Multiple Tuberculoma Involving the Brain and Spinal Cord in a Patient with Miliary Pulmonary Tuberculosis

Although tuberculosis of the central nervous system is well known, the incidence of intramedullary tuberculomas is low and a combination of intramedullary with intracranial tuberculomas is extremely rare. We report a case of disseminated tuberculoma involving brain and spine with miliary pulmonary tuberculosis in a 66-year-old woman initially presenting with fever, general weakness, back pain and motor weakness of both lower extremities. Despite medical therapy, she developed progressive motor weakness of both lower extremities with muscle strength 1/5 in both lower extremities. Urgent surgical intervention was followed and her muscle power and motor functions were improved gradually. The anti-tuberculous drugs were continued and the follow-up magnetic resonance imaging (MRI) of brain and spine showed that the lesions had become smaller or disappeared.     

Brain CT and MRI Findings in 100 Consecutive Patients with Intracranial Tuberculoma

OBJECTIVE: The characteristics of intracranial tuberculoma on computed tomography (CT) and magnetic resonance imaging (MRI) are not well known. The authors reviewed the features of tuberculoma on CT scans and MRI. The authors also correlated the MRI characteristics on various pulse sequences with neuropathological findings. METHODS: The charts of patients with intracranial tuberculoma were consecutively reviewed during the period from 1988 to 1999. The diagnosis of tuberculoma was based on pathology (n = 19), clinical or neuroimaging response to tuberculous chemotherapy (n = 57), or evidence of systemic tuberculosis (n = 24). Neuropathological specimens of tuberculoma were graded for the amount of fibrosis, gliosis, necrosis, and cell types (lymphocytes, macrophages, plasma cells). RESULTS: One hundred patients (43 men) were identified. The age range was 1 to 75 years (mean = 30 y). The number of lesions ranged from 1 to > 100 (mean = 4.5 lesions/patient). Thirty-one patients had solitary lesions, whereas 69 had multiple lesions. Thirty-seven patients had hydrocephalus. After contrast administration, > 450 lesions were seen on CT and MRI images in all 100 scans. The diameter of these enhancing lesions ranged from 1 mm to 5 cm. Lesions > 1 cm showed varied enhancement, including irregular shapes, ringlike shapes, open rings, and lobular patterns. Targetlike lesions were seen in only 2 patients. Other features included cortical and subcortical infarcts (12 patients), calcification (10% of lesions), edema (33 patients), meningeal enhancement (12 patients), mass effect, and/or midline shift (18 patients). A hypointense core with a hyperintense rim was the most common signal characteristic on T2-weighted MRI. The central hypointensity on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images reflected extensive necrosis and hypercellularity. CONCLUSION: Multiple tuberculomas and infratentorial locations were more common in the authors' patient population than in previous reports. The MRI signal characteristics of intracranial tuberculoma are extremely diverse. An isointense or hypointense core with a hyperintense rim on T2-weighted and FLAIR images is the most common presentation. Core hypointensity of lesions on these images is related to necrosis and the large number of cells.     

Thoracic Extradural Cavernous Hemangioma Mimicking a Dumbbell-Shaped Tumor

Dumbbell-shaped spinal extradural cavernous hemangioma is rare. The differential diagnosis of dumbbell-shaped spinal tumors based on magnetic resonance imaging includes schwannoma and lymphoma. Here, we report a dumbbell-shaped spinal extradural cavernous hemangioma with intrathoracic growth on T2-3 in a 64-year-old man complaining of right side infrascapular area back pain with no neurologic deficit. The cavernous hemangioma was resected through combined video-assisted thoracoscopy and laminectomy without a fusion procedure. The patient had tolerable operative wound pain with no neurologic deficit after surgery. Based on magnetic resonance imaging findings and a review of the literature, we discuss cavernous hemangioma among the differential diagnosis of paravertebral dumbbell-shaped spinal tumors and the importance of complete resection.     

