Multiple intracranial tuberculomas with atypical response to tuberculostatic chemotherapy

Summary Approximately 34 cases of intracranial tuberculomas with paradoxical response to antituberculous chemotherapy have been documented worldwide. In most of the previously reported cases of this entity an associated tuberculous meningitis has been reported. The majority of these patients were children or young adults, who had inoperably located intracranial tuberculomas in high risk regions developing a few weeks or months after the start of appropriate chemotherapy. 53% of them recovered completely, 37% improved with mild neurological deficits and 10% died. It is interesting that these intracranial tuberculomas developed or enlarged at a stage when systemic tuberculosis was being treated successfully. We report our recent experience with these potentially curable tumours of the central nervous system. The literature is reviewed and diagnostic and therapeutic considerations are discussed. The possible immunological mechanisms of this phenomenon are analysed. In conclusion, patients, who are suspected to be suffering from CNS-tuberculosis should receive a prolonged (12–30 months) course of effective antituberculous therapy. Evidence of new intracranial tuberculomas or the expansion of older existing lesions require no change in the antituberculous drug programme. In such cases systemic dexamethasone as adjuvant therapy for 4 to 8 weeks is worthwhile and effective. Surgical intervention may be necessary in situations with acute complications of CNS tuberculosis such as shunting procedures for the treatment of hydrocephalus. When the diagnosis is not firm and there is no response to therapy within 8 weeks, a stereotactic biopsy of a suspected tuberculoma should be performed. If the largest lesion is not located in high risk deep regions of the brain, it should be total removed surgically. With this combined management, a satisfactory outcome can be obtained in the majority of cases.     

Intracranial Tuberculoma in a Liver Transplant Patient: First Reported Case and Review of the Literature

A 66-year-old female who had undergone an orthotopic liver transplant two years before admission was admitted with fever and neurological symptoms of several days' duration. Following an extensive work-up, which revealed positive intracranial lesions on computed typography and magnetic resonance imaging, the patient was begun on broad spectrum antimicrobials including corticosteroids. The patient responded though the etiology of infection remained unclear. After a stereotactic biopsy was performed revealing granulomas and acid-fast bacilli, the patient was started on antituberculous medications. A review of the literature reveals that the rare occurrence of intracranial tuberculoma should be considered in an orthotopic liver transplant (OLT) patient with central nervous system pathology.     

Intracranial tuberculous abscess mimicking malignant glioma

Brain abscess is probably the least common manifestation of tuberculous infection of the central nervous system; meningitis and tuberculoma are much more common.A case of tuberculous brain abscess in a 23-year-old man with previous history of Tbc meningitis is presented. The computerized tomographic scan demonstrated a unilocular space-occupying lesion in the left thalamic region, surrounded by a thick hyperdense enhancing rim. It is suggested that a relatively long clinical history and previous Tbc meningitis history together with the appearance of a thick-walled abscesslike lesion on the CT scan may indicate the diagnosis of a tuberculous brain abscess. Only after neurosurgical removal of the abscess, the pathohistological examination reveal tuberculous etiology of the abscess. The patient later died from aspiration bronchopneumonia. Only 28 instances of tuberculous abscess have been reported in the literature.     

Intracranial meningiomas in the elderly (over 70 years old)

Summary The decision to operate on a patient older than 70 years for an intracranial meningioma is always difficult. Therefore a series of meningiomas treated surgically in 30 cases older than 70 years has been reconsidered and studied according to the following parameters: Karnofsky's rating scale, physiological status of the patient (A.S.A. criteria), perifocal oedema and mass effect.The locations of the meningiomas were: convexity¹³, parasagittal⁶, falx², pterion (sphenoid ridge)⁵, orbito-cranial³, jugum sphenoidale¹, tentorium (occipital)¹.Postoperative survival at day 30 shows a mortality rate of 23% which increases to 37% at day 90 including causes like decubitus ulcers and 3 cases of fatal pulmonary embolism. In a comparable series of 31 cases from 60 to 70 years, mortality rate was only 16% at day 90.Two parameters seem essential for quantifying surgical risk: clinical status, oedema and mass effect, evaluated by CT scan. The best conditions seem combined when Karnofsky rating scale is higher than or equal to 50 with no or only limited perifocal hypodensity and without mass effect.Although meningiomas may remain dormant for many years or can be kept under control medically for some time, their development is unpredictable. We think therefore that a reasonable surgical risk can be taken on patients with good physical status and favourable parameters at the time of diagnosis, particulary if the meningioma is located at the convexity where the risk of recurrence is minimal. On the other hand, patients with unfavourable parameters are not recommended for surgery.     

