2 cases of multicentric glioma

We reported two cases of multicentric glioma. The first case was 60-year-old female. In CT scan findings, separate mass lesions were observed in the right parieto-occipital area, left parietal lobe and left thalamic region. The second case was 53-year-old male. In CT scan findings, separate mass lesions were observed in the right fronto-parieto-temporal area and left frontal lobe. These two cases were considered to be metastatic brain tumor and radiation therapy and chemoimmunotherapy were performed. But in the postmortem examinations, both cases were evident to be not metastatic brain tumor but glioblastoma multiforme. And tumor cells were not found in commissural or other nerve pathways and cerebrospinal fluid system histologically. So our cases were considered as multicentric glioma. The pathogenesis of multicentric glioma are not understood till now. Therefore, it is interesting that the different histological findings were observed in the each tumor lesion of the first case.     

Clinicopathological study of multiple gliomas--report of three cases.

Three cases of multiple gliomas with postmortem findings including a rare case of multicentric glioma are presented. A 59-year-old female was hospitalized with decreased mental activity and gait disturbance. Computed tomographic (CT) scans and magnetic resonance (MR) images showed two independent mass lesions in the left frontal and the right temporal lobes, shown by postmortem to have no communication. Histologically, they were a gemistocytic astrocytoma and an anaplastic astrocytoma, respectively. Therefore, multicentric glioma was diagnosed. A 66-year-old male was admitted with slow mentation and gait disturbance. CT scans and MR images demonstrated two mass lesions; one overriding the bilateral frontal lobes through the corpus callosum and the other in the left temporal lobe. Postmortem examination showed that both lesions were glioblastoma and the left temporal tumor was accompanied by subarachnoid dissemination. A 29-year-old male was hospitalized with gustatory hallucination and convulsions of the right upper extremity. CT scans revealed two mass lesions in the right frontal and the left temporal lobes. MR images demonstrated communication between the two lesions through the corpus callosum. The left temporal tumor developed into the occipital lobe and another new lesion appeared in the right temporal lobe despite chemotherapy and irradiation. Postmortem examination revealed communication between the three masses through the corpus callosum. Histologically, all three tumors were glioblastoma. Multicentric gliomas have been reported at various incidences from 2.3 to 9.1%. However, multicentric gliomas with multiple tumors of different histologies are very rare and only 16 cases have been reported. MR imaging is more valuable than CT scanning to detect communication between two or more lesions.     

Anaplastic astrocytoma and anaplastic oligodendroglioma occurring 6 years after subtotal resection of a central neurocytoma. Case report

The authors present the case of a 51-year-old man who presented with an anaplastic astrocytoma and anaplastic oligodendroglioma that developed 6 years after subtotal resection of a central neurocytoma in his right lateral ventricle. He had received neither radiation therapy nor chemotherapy after the original resection. On readmission, neuroimaging revealed a mass in the right parietal lobe and a diffuse lesion in the right temporal lobe, insula, and corona radiata. Because both lesions extended to the right lateral ventricle wall, they were regarded as recurrent rather than metachronous tumors. Histological examination revealed anaplastic oligodendroglioma in the parietal lobe and anaplastic astrocytoma in the insula. One year later, the anaplastic astrocytoma was found to have transformed into a glioblastoma multiforme. Fluorescence in situ hybridization analysis and immunohistochemical examinations detected deletions of the lp36 and 19q13 loci, and nuclear accumulation of TP53 protein in the anaplastic oligodendroglioma but not in the glioblastoma multiforme. These findings suggest that central neurocytoma or progenitor cells have the potential for oligodendrocytic and astrocytic transformation with different genetic aberrations.     

