scotoma due to a solid tumor with surrounding brain edema in the right occipital lobe. The tumor was grossly resected. Histological examinations showed that the tumor was mainly composed of INI1-positive high-grade glioma tissue containing an INI1-negative rhabdoid component. She received radiation therapy and chemotherapy. Three months after the surgery, she again complained of visual disturbances, and tumor recurrence within the resection cavity was noted. A second operation was performed. The findings of histological examinations of the surgical specimen obtained during the second surgery were completely different from those of the specimen obtained during the initial surgery. Only the rhabdoid component showed remarkable proliferation and did not express INI1. Diffuse dissemination along the craniospinal axis eventually progressed, and she died 5months after the initial diagnosis. We suggest that the inactivation of the INI1 gene affects potent proliferation activity and resistance to both chemotherapy and radiation therapy.

Microsurgical treatment of intracranial chondroma

Intracranial chondromas are rare benign tumors. Little data are available on the diagnosis and treatment of these tumors. Thus, we aimed to describe a large series of patients with intracranial chondroma and to analyze and discuss the clinical features and microsurgical treatment of these patients. We retrospectively analyzed the clinical data of 30 patients (12 males and 18 females; mean age 35.4 years; age range 16–60 years) who had pathologically confirmed intracranial chondroma treated at our hospital from September 1996 to June 2008. Surgery was performed on all 30 patients: five patients underwent postoperative radiotherapy; 26 patients were followed up postoperatively for a mean duration of 45.8 months. The surgical approach was selected according to tumor location. Total resection was achieved in 11 patients, subtotal resection in 13, and partial resection in nine (three patients had recurrent chondroma). Follow-up showed that 21 patients recovered without recurrences, three had recurrence, and two patients died. The clinical manifestations included headache and multiple cranial nerve lesions. Imaging usually showed a well-demarcated extramedullary tumor, centrally located, without surrounding brain edema, partially calcified (73.3%) and with minimal vascularity, often accompanied by erosion and destruction of surrounding bone (56.7%). It is difficult to totally remove an intracranial chondroma, and it is not possible to differentiate a chondroma from a myxoma or chordoma at the cranial base on the basis of clinical manifestations and neuroradiological findings. Selection of the appropriate surgical approach is important for resection of the tumor.

Surgical Treatment for Late Complications following Gamma Knife Surgery for Arteriovenous Malformations

Background: To establish the surgical indications and strategy for late complications following gamma knife surgery (GKS) for arteriovenous malformations (AVMs). Methods: Ten male and 7 female patients aged 17–52 years (mean 28.0 years) were retrospectively identified among 686 patients who underwent GKS for AVM at our hospital. Ten patients showed cyst formation (group A), 2 patients had expanding hematoma (group B), and 5 patients had both cyst and expanding hematoma (group C). Results: The mean nidus volume was 10.1 ml (range 0.1–36 ml), and the mean prescription dose at the nidus margin was 19.9 Gy (range 18–28 Gy). Complete obliteration of the nidus was obtained in 12 patients, partial obliteration in 4, and no change in 1. Cyst formation (group A) was asymptomatic in 5 patients, and symptomatic in 5 patients, manifesting as headache, hemianopia, aphasia, and motor weakness. Expanding hematoma (groups B and C) was associated with surrounding brain edema and was symptomatic in all 7 patients. Cyst opening in 1 patient and placement of an Ommaya reservoir in 2 patients were necessary in group A. Both patients in group B underwent craniotomy. Four of the 5 patients in group C required craniotomy. Another patient in group C was lost to follow-up and the final outcome was unknown. Conclusions: Cyst formation is one of the late complications of GKS for AVM. Some cysts show spontaneous regression but others gradually increase in size and become symptomatic, although relatively large asymptomatic cysts are also known. Predicting the future course of a cyst is difficult. Surgery such as placement of an Ommaya reservoir should be considered for symptomatic cases. Expanding hematoma always increases in size and becomes symptomatic, so removal by craniotomy is necessary. Surrounding brain edema decreases rapidly after surgery and neurological symptoms quickly resolve.

Primary Angiitis of the Central Nervous System Mimicking Tumor-Like Lesion -Case Report-

A 60-year-old man presented with a rare case of primary angiitis of the central nervous system mimicking a tumor-like lesion and manifesting as slight disorientation, left hemiparesis, and motor aphasia. Computed tomography showed multiple low density lesions in the left frontal lobe, brain stem, and right parietal lobe. Magnetic resonance images revealed a slightly enhanced mass lesion in the right parietal lobe with surrounding brain edema. Serum, cerebrospinal fluid, and other image examinations did not show any abnormal findings, so surgical removal of the right parietal mass was performed. Histological examination revealed that the mass consisted of hemorrhagic infarction without cellular atypia. Proliferations of endothelial cells in small and medium arteries, and infiltration of macrophages in the perivascular space were detected in the infarction tissues. The histological diagnosis was primary angiitis of the central nervous system.

