Temporal Lesions Research Articles

Surgical Treatment of Mesial Temporal Lobe Epilepsy in a Patient with Neurofibromatosis Type 1

Neurofibromatosis type 1 (NF1) is the most common neurocutaneous disease. Main neurologic manifestations are represented by neoplasms such as optic gliomas, but epilepsy can occur by CNS lesions in less than 10%. Our patient was diagnosed, based on café-au-lait spots and axillary freckles. Her brain MRI did not show only multiple CNS lesions, like hamartomas, but also mesial temporal lesions. On brain-MRI the mesial temporal lesions had increased high signal intensities and suspiciously increased volume. Moreover scalp lesions could be confirmed by thin-slice, fat suppression, enhanced lesions on skin and subcutaneous areas, indicating neurofibromas. The seizure onset zone was confirmed by presurgical evaluation including electrophysiology and neuroimaging. Her seizures were refractory to multiple antiepileptic drugs, but became free after anteromesial temporal resection. We report a patient with the NF1 in mesial temporal lobe epilepsy. Epilepsy surgery was also effective in this case.

Safety and Efficacy of Frameless Stereotactic Brain Biopsy Techniques

To explore the safety and efficacy of frameless stereotactic brain biopsy. Diagnostic accuracy was calculated by comparing biopsy diagnosis with definitive pathology in 62 patients who underwent frameless stereotactic brain biopsy between January 2008 and December 2010 in Xiamen University Southeast Hospital. Preoperative characteristics and histological diagnosis were reviewed and then information was analysed to identify factors associated with the biopsy not yielding a diagnosis and complications. Diagnostic yield was 93.5%. No differences were found between pathological diagnosis and frozen pathological diagnosis. The most common lesions were astrocytic lesions, included 16 cases of low-grade glioma and 12 cases of malignant glioma. Remote hemorrhage, metastasis, and lymphoma were following in incidence. Multiple brain lesions were found in 17 cases (27.4%). Eleven cases were frontal lesions (17.7%), 8 were frontotemporal (12.9%), 6 were frontoparietal (9.7%), and 5 each were temporal, parietal, and parietotemporal lesions (8.1%). Postoperative complications occurred in 21.0% of the patients after biopsies, including 10 haemorrhages (16.1%) and 3 temporary neurological deficits (1 epilepsy, 1 headache, and 1 partial hemiparesis). No patient required operation for hematoma evacuation. Frameless stereotactic biopsy is an effective and safe technique for histologic diagnosis of brain lesions, particularly for multifocal and frontal lesions.

Bisphosphonate-associated osteonecrosis of the external auditory canal

Osteonecrosis is a benign condition characterised by necrotic exposed bone, and is associated with bisphosphonate use. Osteonecrosis of the external auditory canal is rare, with only a few reported cases. Two case reports of temporal bone osteonecrosis are presented. A 64-year-old man with a history of immunoglobulin G kappa multiple myeloma developed a right external auditory canal ulcer 6 years after commencement on clodronate. A 72-year-old woman taking alendronate for osteoporosis, initially diagnosed and treated for right-sided otitis externa, was found to have underlying exposed bone in the right external auditory canal, with a computed tomography scan confirming destruction of the temporal bone. With increasing use of both oral and intravenous bisphosphonates in the community for benign conditions such as osteoporosis and for malignant conditions such as breast cancer and multiple myeloma, the diagnosis of bisphosphonate-associated osteonecrosis should always be considered in patients with a temporal bone lesion, and a relevant drug history taken.

Advanced Neuroimaging Studies in a Patient with Brain Metastases from Transitional Cell Carcinoma of the Bladder

The differential diagnosis in single or oligo-brain lesions in metastatic cancer patients remains broad. Advanced imaging studies can be employed to help refine the differential and potentially guide treatment. Case report of a 52-year-old male patient with known transitional cell carcinoma of the bladder presented with headaches, cognitive symptoms, and episodic presyncope. Brain magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), and octreotide scans were performed to evaluate the underlying etiology of his symptoms. MRI revealed two enhancing mass lesions in left temporal and left cerebellar locations. Both lesions were octreotide avid and MRS of the temporal lesion showed a single large lipid peak at 1.3 ppm, a small NAA peak, and a markedly increased choline:creatine ratio that was relatively characteristic for metastases. Pathology from surgical resection revealed transitional cell carcinoma of the bladder. Resection of both lesions revealed metastatic transitional cell carcinoma. This is the first report of octreotide scan characteristics in a patient with transitional cell carcinoma with central nervous system (CNS) metastases. The octreotide avidity of these transitional cell CNS metastases suggests the presence of somatostatin receptors that may be considered as a potential therapeutic target.