An autopsy case of multicentric glioma of multiple histopathology

An autopsy case is described of an 66-year-old man with multicentric glioma of multiple histopathology, i.e. protoplasmic astrocytoma and glioblastoma. Enhanced CT scan revealed three separate lesions in the right cerebral hemisphere, pons, and cerebellar vermis. Initial diagnosis by CT included metastatic and primary brain tumor, multiple abscess, fungal infection, parasites, tuberculoma, and so on. Biopsy of the right frontal mass revealed astrocytoma grade-2. An autopsy revealed gelatinous, clear marginal mass in the right frontal, parietooccipital and cerebellar vermis; an opaque marginal mass with necrosis in dorsal pons was found. At microscopic examination, the right frontal tumor exhibited continuity with both the paraventricular and the right parietooccipital tumor. The right cerebral hemisphere and cerebellar vermis tumors showed protoplasmic astrocytoma; the dorsal pons tumor showed glioblastoma. CSF examination revealed no tumor cells. Tumor invasion of the internal capsule and the meninges was also not found. Accordingly, we diagnosed as multicentric astrocytoma of multiple histopathology. Only 11 case reports of multicentric glioma were recorded in Japan; only one of which was of multiple histopathology. Worldwide, only 7 case reports of multicentric glioma of multiple histopathology were recorded; this is the first case of protoplasmic astrocytoma and glioblastoma. Seen in terms of pathogenesis of multicentric glioma, this case is thought to be very interesting.     

Peculiar computed tomographic images after intracranial use of microfibrillar collagen hemostat: report of three cases

After the intracranial application of microfibrillar collagen hemostat (Avitene), CT revealed contrast enhancement suggestive of brain abscess or residual or recurrent tumor in three patients. The first case was a 22-year-old male with left ventricular oligodendroglioma. At operation Avitene was applied to the ventricular wall and incised frontal lobe. Two months after the operation CT revealed ring enhancement at the left frontal lobe and ventricular enlargement. Craniotomy was performed again. Histological examination, however, revealed no recurrent tumor but residual Avitene and granulation. The second case was a 57-year-old female with left parietal glioblastoma multiforme. At operation Avitene was applied to the tumor cavity. Two months after the operation CT showed ring enhancement and craniotomy was performed again. Histological examination revealed residual Avitene and necrotic tissue. Five months after the first operation, craniotomy was performed for the third time, because recurrence was suspected after a CT scan. Histological examination revealed recurrent tumor and residual Avitene. The third case was a 19-year-old male with left frontal astrocytoma. Two months after the operation when Avitene was used for hemostasis, marked ring enhancement was observed. Five months after the operation, however, enhancement in CT was weak. The CT findings in these patients were characterized by the abnormally long duration of enhancement (five months) and by enhancement more marked two to three months after the operation than immediately after it. Based on these findings brain abscess or residual or recurrent tumor rather than normal healing was more suspect as the cause of this phenomenon. Brain abscess was ruled out, because the peripheral leukocyte count, erythrocyte sedimentation rate, CRP, etc. were normal.(ABSTRACT TRUNCATED AT 250 WORDS)     

Right temporal lobe glioblastoma presenting in the left orbit. Case report

Dissemination of gliomas outside the central nervous system without preceding neurosurgery is a rare phenomenon. Glial neoplasms presenting as bone lesions are even more rare. A case of glioblastoma multiforme (GBM) with initial presentation in the orbit following a single generalized seizure is described. Signs of intracranial hypertension resulted from subarachnoid tumor invasion. The patient was treated with whole-dose radiation therapy but survived for only 6 months following the initial presentation. An autopsy revealed a right temporal GBM with extensive subarachnoid spread and invasion in the left orbit and skull base. The literature on dissemination of primary tumors of the brain is reviewed.     

Multiple Cerebral Arteriovenous Malformations (AVMs) Associated with Spinal AVM

Summary  The co-existence of multiple cerebral arteriovenous malformations (AVMs) and a spinal AVM is extremely rare. A 22-year-old man suddenly developed severe headache. Computed tomography (CT) scan showed intracerebral haemorrhage in the left occipital lobe. Cerebral angiography revealed eight AVMs; four were in the right frontal lobe and two each were in the right temporal and left occipital lobe, respectively. A huge high-flow spinal AVM was found incidentally. He had no other vascular lesions such as hereditary haemorrhagic telangiectasia. A left occipital craniotomy was performed and the ruptured left occipital AVMs were removed. Further therapeutic treatment was refused. To our knowledge, except for one autopsy case, this is the first reported patient with multiple cerebral AVMs with a spinal AVM. We discuss the characteristics of this case and review reported cases with cerebral and spinal AVMs.     