Intracranial epidermoids—Concerning the low absorption value on computerized tomography

Summary The authors analysed the contents of two intracranial epidermoids showing low density on computerized tomography. Although both cases had approximately similar composition, 85, 83% for water, 12,12.5% for protein, 3,4.5% for total lipid including cholesterol, respectively, the absorption values differed from each other. Both tumours were identified to communicate with CSF, one by delayed metrizamide CT scan and the other by direct aspiration during operation. The low absorption values in both cases resembled or were slightly higher than that of CSF in each case, and not a single pixel showed negative values for lipid. These findings suggest that it is the CSF content within the anatomical interstices or structural crevice of the tumour, rather than cholesterol, which is responsible for the low absorption values which appeared in the CT scan.     

Intracranial plasma cell granuloma: A report of four cases

Inflammatory pseudotumors (IPT) are rare lesions composed of inflammatory cells admixed with collagen tissue. Although IPT are ubiquitous, intracranial locations are rare. In this study, four intracranial IPT of the plasma-cell-granuloma (PCG) type are reported. Four patients presented with lesions located, respectively, in the right cavernous sinus, the left cavernous sinus with extension to the tentorium cerebelli, the vermis cerebelli, and the pituitary stalk. All patients were operated on, but complete resection could not be achieved in cases 1 and 2. Follow-up was favorable in all cases, although case 1 still complained of headaches 2 years after operation. All cases were studied on histologic and immunohistochemical bases, and ultrastructural analysis was performed on two cases. In cases 1, 2, and 4, IPT were made up of plasma cells admixed with lymphocytes and rare histiocytes in a fibrous tissue —the density of which varied from case to case. In case 3, the mass was composed of plasma cells associated with numerous foamy histiocytes and polymorphonuclear cells. No light chain restriction could be demonstrated when immunohistochemistry was performed, and ultrastructural study did not disclose features reminiscent of meningioma or histiocytosis X. Intracranial IPT should not be confused with other diseases such as meningioma, lymphoproliferative disorders, or histiocytosis X. Although intracranial locations are much rarer than pulmonary ones, histology is identical in both sites and shows different patterns in its evolution. This is in agreement with the inflammatory origin of this lesion.     

Computerized tomography findings in multifocal glioma

Summary Six patients with multifocal glioma are presented. Computerized tomography revealed multiple, discrete, contrast-enhancing lesions in the cerebral hemispheres, suggestive of multiple intracranial metastases. The most accessible lesion was resected at craniotomy in each patient, confirming the diagnosis of primary malignant glioma. Postoperative radiation therapy and chometherapy were instituted according to current protocols. Since neuroradiological studies may not allow distinction of multifocal gloima from multiple brain metastases, surgical biopsy is suggested in those patients who have no history of cancer.     

Sequential computerized tomography changes and related final outcome in severe head injury patients