Dysglycemia, brain volume and vascular lesions on MRI in a memory clinic population

ObjectiveIt is unclear, if the association between abnormalities in glucose metabolism (dysglycemia) and impaired cognitive functioning is primarily driven by degenerative or vascular brain damage. We therefore examined the relation between dysglycemia and brain volume and vascular lesions on MRI in a memory clinic population. MethodsThe relations between markers of glycemia (HbA1c and fasting glucose levels) and normalized brain volume, medial temporal lobe atrophy and vascular lesions (white matter hyperintensities, lacunes) were assessed in 274 consecutive patients attending a memory clinic, using linear regression analyses. ResultsClinical diagnoses were subjective complaints (n=117), mild cognitive impairment (n=62), Alzheimer's disease (n=61) and other type of dementia (n=34). Twenty patients had a history of diabetes. Across the whole study population there was no relation between HbA1c or fasting glucose and the brain MRI measurements, after adjustments for age, sex and diagnostic group. Secondary analyses after stratification by diabetes status, diagnosis and median age (67years) did not change the results. ConclusionIn this memory clinic population, dysglycemia was not associated with either brain volume or vascular lesions. Apparently, dysglycemia is not associated with a specific class of brain pathology in patients with cognitive complaints.

Dehiscences of the semicircular canals as discrete third window lesions of the inner ear

The aim of this study was to assess the role of high resolution multi-detector CT in diagnosis of different dehiscences of the semicircular canals (SCC). Material and MethodsThis study was conducted on 20 patients within one year interval. All the patients had given clinical diagnosis of dehiscences of the SSC by clinical examination and/or audiogram. Sixty-four MDCT was used in assessment of all patients. ResultsCongenital defects of the SCC were encountered in 9 cases (45%); acquired defects were encountered in 11 cases (55%). Among the congenital defects, superior and posterior SCC were involved in 6 and 3 patients (30 and 15%) respectively. Congenital defects of lateral SSC were not encountered in this study. Cholesteatoma was the most common single etiology causing defect within the SCC. ConclusionRadiological diagnosis of SCC dehiscences depends on the use of high resolution MDCT. Ultrathin reconstruction with MPR is mostly sufficient in accurate display of the defects. Primary congenital dehiscences do occur in the superior SCC but also less commonly within the posterior canal. In this study, lateral canal dehiscence was only acquired. Secondary semicircular canal dehiscences could be caused by cholesteatoma and temporal bony aggressive mass lesions.

Attention network impairments in patients with focal frontal or parietal lesions

Recently, research on attention has focused on 3 networks that are linked to separate brain regions, i.e. orienting, alerting, and executive control. The attention network test (ANT) is one of the methods to measure the three attention functions. However, neuropsychological investigations have not examined the anatomical disassociation of different attention networks with the same task. We compared the efficiencies of the 3 networks between brain-damaged patients (27 frontal lesions, 20 temporal lesions, and 21 parietal lesions) and healthy controls (N=58) with ANT. Comparing the brain damaged group with the normal controls, a reduced efficiency of the executive network was found in patients with frontal lobe and parietal lobe injuries, and there was also a deficit in the orienting network in patients with parietal lobe injuries. Analysis of lateralization indicated the right hemisphere superiority to the alerting system. The present study found that the three attentional networks were selectively impaired following brain damage which affected different areas in the brain.

Inflammatory Pseudotumor of the Temporal Bone: Three Cases and a Review of the Literature

Inflammatory pseudotumor (IP) is a clinically aggressive but histologically benign condition of unknown cause. Its appearance in the temporal bone is uncommon. We present clinical, radiological, and histopathologic findings of three cases originating in the temporal bone. In the first case, a simultaneous IP of the temporal bone and parotid gland was found with histopathologic confirmation. In the second case, an enlarged cervical node, which was also believed to be related to IP, was observed accompanied with the temporal lesion. While the third case presented with chronic suppurative otitis media. Two of them were treated by surgery alone with complete resolve of the diseases. Another one underwent tympanomastoidectomy in combination with oral steroids, radiation, and chemotherapy, but the IP still recurred. A comprehensive review of the literature on clinical features of the temporal pseudotumor was conducted.