Cerebral amyloid angiopathy complicated by multiple cerebral infarcts and intracerebral hemorrhages: case report

Recently, cerebral amyloid angiopathy is stressed as an unusual and infrequent cause of cerebral infarct or intracerebral hemorrhage. This report described a case of cerebral amyloid angiopathy complicated by multiple cerebral infarcts and multiple intracerebral hemorrhages. This 70-year-old man was admitted to our hospital on November 10, 1984 for evaluation of the gradual onset of dysarthria. Examination showed only slight dysarthria. There was no history of hypertension or dementia. A computed tomography (CT) showed enlarged ventricles with cortical atrophy and multiple low-density lesions, deep in the left frontal, left parietal, right parietal lobes, and in the both basal ganglias. The patient discharged from the hospital with only slight dysarthria. On November 20, 1984, he was admitted to our hospital again, because he was found unresponsive on the floor. He was somnolent but arousable. Examination showed disorientation, impairment of recent memory and impairment of calculation, A CT scan demonstrated three small intracerebral hemorrhages in the left frontal, right parietal lobes and left basal ganglia. On the fifth hospital day he deteriorated acutely, becoming semicomatose and hemiparetic on the right side. A repeated CT scan showed two new intracerebral hemorrhages in the left frontal lobe. Cerebral angiograms showed only minimal changes due to the occupying lesions in the above mentioned area. The hematomas was evacuated via left fronto-parietal craniotomy. The specimens removed with hematoma (stained with hematoxylin-eosin, Congo red and thioflavin T) showed extensive amyloid angiopathy. Postoperatively he made a good recovery, although he had residual mental dysfunctions. He expired by pneumonia on March 30, 1985.(ABSTRACT TRUNCATED AT 250 WORDS)     

A multicentric glioma presenting different pathological appearances: a case report

We report a multicentric glioma case which revealed different pathological appearances. A 45-year-old male had been admitted to our hospital complaining of an attack of transient sudden aphasia. On magnetic resonance imaging (MRI), T1-weighted images revealed a low intensity and T2-weighted images demonstrated a homogeneous high intensity abnormal mass in the frontal lobe, which was not enhanced with gadolinium. Removal of the tumor was performed through a right frontal transcortical approach in March, 2002. Histological diagnosis was gemistocytic astrocytoma. The patient's condition was uneventful and postoperative MRI revealed a marked decrease in the volume of the tumor. A total of 54 Gy radiation to the brain in the locality was performed. Four months after the initial surgery, the patient suffered from incomplete right hemiparesis. MRI showed a left parietal abnormal mass which had a ring formation enhancement after gadolinium administration. This Neuro-radiological examination demonstrated complete independence from the initial right frontal tumor. A second surgery which was concerned with cyst aspiration was carried out on August 10, 2002. During the next month, a third operation for partial removal of a left parietal abnormal mass was performed. Histological diagnosis was anaplastic astrocytoma. The right frontal and left parietal tumors revealed neither continuous relation suggesting intracerebral invasion, nor dissemination through the subarachnoid space nor intracerebral metastasis. Our case was diagnosed as multicentric glioma with different pathological appearances, of which only 9 cases have been reported previously.     

A case of cerebral cysticercosis: cyst growth is confirmed by CT scan during 6 years of follow-up

A rare case of a 40-year-old woman with cerebral cysticercosis is reported. She has lived on the Island of Tokunoshima and has never travelled overseas. She was hospitalized in the hospital of Kagoshima University in 1980. A small cyst in the right temporal lobe, and a calcified area in the left parietal lobe was noticed on CT scan. When she was admitted to our hospital in December 1986, the cyst in the right temporal lobe was larger than it was 6 years before. An operation was performed for the cyst in the right temporal lobe. The cyst was pathologically confirmed as cysticercosis. Postoperatively, immunological reaction of cysticercosis was positive, but X-rays and CT scan of extremities showed no abnormal findings. Cerebral cysticercosis is a rare disease in Japan. CT scan is very useful in the diagnosis of this disease. Multiple cysts and calcified area in the parenchymal region are specific findings on CT scan.     