Importance of Differential Diagnosis of a Possible Brain Tumor in Patients with Cervical Radiculopathy

Lesions occurring simultaneously in the somatosensory or motor cortex of the brain and the cervical spine are rare. Brain tumors can cause similar symptoms to cervical lesions which can lead to confusion in treatment priorities. Moreover, if cervical disease is noticeably observed in radiologic findings of a patient complaining of cervical radiculopathy with non-specific electromyography results, it is common to no longer perform further evaluation. Here we introduce two cases where the cause of cervical radiculopathy was first considered to be the result of a degenerative cervical disease but was later discovered to be a result of a brain tumor.     

脑干肿瘤的显微手术治疗

目的 总结分析脑干肿瘤的临床特点和治疗方法。方法1 0例脑干肿瘤经枕下中线或中线旁入路，采用显微外科手术切除肿瘤。结果肿瘤全切除3例，次全切除5例，大部分切除2例。术后症状消失6例，好转2例，无变化1例，死亡1例。病理证实星形细胞瘤6例(Ⅰ级1例，I～Ⅱ级5例)，血管母细胞瘤3例，室管膜瘤1例。结论脑干肿瘤的切除率和预后与肿瘤性质和生长方式有密切关系。显微手术治疗应尽可能多地切除肿瘤，减少并发症，以解除患症状和延长其生存期。     

生物波调控因子对脑梗死大鼠脑组织 TNF-α表达的影响

目的 探讨生物波调控因子（Bio-wave regulation factor，BRF）对大鼠局灶性脑缺血损伤后行为学及 脑组织内肿瘤坏死因子-α（tumor necrosis factor－α，TNF-α）表达的影响。 方法 成年健康雄性SD大鼠90只随机分为3组，即假手术组、生理盐水组、BRF治疗组，每组分为6、24、 48、72 h、7 d，5个亚组，每亚组6只大鼠。参照Longa等的线栓法制成大脑中动脉闭塞（middle cerebral artery occlusion，MCAO）模型，术后1 h以1 ml/100 g体重的剂量分别腹腔注射1.25% BRF溶液和生理盐 水，此后1次/d重复注射，至相应时间点处死动物。采用Longa等4种方法进行行为学评分、干湿重法测 定脑组织含水量、HE染色观察组织病理学改变、免疫组织化学方法观察脑组织TNF-α的动态变化。 结果 1.行为学评分：MCAO大鼠对侧肢体存在不同程度瘫痪，在术后48 h和72 h神经功能缺损最为 明显，7 d基本恢复正常；2.脑组织含水量测定：脑梗死组脑组织含水量在各时间段均增加，其中术后 48 h BRF组低于同期的生理盐水组(P <0.05)；3.脑组织HE染色观察：除假手术组外，其余各组在脑梗死 后6 h局部可见炎性细胞浸润，48 h明显增多，并持续到7 d；4.脑组织TNF-α的表达：与假手术组相比， 脑梗死组TNF-α阳性细胞在各时间段均增加，术后48 h、72 h BRF组低于同期的生理盐水组(P <0.05)。 结论 BRF通过减轻脑水肿，降低脑内肿瘤坏死因子-α的表达，对大鼠缺血脑组织产生保护作用。     

Cerebral ganglioneuroblastoma of adult onset: two patients and a review of the literature

Ganglioneuroblastoma is a rare tumor variant of neuroblastoma. Only five cases have been observed in the adult brain, and we report here on two more adult patients with cerebral ganglioneuroblastoma. Additionally, a review was carried out on all 50 published adult cases with ganglioneuroblastoma, located in the adrenal gland (9), mediastinum (8), retroperitoneal area (7), the brain parenchyma (7), or the spinal cord (3). Median age at onset was 39 years, and 52% of patients were female. For extracranial locations, treatment usually consisted of surgery followed by radiotherapy and adjuvant chemotherapy. Of the cases with cerebral involvement only one patient did not receive any treatment. The other six patients underwent surgical resection and radiation therapy, in four cases followed by chemotherapy with temozolomide. The median survival of cerebral ganglioneuroblastomas was 14 months and did not differ from the whole group of ganglioneuroblastomas (12 months). For cerebral ganglioneuroblastoma, the preferred regimen would seem to be neurosurgical removal, followed by chemoradiotherapy including temozolomide.     