Global Aphasia Without Hemiparesis

Global aphasia without hemiparesis (GAWH) is a rare stroke syndrome. Using transcranial magnetic stimulation (TMS), we evaluated 2 possible pathogenic mechanisms for GAWH: sparing of the decussated pyramidal tract, or alternatively, compensation by the ipsilateral pyramidal tract. Six patients were diagnosed to have GAWH by the Standard Language Test of Aphasia for Japanese. All patients underwent brain magnetic resonance (MR) imaging and angiography. According to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria, stroke subtype was determined as 3 patients with cardioembolic stroke, 2 with large-artery atherosclerosis, and 1 with another type. All patients underwent TMS, using a figure-of-8 coil, from 3 to 12 months after the onset, and motor evoked potentials were recorded on the abductor digiti minimi muscles. All patients had left-sided frontal or temporal lesions that were confirmed by MR diagnostic imaging. No motor evoked potential could be recorded by ipsilateral TMS. In 3 patients, brain stimulation on either side evoked the same amplitude on the contralateral abductor digiti minimi, whereas in the other 3 patients, the amplitude was suppressed on the right side. The infarction in the former patients was caused by cardioembolism and in the latter was not. In serial slices of brain MR imaging, the pyramidal tract was spared in the former and was involved to various degrees in the latter 3 patients. We recommend that GAWH was caused by the sparing of the decussated pyramidal tract. The pyramidal tract was intact in cases of GAWH caused by cardioembolism and subclinically impaired by other causes.

Crystal storing histiocytosis presenting as a temporal lobe mass lesion

Background:Crystal storing histiocytosis (CSH) is a disorder characterized by local or diffuse infiltration of histiocytes containing crystalline inclusions most commonly of immunoglobulin light chain. Involvement of the central nervous system is extremely rare. CSH may be misdiagnosed as an infection or tumor. In patients with involvement of other organs, it is frequently associated with lymphoplasmacytic diseases.Case Description:A 20-year-old female was evaluated for 2 weeks of progressively worsening headaches. At presentation, she had no history of fevers but reported a sore throat without cough 3-4 days prior. Her past medical history was unremarkable. She denied intravenous drug use or sexually transmitted diseases but lived with an individual with a history of fungal meningitis. On examination she was afebrile, alert, and oriented with a blood pressure of 110/70 mmHg. She had no adenopathy or neurological deficits. Her white blood cell count was minimally elevated. Magnetic resonance imaging revealed a 3.5 × 1.3 × 1.9 cm contrast enhancing lesion of the left temporal lobe with a mild midline shift. Evaluation by multiple specialists suggested a differential diagnosis of an infectious or neoplastic process. Cultures for infectious agents were negative. The biopsy showed CSH. Postoperatively and at 1 month follow up, she was neurologically intact.Conclusion:Radiographically and intraoperatively, CSH may mimic an infectious process or neoplasm. Its recognition is critical to facilitate appropriate therapy and prompt screening for an occult lymphoplasmacytic neoplasm, plasma cell dyscrasia or other underlying disease.

Rapidly Progressive Anomic Aphasia: A Rare Presentation of Temporal Lobe Tumor

Rapidly Progressive Anomic Aphasia: A Rare Presentation of Temporal Lobe Tumor

A neuropsychological approach to time estimation

Time estimation, within a range of seconds, involves cognitive functions which depend on multiple brain regions. Here we report on studies investigating the reproduction and production of three durations (5, 14, and 38 seconds) in four groups of patients. The amnesic patient underproduced the length of the long durations because of episodic memory deficit following bilateral medial temporal lesions. Epileptic patients (n = 9) with right medial temporal lobe resections underproduced the three durations because of a distorted representation of time in long-term memory. Traumatic brain injury patients (n = 15) made more variable duration productions and reproductions because of working memory deficits following frontal-lobe dysfunction. Patients with Parkinson's disease (n = 18) overproduced the short duration and underproduced the long duration because of a possible increase in internal clock speed following levodopa treatment, as well as working memory deficits associated with frontal-lobe damage. Further research, in neurological and psychiatric patients, is required to better understand the underlying mechanisms of time estimation.