Summary The authors analysed the serial computerized tomography (CT) findings in a large series of severely head injured patients in order to assess the variability in gross intracranial pathology through the acute posttraumatic period and determine the most common patterns of CT change. A second aim was to compare the prognostic significance of the different CT diagnostic categories used in the study (Traumatic Coma Data Bank CT pathological classification) when gleaned either from the initial (postadmission) or the control CT scans, and determine the extent to which having a second CT scan provides more prognostic information than only one scan.92 patients (13.3% of the total population) died soon after injury. Of the 587 who survived long enough to have at least one control CT scan 23.6% developed new diffuse brain swelling, and 20.9% new focal mass lesions most of which had to be evacuated. The relative risk for requiring a delayed operation as related to the diagnostic category established by using the initial CT scans was by decreasing order: diffuse injury IV (30.7%), diffuse injury III (30.5%), non evacuated mass (20%), evacuated mass (20.2%), diffuse injury II (12.1%), and diffuse injury I (8.6%).Overall, 51.2% of the patients developed significant CT changes (for worse or better) occurring either spontaneously or following surgery, and their final outcomes were more closely related to the control than to the initial CT diagnoses. In fact, the final outcome was more accurately predicted by using the control CT scans (81.2% of the cases) than by using the initial CT scans (71.5% of the cases only). Since the majority of relevant CT changes developed within 48 hours after injury a pathological categorization made by using an early control CT scan seems to be most useful for prognostic purposes.Prognosis associated with the CT pathological categories used in the study was similar independently of the moment of the acute posttraumatic period at which diagnoses were made.     

Extraosseous extradural tuberculous granuloma of the cervical spine: A case report and review of intraspinal granulomatous infections

A 70-year-old woman presented with a 5-month history of tetraparesis. Her cerebrospinal fluid and roentgenographic examination of the cervical spine were both normal. Myelography showed an extradural type of spinal cord compression at the C7 level. At operation, an extraosseous extradural mass of granulation tissue was removed, which proved on histological and bacteriological examination to be a tuberculous granuloma.     

Intracranial lipomas

Summary Intracranial lipomas are very rare, probably congenital lesions. Though they can occur anywhere in the intracranial space, a good proportion of cases tend to be located around the midline. Review of the literature as well as our own three cases — which forms the basis of this article — shows that they are mostly asymptomatic. When symptoms occur, they are frequently the result of coexisting general clinical conditions. Lipomas used to be reported mainly as incidental findings at autopsy. Advances in neuro-imaging techniques have vastly improved the likelihood of their being discovered during life. At present however, significant increase in the reported incidence of these tumours is yet to be seen. Surgical extirpation of the tumour is not considered necessary in the majority of patients, many of whom show remarkable clinical improvement following shunt procedures for obstructive hydrocephalus as well as treatment of coexisting conditions such as epilepsy.     

Intracranial tuberculomas and the CAT scan

Summary Tuberculomas of the brain are rare in the United States. Although CAT (computerized axial tomography) scanning cannot distinguish these infections from other intracranial mass lesions, it provides a non-invasive technique with which to follow the course of presumptive lesions during medical therapy, and with which to search for clinically unsuspected infections. The necessity for and timing of surgery can be considered more easily with this technique. Two cases are presented with their CAT scans, including one example of the disappearance of a presumptive tuberculoma, during appropriate medical therapy.     

Basal ganglia calcification. Characteristics of CT scans and clinical findings

Summary Intracranial calcifications are attributed to many diseases. The globus pallidus is almost always the site of bilateral idiopathic calcium deposits. Computed tomography is superior to conventional skull radiographs in detecting intracranial calcifications. Patients had symptoms that were often explained by other findings. Basal ganglia calcification alone is not a nosological entity and does not justify invasive diagnostic procedures.Dedicated to Professor Dr. K. J. Zülch on the occassion of his 70th birthday.     

Diagnosis of a proximal tracheoesophageal fistula using three-dimensional CT scan: a case report

Missed proximal tracheoesophageal fistulas (TEF) after repair of an esophageal atresia (EA) with distal TEF are rare. The diagnosis usually is made on the basis of bronchoscopy and esophagoscopy, which can be inaccurate. Recent advances in computerized tomography (CT) have allowed saggital, coronal, and 3-dimensional reconstruction of any structure or organ. The authors report a case in which 3-dimensional CT was used to assist in the diagnosis of a missed proximal TEF in a 16-year-old girl.     