Diffuse cerebrospinal gliomatosis. Case report]

A 65-year-old male was admitted with memory and gait disturbance. A computed tomography (CT) scan showed bilateral, diffuse, low-density areas with two round, slightly enhanced masses. T1-weighted magnetic resonance image revealed a low-intensity area in the left paraventricular region, which converted to increased signal intensity, extending to the right paraventricular region through the splenium, on T2-weighted images. The tumor was diagnosed as glioblastoma multiforme after needle biopsy and treated by irradiation and chemotherapy. Seven months after admission, a CT scan revealed subependymal infiltration of the tumor with spotty calcification. He died of respiratory complications 11 months after the onset of symptoms. The autopsy showed brain swelling with flattened gyri. Horizontal sections of the brain showed diffuse enlargement of the white matter and basal ganglia with scattered hemorrhage and necrosis. Microscopically, the lesion was far more extensive and diffuse than was suspected from gross examination. Wide glial tumor cell infiltration was observed in the cerebral hemispheres, basal ganglia, brainstem, cerebellum, and even the cervical spinal cord with minimum destruction of the pre-existing architecture. Calcification was found around the thrombosed vessels and necrotic lesions. The clinical diagnosis and histological features of gliomatosis cerebri are discussed with reference to reported cases.     

Spinal cord glioblastoma multiforme with intracranial dissemination--case report.

A case of spinal cord glioblastoma multiforme with intracranial dissemination is reported. A 23-year-old female was admitted to a local hospital complaining of lumbago. Myelography revealed an intramedullary thoracic tumor. The tumor was partially removed through a laminectomy at Th11-L1. The histological diagnosis was glioblastoma multiforme, and focal irradiation (total 50 Gy) was given. Eight months after the operation, symptoms of increased intracranial pressure appeared. Computed tomographic (CT) scans showed marked hydrocephalus, and multiple tumors at anterior horns of bilateral lateral ventricles. A ventriculoperitoneal shunt and an Ommaya reservoir into the left lateral ventricle were emplaced. Three months later, she was transferred to our hospital. CT scans showed enhanced lesions in the fourth ventricle, anterior horn of the left lateral ventricle, septum pellucidum, and pituitary gland. Suboccipital craniectomy was performed, and the mass around the fourth ventricle was partially removed. Histological examination of the tumor specimens showed glioblastoma multiforme. Postoperatively, she received whole brain irradiation (total 50 Gy), and intrathecal injection of beta-interferon via the Ommaya reservoir. However, she died of respiratory insufficiency. It is considered that the spinal cord glioblastoma multiforme disseminated into the intracranial space.     

Siblings with malignant glioma--report of two cases.

The authors report malignant glioma occurring in two sibling cases. The elder brother presented with right hemiparesis and hemihypesthesia at 14-year-old. Computed tomographic (CT) scanning demonstrated a low-density area in the left frontoparietal lobe. The tumor was partially removed. Histologic diagnosis was glioblastoma multiforme. Radiation therapy was given postoperatively, but he died due to tumor recurrence 15 months after onset. The younger sister was admitted comatose due to intratumoral bleeding at 19-year-old. CT scans showed a high-density area in the right temporal lobe. The tumor was excised subtotally. Histological diagnosis was malignant astrocytoma (grade III). Radiation therapy, chemotherapy (ACNU), and immunotherapy (interferon) were given postoperatively, but she died due to recurrence 34 months after onset.     