Surgical outcome in neocortical resections of type IIId focal cortical dysplasia with accompanying medial temporal pathology.

Focal cortical dysplasia (FCD) type IIId is a newly proposed type associated with early-life brain insults. Such patients are often considered unsuitable for resective epilepsy surgery, given the usually wide extent of the lesion and the poor correlation of MRI to the epileptogenic pathology. Two patients with intractable epilepsy, early-life ischemic/traumatic injury and MRI findings of extensive unilateral cystic-gliotic and ipsilateral medial temporal sclerotic-malformative lesions were subjected to presurgical evaluation revealing well-localized neocortical ictal onsets. They underwent tailored neocortical resections sparing medial temporal areas and achieved Engel class I postsurgical outcomes. Histopathology was consistent with type IIId focal cortical dysplasia. Successful outcomes with tailored resections may be achieved in cases with this subtype of focal cortical dysplasia, in the presence of converging and well-localized semiological, EEG and functional imaging data, even on a background of complex and extensive MRI abnormalities. Medial temporal pathology, although often present in this setting, is not necessarily the site of ictal onsets, and its resection may not be always mandatory for a favorable outcome.

Lower Susceptibility to Cerebral Small Vessel Disease in Human Familial Longevity

On MRI, cerebral white matter lesions, lacunar infarcts, and cerebral microbleeds are common imaging correlates of cerebral small vessel damage in apparently healthy elderly individuals. We investigated whether middle-aged to elderly offspring of nonagenarian siblings, who are predisposed to become long-lived as well, have a lower prevalence of white matter lesions, lacunar infarcts, and cerebral microbleeds than control subjects. All subjects were from the Leiden Longevity Study. In this study, middle-aged to elderly offspring of nonagenarian siblings, who are predisposed to become long-lived as well, were contrasted to their spouses. Cerebral small vessel disease was assessed using 3-T MRI. Offspring were less likely to have severe periventricular frontal caps (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.1-1.1; P trend=0.01) and severe periventricular bands (OR, 0.4; 95% CI, 0.2-0.8; P trend=0.02). Moreover, offspring were less likely to have frontal (OR, 0.4; 95% CI, 0.2-0.9; P trend=0.05), parietal (OR, 0.4; 95% CI, 0.1-0.9; P trend=0.001), temporal (OR, 0.3; 95% CI, 0.1-0.8]; P trend=0.004), and occipital subcortical white matter lesions (OR, 0.3; 95% CI, 0.1-0.6; P trend=0.001). Prevalence of lacunar infarcts also was lower in offspring (OR, 0.3; 95% CI, 0.1-1.1; P=0.07). Prevalence of microbleeds was not significantly different in offspring and control subjects. Exceptional familial longevity is associated with a lower susceptibility to white matter lesions and lacunar infarcts, but not cerebral microbleeds.

Unusual clinico-pathological features in primary Hodgkin’s lymphomas of the central nervous system

Primary Hodgkin's lymphomas of the central nervous system (CNS) as well as cerebral involvement as the first manifestation of a systemic Hodgkin's disease are very rare. CNS involvement usually occurs in patients with advanced or relapsing systemic disease. Because primary CNS Hodgkin's lymphoma may present unexpected and sometimes misleading clinical and neuroradiological features, the description of unusual cases is important for expanding the awareness of this rare disease of the central nervous system. We describe three cases of primary Hodgkin's lymphoma of the CNS with peculiar features. None of the three patients had a previous clinical history of systemic Hodgkin disease. Case 1 and case 2 presented an unusual localization in the cerebellar hemisphere and in the brainstem, respectively. The third case occurred as a temporal lesion in the settings of a Richter transformation of a chronic lymphocytic leukemia.