Brain Tissue Water Uptake after Middle Cerebral Artery Occlusion Assessed with CT

BACKGROUND AND PURPOSE: To study whether computed tomography (CT) can measure the water content of early ischemic edema. METHODS: The authors obtained cranial CT in 5 groups of rats subjected to 1 hour (n = 8), 2 hours (n = 11), 3 hours (n = 13), 4 hours (n = 13), or 6 hours (n = 14) of right middle cerebral artery (MCA) occlusion. Immediately after CT, the authors removed the rats' brains and determined tissue water content by the dry-wet weight method. They correlated brain x-ray attenuation with brain tissue water content. RESULTS: Mean brain tissue water content remained constant in the nonischemic left hemispheres at 77.9% +/- 0.6% and increased up to 79.3% +/- 1.0% in the right hemispheres after 6 hours of permanent right MCA occlusion. X-ray attenuation remained constant in the left hemispheres at 75.6 + 2.2 Hounsfield units (HU) and decreased to 71.7 +/- 3.4 HU in the right hemispheres after 6 hours of right MCA occlusion. The decrease in x-ray attenuation correlated significantly with the increase in ischemic brain tissue water content (y = 217.3 - 1.8x x; r = .55, P < .0001). That means that a 1% increase in hemispheric tissue water content causes a decrease in x-ray attenuation of 1.8 HU. CONCLUSIONS: After MCA occlusion, immediate brain tissue net water uptake is associated with a decrease in x-ray attenuation. CT can monitor ischemic edema in an acute stroke.     

Disseminated Intravascular Coagulation in a Patient Undergoing Removal of Metastatic Brain Tumor

The authors present a case of 68-year-old woman who underwent resection of a metastatic adenocarcinoma in the left parietooccipital area. The intraoperative course was uneventful; however, after closure of the scalp incision, increased bleeding from the suture line was noted. A computerized tomography scan that was performed immediately after operation revealed acute epidural hemorrhage with mass effect under the bone flap. The patient developed disseminated intravascular coagulation and immediate re-exploration was performed. This patient was successfully treated owing to early recognition of the condition and immediate treatment with transfusion. Neurosurgeons should be alert that hypercoagulabe state is common in cancer patients and consumptive coagulopathy can occur after resection of metastatic brain tumor.     

颅脑损伤后AQP-4在脑组织中表达与脑水肿的关系

目的探讨水通道蛋白-4（AQP-4）在急性颅脑损伤早期脑水肿发生中的作用。方法应用免疫组织化学方法检测人脑组织中AQP-4的表达。创伤组标本取自28例急性颅脑损伤患者急诊开颅血肿清除时所获挫伤灶周围脑组织；对照组取自8例原发性癫痫患者手术切除的相对正常脑组织。结果急性颅脑损伤后早期挫伤灶周围脑组织有明显的脑水肿发生，AQP-4的表达水平明显高于对照组（P〈0．01），且其表达主要见于小血管及神经胶质细胞。结论AQP-4表达的早期上调与急性颅脑损伤后脑水肿的发生有密切的关系。     

Cerebral Phaeohyphomycosis: A Rare Cause of Brain Abscess

Cerebral phaeohyphomycosis (CP) is a very rare but serious form of central nervous system fungal infection that is caused by dematiaceous fungi. It is commonly associated with poor prognosis irrespective of the immune status of the patient. In this study, the authors describe the first case of CP in Korea that occurred in a 75-year-old man without immunodeficiency and showed favorable outcome after surgical excision and antifungal therapy. In addition, the authors herein review the literature regarding characteristics of this rare clinical entity with previously reported cases.     