Non-enhancing de novo glioblastoma: report of two cases

Malignant gliomas arise from two distinct pathways, as de novo lesions or from secondary transformation from low-grade lesions. Herein, we describe the cases of two patients to illustrate the proposition that de novo malignant gliomas can originate as non-enhancing tumors and rapidly progress to a pattern of ring enhancement characteristic of a glioblastoma. Both patients presented with new-onset seizures (simple partial and generalized). Their neurological examinations were unremarkable. Initial MRI evaluations revealed a right precentral gyrus and right medial temporal lobe lesions in each case, respectively. These lesions demonstrated increased T2 signal changes without contrast enhancement. The biopsy of the right frontal lesion in the first patient was consistent with an anaplastic astrocytoma; the second patient was followed expectantly. Repeat MRI for both patients within 17 weeks disclosed ring-enhancing lesions, consistent with an unusually rapid evolution to glioblastoma multiforme (GBM). Subsequent resection of the right medial temporal lesion in the second patient revealed a GBM. Neither tumor displayed abnormal overexpression of P53 by immunohistochemistry. Early MRI of de novo glioblastomas may demonstrate a non-enhancing tumor suggestive of a low-grade lesion. These tumors can rapidly evolve into ring-enhancing lesions more consistent with the traditional imaging findings.     

Radiologically Confirmed de novo Glioblastoma Multiforme and Hippocampal Sclerosis Associated with the First Onset of Nonconvulsive Simple Partial Status Epilepticus

Summary  The authors report a case of an unusual progression of glioblastoma multiforme in the temporal lobe associated with the first onset of nonconvulsive simple partial status epilepticus (SPSE), a rare form of status epilepticus. The patient underwent a left temporal craniotomy and the tumor was removed. Concurrently, the hippocampus was removed as well. The pathological diagnosis of the tumor and the hippocampus were glioblastoma multiforme and hippocampal sclerosis. The patient's postoperative course was uneventful.     

Tumor bed cyst formation after BCNU wafer implantation: report of two cases

BACKGROUND: Interstitial implantation of BCNU wafers is currently used to treat glioblastoma multiforme. Known complications of BCNU wafer implantation include abnormalities of wound healing (including CSF leak), edema formation, and intracranial infection. The purpose of this report is to alert neurosurgeons to an additional potential side effect: formation of a cystic mass within the implanted tumor bed.CASE PRESENTATIONS: Two patients are described: a 54-year-old male, who presented with a large right parieto-occipital mass, and a 47-year-old woman with a large right frontal lobe tumor. Both tumors were found on initial craniotomy to be glioblastoma multiforme; both recurred rapidly despite radiation therapy. Patients were treated with a second craniotomy for tumor resection and placement of BCNU wafers. After implantation, the first patient did well for 6 weeks, then developed lethargy, headaches, and vomiting. CT scan showed a large cyst at the craniotomy site; this required reoperation for drainage. The second patient had a seizure, deterioration of mental status, and progressive hemiparesis 10 days after wafer implantation. CT scan again showed that a large cyst had formed in the area of the previous surgery; she also required reoperation. In each case, minimal tumor and no evidence of infection were found. Within a few more weeks, each patient succumbed to progressive disease. CONCLUSIONS: The hypodense, roughly spherical cysts clearly demonstrated clinically significant mass effect, and required reoperation despite treatment with high-dose corticosteroids. Neurosurgeons should be alert to the possibility of tumor bed cyst formation in patients treated with interstitial BCNU wafers.     

Combined chronic subdural and acute epidural hematoma secondary to metastatic hepatocellular cancer: case report]

We report a case of combined chronic subdural and acute epidural hematoma caused by metastatic hepatocellular cancer of the dura mater. A 44-year-old woman, who had been under treatment for hepatic cancer for one year, presented with right hemiparesis. MRI revealed a chronic subdural hematoma on the left fronto-parietal region with subgaleal and epidural metastasis. The patient was found comatose 7 days later. A huge epidural hematoma in the left parietal region was disclosed with CT scan. She died of hepatic failure despite the evacuation of the hematoma. This is the first reported case with a combined subdural and epidural hematoma secondary to metastatic brain tumor of the dura mater.     