Glioblastoma Multiforme Mimetizando Encefalite Límbica

Selective and bilateral involvement of the limbic system by gliomas is rarely reported. The authors report the case of a 58 years-male complaining of short-term memory loss in the preceding three weeks. The initial MRI revealed areas of hyperintensity on T2 and FLAIR sequences involving both hippocampus, amygdala, parahippocampus gyrus and the fornix, with contrast enhancement in the right mesial temporal region. Limbic encephalitis diagnosis was assumed and steroid therapy was applied. All other evaluation work-up was negative and follow-up imaging was compatible with tumor. The neuropathologic study of the right temporal lesion revealed glioblastoma multiforme. Glioblastoma can crossover through the commissural white matter to the opposite cerebral hemisphere, most often through the corpus callosum. However, selective and bilateral invasion of the limbic system is rare and when it occurs it may mimic limbic encephalitis.

Antibody Mediated Rejection (AMR) Lesions in Renal Biopsies: Evidence of Progression with a Specific Microvascular Inflammatory Phenotype. Diagnostic Implications

Introduction: The diagnosis of AMR hinges on the combination of DSA, C4d and microvascular injury/inflammation (MVI) but is complicated by temporal lesion variations and the fluctuations of C4d staining and DSA levels. MVI needs therefore to be fully analized for optimal diagnostic use. Methods: 563 consecutive renal biopsies (Bx) from 496 patients were analyzed using current Banff criteria and were stained with C4d, CD68 and CD3. For each biopsy, concurrent DSA measurements were also available. The mean number of biopsies per patient was 1.44 ((+/- 0.91, median 1). Mean patient age was 50.27 yeras (+/-13.79). 63.1% of the patients were male, 8.1% had regrafts and 6.6% were hepatitis C positive. Specific definitions used for analysis: C4d+ ≥10% staining in peritubular capillaries; DSA+ >1000MFI; MVI defined as glomerulitis (g), transplant glomerulopathy (cg) and peritubular capillaritis (ptc) >0 scores. On electron microscopy (EM), TG was defined by duplication of the basement membranes, whereas endothelial injury (EI) was defined as swelling, loss of fenestrations ± expansion of the subendothelial space. The maximum nubmer of glomerular macrophages and lymphocytes were also counted (GM and GL) with CD68 and CD3 stains, respectively. Results: Cases with acute T-cell mediated rejection (ACMR) (n=76) or cases lacking any AMR or ACMR features (n=187) had an average of 5±6 GM/3.4±4.8 GL and 3.67±4.62 GM/1.57±2.52 GL respectively (NS), whereas cases with any combination of AMR parameters that includes MVI displayed a similarly marked increase of GM/GL (up to 16.58±12.19 GM/ 7.94±6.64 GL, p=.000). In contrast cases with only C4d and/or DSA without MVI showed low GM/GL (up to 5.37±6 GM/1.87±2.23 GL) statistically indistinguishable from the ACMR or cases lacking any AMR or ACMR features. The time post Tx was also higher in cases with MVI, irrespective of C4d or DSA presence (34.38± 35.73) than in cases with DSA and/or C4d only (16.96± 34.74)(p=.000), indicating a temporal sequence. This particular glomerular inflammation immunophenotype characterized not only the entire spectrum of MVI but was also associated to EM microvascular pathology, time post Tx and C4d results (Table 1).Table: [Correlations with EM findings]Conclusions: AMR displays a temporal an immunophenotypical spectrum ranging from an earlier DSA± C4d stage without MVI and progression to the full spectum (DSA+C4d+MVI) including a marked increase in GM accompanied by a definite but lesser increase in GL (2:1 ratio). This glomerular immunophenotype is so characteristic and constant that its presence would serve as a surrogate to the more variable C4d staining for the diagnosis of AMR (i.e. C4d negative AMR).

Antibody Mediated Rejection (AMR) Lesions in Renal Biopsies: Evidence of Progression with a Specific Microvascular Inflammatory Phenotype. Diagnostic Implications