脳動静脈奇形のガンマナイフ後に生じた血管腫様病変の３手術例

We evaluated surgical treatment for angiomatous lesion developing after gamma knife radiosurgery (GKS) for arteriovenous malformation (AVM) by retrospectively examining the medical records of 3 female patients aged 20 to 52 years (mean 31.3 years) at the time of GKS, who developed symptomatic angiomatous lesion associated with severe surrounding brain edema 9-11 years after GKS. Angiomatous lesions were dark red and well demarcated from the brain. Bleeding during resection was slight and easily controlled, but the angiomatous lesions were very fragile and difficult to remove en bloc. Therefore, total removal is not easy in the case of angiomatous lesions in deep locations such as interhemispheric sites with lateral extension. Angiomatous lesion developing after GKS for AVM is rare but becomes progressively symptomatic with severe surrounding brain edema, and the only treatment is surgery.

Giant Skull Base Atypical Meningioma Presenting With Rapidly Progressive Impaired Consciousness Caused by Severe Venous Congestion -Case Report-

A 43-year-old female presented with a giant skull base atypical meningioma manifesting as rapid progression of impaired consciousness. The meningioma was located in the ethmoid sinus, sphenoid sinus, nasal cavity, and left middle temporal fossa, and the intracranial portion of the tumor involved the left temporal region with massive surrounding brain edema in the left temporal lobe and basal ganglia. She underwent emergent fronto-temporo-parietal decompressive craniectomy, and the intracranial portion of the tumor was resected to control intracranial pressure. She recovered consciousness and neurological function dramatically, and subsequently underwent radical tumor resection via combined extended transbasal and left lateral transzygomatic infratemporal fossa approaches one month after the initial surgery. The extensive brain edema completely disappeared after tumor resection, and the patient fully recovered without neurological deficits except anosmia and small visual field defect. Rapid neurological deterioration and disturbance of consciousness caused by extensive peritumoral brain swelling are unusual in meningioma. In this case, the extemporaneous decompressive craniectomy was highly useful in the management of increased intracranial pressure.

Claude's Syndrome Associated with Neurocysticercosis

Claude's syndrome is a distinctive brainstem syndrome characterized by ipsilateral third cranial nerve palsy with contralateral hemiataxia and is due to an intrinsic or extrinsic lesion in the midbrain. We report a case of Claude's syndrome caused by neurocysticercosis infection. A 68 year-old Asian man was admitted to our hospital because of ataxia, left ptosis, and diplopia. Brain magnetic resonance imaging (MRI) showed a cystic lesion in the midbrain, which was surrounded by ring enhancement and peripheral edema. Neurocysticercosis infection was diagnosed by the cerebral spinal fluid study. The patient was treated with albendazole and steroids. A follow-up brain MRI three months later demonstrated the disappearance of a surrounding brain edema and rim enhancement. The most common cause of Claude's syndrome is cerebrovascular disease and malignancy. However, there is no report caused by neurocysticercosis infection. Therefore, if we encounter Claude's syndrome, we should consider neurocysticercosis infection as one of the etiologic factors.

INTRAOPERATIVE FLUORESCENCE STAINING OF MALIGNANT BRAIN TUMORS USING 5-AMINOFLUORESCEIN-LABELED ALBUMIN

The newly developed conjugate 5-aminofluorescein (AFL)-human serum albumin (HSA) was investigated in a clinical trial for fluorescence-guided surgery of malignant brain tumors to assess its efficacy and tolerability. AFL, covalently linked to human serum albumin at a molar ratio of 1:1, was administered intravenously 0.5 to 4 days before surgery at 0.5 or 1.0 mg/kg of body weight to 13 patients aged 38 to 71 years who were suspected of having malignant gliomas. Fluorescence guidance using a 488-nm argon laser was performed during surgery at will. The extent of tumor resection was verified by early postoperative magnetic resonance imaging. Fluorescent and nonfluorescent samples were collected for neuropathology. Blood samples for laboratory and pharmacokinetic analyses were taken over the course of 4 weeks. Fluorescence staining of tumor tissue was bright in 11 patients (84%), resulting in complete resection of fluorescent tumor tissue in 9 patients (69%). In 2 patients, residual fluorescent tumor tissue was also confirmed by magnetic resonance imaging. Neither bleaching nor penetration of AFL-HSA into the surrounding brain edema or into necrotic tissue was seen. The agreement between fluorescence and histopathology in tumor samples and samples of the tumor border was 83.3%. There were no toxic side effects. The quality of fluorescence was independent of the dose administered. The optimal time for surgery is between 1 and 4 days after AFL-HSA administration. Tumor fluorescence using AFL-HSA made fluorescence-guided brain tumor resection possible, demonstrating that albumin is a suitable carrier system for selective targeting of aminofluorescein into malignant gliomas.