Glioblastoma multiforme developing separately from the initial lesion 9 years after successful treatment for gliomatosis cerebri: a case report

Gliomatosis cerebri is a diffuse growth pattern of glioma consisting of exceptionally extensive infiltration of at least three cerebral lobes. We report a case of histologically confirmed glioblastoma multiforme in the cerebellar vermis which occurred 9 years after treatment for gliomatosis cerebri. A 33-year-old woman presented to our department for evaluation of visual disturbance. T2-weighted magnetic resonance (MR) imaging revealed hyperintense lesions in the bilateral frontal and parietal lobes. Histological examination of biopsy specimens from the left frontal lobe lesion demonstrated diffuse infiltration of glial neoplastic cells with preservation of the underlying cytoarchitecture, leading to the diagnosis of gliomatosis cerebri. She received 60 Gy hyperfractionated irradiation to the whole brain, and the lesion responded partially. The patient remained stable for 4 years, but T2-weighted MR imaging 5 years after the initial treatment showed enlargement of the hyperintense area. She received nimustine hydrochloride chemotherapy, and again partial response was observed. However. T1-weighted MR imaging after administration of gadolinium-diethylenetriaminepenta-acetic acid detected enhanced lesions in the cerebellar vermis, cerebellar hemisphere, and left posterior limb of the internal capsule 9 years after the initial treatment, although no abnormal findings were observed on initial and follow-up MR imaging. She underwent subtotal removal of the lesion in the cerebellar vermis. The surgical specimens were characterized by dense proliferation of atypical tumor cells with scattered mitosis and endothelial proliferation. The histological diagnosis was glioblastoma multiforme. The patient received gamma knife irradiation for the remnant lesion in the cerebellar vermis, and the lesions in the cerebellar hemisphere and left posterior limb of the internal capsule, and chemotherapy with temozolomide. However, multiple enhanced lesions were detected in the cerebellar vermis 2 months after the start of the temozolomide chemotherapy, and she died 8 months later. This case suggests that glioblastoma multiforme could develop in the long term after initial treatment for gliomatosis cerebri, and in a location separate from the initial lesion.     

A case of disproportionately large communicating fourth ventricle after resection of temporal astrocytoma that evolved an isolated fourth ventricle]

The isolation and enlargement of the fourth ventricle after a ventriculoperitoneal (V-P) shunt was classified as "isolated fourth ventricle (IFV)". The term, "disproportionately large communicating fourth ventricle (DFV)" was first introduced by Scotti et al as being an enlarged fourth ventricle communicating with the third ventricle. The authors present a case of DFV after the resection of an astrocytoma. Upon recurrence of the tumor a second resection was carried out 5 years later. It was found that IFV had evolved because a cyst in the right temporal lobe was obstructing the aqueduct. After shunting of the tumor cyst, the aqueduct was again found to be patent and the fourth ventricle gradually decreased in size. A 34-year-old female presented headache, nausea, and a mild left hemiparesis. An initial CT scan demonstrated a fourth ventricle of approximately normal size and a right temporal mass. The first craniotomy revealed an astrocytoma. A CT scan after the surgical procedure showed enlargement of all ventricles, especially the fourth, resulting from the blockage of the foramina of Luschka and Magendie. The insertion of a V-P shunt was followed by a reduction in size of all ventricles. The diagnosis of DFV was thus confirmed because the fourth ventricle had a demonstrated communication with the third ventricle. After a second craniotomy for tumor recurrence five years later, a CT scan revealed the enlargement of the fourth ventricle and a cyst in the right temporal lobe. A metrizamide CT scan revealed that the cyst was isolated and an RI ventriculogram confirmed obstruction of the aqueduct.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intracranial malignant fibrous histiocytoma with abscess-like tumor necrosis. Case report

A case of a malignant fibrous histiocytoma (MFH) in the right temporal lobe of a 75-year-old man is reported. The tumor involved the brain and the overlying dura as one continuous mass and had undergone extensive liquefaction necrosis of its center that had a gross appearance similar to that of an abscess. The preoperative computerized tomography scan with injection of contrast material showed the lesion to have central and peripheral enhancement suggestive of metastatic tumor, glioblastoma multiforme, or abscess. Microscopically, the tumor showed the typical features of a MFH with marked acute inflammation in the areas of necrosis. No extracranial sources for this tumor were found clinically. This is the 15th reported case of MFH involving the central nervous system as a primary neoplasm and the first case with gross pathological and radiological features resembling in many respects those of an abscess.