Introduction: The diagnosis of AMR hinges on the combination of DSA, C4d and microvascular injury/inflammation (MVI) but is complicated by temporal lesion variations and the fluctuations of C4d staining and DSA levels. MVI needs therefore to be fully analized for optimal diagnostic use. Methods: 563 consecutive renal biopsies (Bx) from 496 patients were analyzed using current Banff criteria and were stained with C4d, CD68 and CD3. For each biopsy, concurrent DSA measurements were also available. The mean number of biopsies per patient was 1.44 ((+/- 0.91, median 1). Mean patient age was 50.27 yeras (+/-13.79). 63.1% of the patients were male, 8.1% had regrafts and 6.6% were hepatitis C positive. Specific definitions used for analysis: C4d+ ≥10% staining in peritubular capillaries; DSA+ >1000MFI; MVI defined as glomerulitis (g), transplant glomerulopathy (cg) and peritubular capillaritis (ptc) >0 scores. On electron microscopy (EM), TG was defined by duplication of the basement membranes, whereas endothelial injury (EI) was defined as swelling, loss of fenestrations ± expansion of the subendothelial space. The maximum nubmer of glomerular macrophages and lymphocytes were also counted (GM and GL) with CD68 and CD3 stains, respectively. Results: Cases with acute T-cell mediated rejection (ACMR) (n=76) or cases lacking any AMR or ACMR features (n=187) had an average of 5±6 GM/3.4±4.8 GL and 3.67±4.62 GM/1.57±2.52 GL respectively (NS), whereas cases with any combination of AMR parameters that includes MVI displayed a similarly marked increase of GM/GL (up to 16.58±12.19 GM/7.94±6.64 GL, p=.000). In contrast cases with only C4d and/or DSA without MVI showed low GM/GL (up to 5.37±6 GM/1.87±2.23 GL) statistically indistinguishable from the ACMR or cases lacking any AMR or ACMR features. The time post Tx was also higher in cases with MVI, irrespective of C4d or DSA presence (34.38± 35.73) than in cases with DSA and/or C4d only (16.96± 34.74)(p=.000), indicating a temporal sequence. This particular glomerular inflammation immunophenotype characterized not only the entire spectrum of MVI but was also associated to EM microvascular pathology, time post Tx and C4d results (Table 1).Table: [Correlations with EM findings]Conclusions: AMR displays a temporal an immunophenotypical spectrum ranging from an earlier DSA± C4d stage without MVI and progression to the full spectum (DSA+C4d+MVI) including a marked increase in GM accompanied by a definite but lesser increase in GL (2:1 ratio). This glomerular immunophenotype is so characteristic and constant that its presence would serve as a surrogate to the more variable C4d staining for the diagnosis of AMR (i.e. C4d negative AMR).

Operative effect and pertinent factors analysis in intractable epilepsy patients with normal cerebral MRI

Objective To investigate the operative effect in intractable epilepsy patients with normal cerebral MRI and pertinent factors of indications about operative prognosis.Methods The study involved cases with intractable epilepsy undergone operative procedures between August 1997 and October 2010,released from our hospital a year and more.Of them,patients with normal cerebral MRI were followed up.Complete clinical data from 62 patients were analyzed.By Engel standard,grade Ⅰ and Ⅱ are considered good prognosis,grade Ⅲ and Ⅳ are considered unsatisfactory results.Correlations between operative effect and good prognosis were evaluated.Results There are 47 cases with Engel grading Ⅰ and Ⅱ,accounting for 76％. Patients undergone temporal lobe cortex lesion resection had better prognosis than do those undergone frontal and occipital lobe lesion resection ( P ＜ 0.01 ).The operative effect between frontal and occipitoparietal lobe focus resection was not different significantly. Patients with slight pre - operative seizures had better prognosis than do those with sever seizures post - operatively ( P ＜ 0.05 ).Patients with seizures long after operation have worse prognosis than early after operation ( P ＜ 0.05 ). Patients with abnormal pathological exam had better prognosis than do those with normal pathological exam (P ＜ 0.05 ).Ages were not correlated with prognosis.Conclusions In the intractable epilepsy patients whose cerebral MRI are normal,temporal lobe lesion resection signifies better prognosis than those lesion outside temporal lobe.Cases with slight pre - operative seizures and post - operative abnormal pathological exam signify better prognosis.Seizures appeared long after operation signifies worse prognosis. Key words: MRI; Epilepsy; Surgical procedures, operative; Prognosis; Intraoperative inducing test

Increased IL-17A expression in temporal artery lesions is a predictor of sustained response to glucocorticoid treatment in patients with giant-cell arteritis

BackgroundInterleukin 17A (IL-17A) exerts pivotal proinflammatory functions in chronic inflammatory and autoimmune diseases.ObjectiveTo investigate IL-17A expression in temporal artery lesions from patients with giant-cell arteritis (GCA), and its relationship with...