脑内及脑外双源性肿瘤4例报告

目的 探讨脑内及脑外双源性肿瘤临床诊断及发病机理。方法 分析4例脑及脑外双源性肿瘤的临床、影像资料和治疗,结合文献予以讨论。结果 4例中3例为女性;脑外肿瘤分别为乳癌、直肠癌、肾上腺肿瘤和纤维肉瘤,而脑部均为良性肿瘤并经手术治愈。结论 肿瘤的早期诊断及综合治疗使原发癌的生存率增加,而放、化疗可降低免疫功能诱发新的癌肿,不可将其视为转移瘤。     

Paradoxical brain embolism in a young man with isolated pulmonary arteriovenous fistula

We herein report a case of ischemic stroke due to paradoxical brain embolism in a young man, a trumpet player. Extensive diagnostic investigations revealed the presence of an isolated pulmonary arteriovenous fistula as the only risk factor for stroke. The peculiarity of this case is the early onset of neurological symptoms in the absence of Hereditary Hemorrhagic Teleangiectasia. The Authors suppose the repeated Valsalva maneuvers as a possible factor promoting fistula enlargement and symptoms development.     

脑缺血再灌注大鼠脑组织水孔蛋白4的动态表达及其与脑水肿的关系

目的 探讨水孔蛋白4（aquaporin-4,AQP-4）在大鼠脑缺血再灌注后的动态表达及其与脑水肿的关系。方法 60只健康成年雄性SD大鼠,随机分成2组：大脑中动脉闭塞/再灌注（middle cerebral artery occlusion/reperfusion,MCAO/R）组和假手术组,采用Longa、Berderson、平衡木评分法进行行为学评分,干-湿重法测定脑组织含水量,HE染色观察大鼠脑组织的病理改变,免疫组化法检测脑组织AQP-4的表达。结果 MCAO/R组大鼠行为学异常,以48 h和72 h为著,7 d时已基本恢复至正常水平;脑含水量24 h开始升高（82.42%±0.12%）,48 h达高峰（85.40%±0.10%）,并持续到72 h（84.87%±0.15%）,7 d时下降至大致正常水平。脑水肿及炎性细胞浸润,以48 h和72 h为著。AQP-4阳性表达于梗死后6 h开始增多（110.0±4.4）,48 h～72 h达高峰（126.2±2.6;140.1±1.2）,7 d时有所下降（111.3±8.0）,但仍处于较高水平,与假手术组比较,差异有统计学意义（P<0.05）。结论 脑缺血再灌注后脑组织AQP-4的表达的变化与脑水肿的动态变化存在时间上的一致性,提示AQP-4可能参与了早期脑缺血再灌注后脑水肿形成的病理生理过程,而后期可能与脑内多余水分的清除有关。     

Evaluation of 3-Dimensional Exoscopes in Brain Tumor Surgery

ObjectiveThough the operating microscope (OM) has been the standard optical system in neurosurgery, a new technology called three-dimensional (3D) exoscope has emerged as an alternative. Herein, two types of 3D exoscopes for brain tumor surgery are presented. In addition, the advantages and limitations compared with the OM are discussed. MethodsIn the present study, 3D exoscope VOMS-100 or VITOM 3D was used in 11 patients with brain tumor who underwent surgical resection; the Kinevo 900 OM was used only in emergency. After completion of all surgeries, the participants were surveyed with a questionnaire regarding video image quality on the display monitor, handling of equipment, ergonomics, educational usefulness, 3D glasses, and expectation as a substitute for the OM. ResultsAmong 11 patients, nine patients underwent neurosurgical resection with only 3D exoscope; however, two patients required additional aid with the OM due to difficulty in hemostasis. Regarding video image quality, VITOM 3D was mostly equivalent to the OM, but VOMS-100 was not. However, both 3D exoscopes showed advantages in accessibility of instruments in the surgical field and occupied less space in the operating theater. Differences in ergonomics and educational usefulness between the exoscopes were not reported. Respondents did not experience discomfort in wearing 3D glasses and thought the exoscopes could be currently, and in the future, used as a substitute for the OM. ConclusionAlthough many neurosurgeons are not familiar with 3D exoscopes, they have advantages compared with the OM and similar image quality. Exoscopes could be a substitute for OM in the future if some limitations are overcome.     