Olfactory colloid cyst

Colloid cysts are rare intracerebral lesions that are predominantly located in the third ventricle. Extraventricular colloid cysts have only rarely been reported but so far there are no reports of a colloid cyst residing in the olfactory groove. A 74-year-old patient underwent a brain computed tomography scan for a mild head trauma that incidentally revealed a space-occupying lesion near the olfactory groove. Brain magnetic resonance imaging that ensued demonstrated a hyperintense lesion in T 1, T 2, and FLAIR sequences, without evidence of surrounding brain edema. To evaluate the metabolic status of the lesion, brain single-photon emission computed tomography with 99mTc-Tetrofosmin was then performed, revealing no tracer uptake, a finding consistent with benignity. Due to the diagnostic uncertainty the excision of the lesion was proposed. The patient underwent surgery and intraoperative a cyst was revealed. Furthermore the cyst seemed to erode the dura and due to its location there was an imminent danger for cerebrospinal fluid leak. Therefore a repair of the dura was performed and the cyst was excised totally. Histology verified the presence of a colloid cyst. Colloid cysts should be included in the differential diagnosis of lesions in the anterior fossa and although benign they may have an aggressive presentation by eroding the dura and producing CSF leak.

Identification of brain tissue necrosis by MRI: validation by histomorphometry.

The volume of an experimental necrotic lesion of the cortex expands up to 400% of its initial size within the first 24 h after the insult. Lesion expansion, a clinically well known phenomenon, is often accompanied by perifocal brain edema and consequently difficult to image and to analyze by magnetic resonance imaging (MRI). Therefore we aimed to validate a T(2)-weighted spin echo sequence upon its ability to distinguish necrotic from edematous brain tissue. Male Sprague-Dawley rats (n = 5 per group) were subjected to a cortical freezing lesion leading to immediate tissue necrosis with subsequent perifocal vasogenic brain edema. Immediately and 4, 12, and 24 h after the lesion the maximal area of necrosis was quantified longitudinally by coronal T(2)-weighted spin echo MRI-scans. After the last scan, animals were sacrificed for direct comparison of the lesion area obtained by MRI and histomorphometry. In parallel groups of animals, lesion expansion was quantified by histology. The acquired T(2)-maps clearly distinguish the cortical necrosis from perifocal edema and healthy brain. Focal freezing led to a cortical lesion of 5.24 +/- 0.36 mm(2) immediately after trauma (0 h; 100%) which expanded progressively to a maximum of 6.82 +/- 0.34 mm(2) after 24 h (131%; *p < 0.01 vs. 0 h). Lesion expansion quantified by histology was almost identical (132% within 24 h). Histological assessment resulted in smaller absolute lesion areas compared to MRI, most likely due to shrinking during tissue processing (4.72 +/- 0.26 mm(2) vs. 6.82 +/- 0.34 mm(2), p < 0.01). The current study shows that necrotic brain tissue can be distinguished from surrounding brain edema by T(2)-mapping. The technique is sensitive enough to detect small changes in necrosis expansion in vivo as validated by histology. The presented technique may be a useful future tool for the non-invasive identification of necrotic brain tissue following brain injury (e. g., from trauma or ischemia).

Role of hydrodynamic processes in the pathogenesis of peritumoral brain edema in meningiomas.

In a prospective study, 28 patients with 32 intracranial meningiomas were examined to determine the role of hydrodynamic interaction between tumor and surrounding brain tissue in the pathogenesis of peritumoral brain edema. Gadolinium-diethylenetriamine pentaacetic acid (Gd-DPTA), an extracellular contrast agent used for routine clinical imaging, remains strictly extracellular without crossing an intact blood-brain barrier. Therefore, it is well suited for investigations of hydrodynamic extracellular mechanisms in the development of brain edema. Spin-echo T1-weighted magnetic resonance images were acquired before and after intravenous administration of 0.2 mmol/kg Gd-DPTA. Additional T1-weighted imaging was performed 0.6, 3.5, and 6.5 hours later. No significant Gd-DPTA diffused from tumor into peritumoral brain tissue in 12 meningiomas without surrounding brain edema. In contrast, in 17 of 20 meningiomas with surrounding edema, contrast agent in peritumoral brain tissue was detectable after 3.5 hours and 6.5 hours. In three of 20 meningiomas with minimum surrounding edema (<5 cm3), contrast agent effusion was absent. After 3.5 hours and 6.5 hours strong correlations of edema volume and the maximum distance of contrast spread from the tumor margin into adjacent brain parenchyma (r = 0.84 and r = 0.87, respectively, p < 0.0001) indicated faster effusion in larger areas of edema. The results of this study show that significant contrast agent effusion from the extracellular space of the tumor into the interstitium of the peritumoral brain tissue is only found in meningiomas with surrounding edema. This supports the hypothesis that hydrodynamic processes play an essential role in the pathogenesis of peritumoral brain edema in meningiomas.