反常性栓塞风险量表在合并卵圆孔未闭的隐源性卒中或短暂性脑缺血发作患者中的应用

目的 描述卵圆孔未闭（patent foramen ovale,PFO）造成反常性栓塞（paradoxical embolism,PE）的临
床表现、影像学特点。验证反常性栓塞风险量表（Risk of Paradoxical Embolism,RoPE）评分。
方法 本研究为单中心观察性研究,连续性入选2013年1月～2014年6月首都医科大学附属北京天
坛医院神经科收治的隐源性卒中或短暂性脑缺血发作（transient ischemic attack,TIA）患者79例,其
中经经颅多普勒超声发泡试验（contrast-enhanced transcranial Doppler,cTCD）和经食管超声心动图
（transesophageal echocardiography,TEE）确诊合并PFO的患者44例,其中37例为PFO所致PE,7例仅合并
PFO无栓塞症状。由另一名神经科医师盲法评价颅脑磁共振成像,确定其影像学的特点,收集两组
患者的人口学信息,临床资料,相关辅助检查（如cTCD、TEE、颈部血管超声及双下肢静脉超声结果）,
计算并比较两组RoPE评分情况。PFO所致PE患者根据PFO大小分为3组,依据右向左分流量（rightto-
left shunt,RLS）大小分为3组。比较不同PFO大小和不同RLS患者之间的临床和影像学特点,并评
估不同PFO大小和不同RLS之间的关联性及RoPE评分与PFO的大小和RLS的严重程度之间的关系。
结果 两组的RoPE评分分别为5（4.5,7.0）和6（4.0,8.0）,差异无显著性（P＞0.05）。合并颈内
动脉重度狭窄或闭塞,高度提示非PFO相关缺血性卒中（P＜0.01）。小PFO组（＜2 mm）和中/大PFO组
（≥2 mm）相比较,两组的RoPE评分分别为（5.5±1.9 vs 6.3±2.0,P＞0.05）,后者更容易累及后循
环。不同RLS患者之间相比较,3组的RoPE评分分别为（5.4±1.7,6.5±2.7,5.8±2.0,P＞0.05）。PFO
大小和RLS之间无显著性相关（r =0.031,P＞0.05）。
结论 PFO和脑梗死的关系可以分为：无相关性（即PFO合并存在）或有相关性（即PE）,PE的影像学
特点和PFO大小有一定的相关性。RoPE可能有助于进一步区分PFO的大小和RLS的严重程度。     

脑出血患者血肿周围水肿形成机制:脑内细胞因子的作用

目的 :探讨脑出血患者脑内炎性细胞因子与血肿周围水肿的形成是否相关。方法 :32例脑出血患者行血肿清除术后 ,留取脑血肿液 ,放免法测定其中肿瘤坏死因子α(TNFα)和白细胞介素 - 6 (IL - 6 )的含量 ,测量术前检查的头 CT上的血肿周围水肿带大小 ,用 SPSS10 0对两者进行相关分析。结果 :脑出血患者脑血肿液中 IL - 6和 TNFα的含量明显高于正常人溶血血清中的含量 (P<0 .0 1) ;脑血肿液中 TNFα和 IL - 6含量与血肿周围水肿带大小呈正相关 (r TNF=0 .5 39,P<0 .0 1;r IL- 6 =0 .5 6 9,P<0 .0 1)。结论 :脑出血患者急性期脑血肿液中 IL - 6和 TNFα含量升高 ;脑内炎性细胞因子可能参与血肿周围水肿的形成