Benign intracranial hypertension vs. intracranial arteriovenous malformation: A possible CT dilemma

Summary A nine-year-old boy, presenting only with signs of increased ICP, underwent computerized tomography. This examination demonstrated no abnormalities in the precontrast scan. Following C. E., it showed scattered areas of blood-like density in both hemispheres, as well as a presumedly abnormal vessel in the left occipital region and dilated vein of Galen, sinus rectus, and tentorial veins. The presumptive diagnosis of left occipital AVM was not confirmed by angiography, which also ruled out obstructions of the intracranial sinuses.The possible mechanism responsible for this atypical CT picture is briefly discussed in the light of pertinent literature. It is suggested that careful consideration should be given to the indications for angiography in similar cases, in the presence of a hypervascular aspect of the postcontrast CT scan, particularly if a considerable amount of contrast medium has been used.     

Intracranial hemorrhage from undiagnosed metastatic brain tumor during general anesthesia

A patient with endometrial cancer presented with intracranial hemorrhage from an undiagnosed metastatic brain tumor during abdominal radical hysterectomy. Since she was neurologically intact, a systematic examination for brain metastasis had not been performed preoperatively. After the surgery, she had delayed recovery from general anesthesia with right hemiplegia and aphasia. Computed tomography and magnetic resonance imaging showed left putaminal hemorrhage from brain metastasis.     

Brain oedema in patients with intracranial meningioma

Summary The authors analysed the correlation between different clinical, radiological, and pathological variables and the presence and intensity of brain oedema associated to intracranial meningioma in 400 consecutive patients studied by computerized tomography (CT).The following factors did not show significant correlation with brain oedema development: the age and sex of the patient, the occurrence of focal deficits, the presence of skull changes (endostosis, exostosis, osteolysis), the occurrence of tumour calcification, the density of the tumour on plain CT scan, the presence of a cystic component, the pathological subtype of meningioma (both conventional and non-conventional), and the presence of histological features of tumour aggressiveness, such as an increased vascularization, high cellularity, high mitotic index, pleomorphism, necrosis, and brain infiltration.Factors showing a statistically significant correlation with the presence and intensity of brain oedema at the bivariate analysis were: the presence of symptoms (p < 0.001), the duration of the clinical history (p < 0.05), the location and size of the tumour (p < 0.001), the type (heterogeneous vs homogeneous), and intensity of tumour contrast enhancement (p < 0.001), the presence of irregular tumour margins (p < 0.001), and the existence of focal low density intratumoural areas (p < 0.001).The multivariate analysis using only clinical parameters showed that the group of variables with the highest power for predicting the presence of brain oedema (concordance level of 76.8%) included: the presence of symptoms, the occurrence of seizures (focal or generalized), the presence of an intracranial hypertension syndrome, and the age of the patient. The multivariate analysis using only anatomico-radiological parameters showed that the model which included the size of the tumour, the intensity of contrast enhancement, the tumour margins, and meningioma location, predicted the presence of brain oedema in 80.8% of the cases.Though the results of the present study do not definitively support any of the major physiopathological theories proposed to explain brain oedema formation in patients with intracranial meningioma, some findings could favour the so-called hydrodynamic theory.     

前循环动脉瘤的诊治(附56例报告)

目的探讨前循环动脉瘤的诊断方法,治疗时机的选择,术中注意事项及术后处理的相关问题。方法回顾性分析确诊为颅内前循环动脉瘤的56例患者的临床资料,包括检查手段、手术时机、手术方法、术后处理及预后。结果在56例患者61个动脉瘤中,直接手术夹闭57个,行载瘤动脉孤立术2例(均为眼动脉瘤),行动脉瘤包裹术2例(眼动脉瘤1例,前交通动脉瘤1例)。本组治愈40例(71.4%),轻残6例,重残4例,植物生存2例,死亡4例(7.1%)。结论三维DSA使动脉瘤的诊断更加准确;动脉瘤确诊后应尽早手术,翼点入路是治疗前循环动脉瘤行之有效的方法;手术后脑水肿和脑血管痉挛是致残和死亡的主要原因。     

Intracranial venous angiomas

Publications in the scientific literature are controversial in regard to the clinical significance of intracerebral venous angiomas. The present study of 11 patients with venous angiomas underscores the clinical importance of these lesions as potential causes of cerebral hemorrhage and obstructive hydrocephalus. The clinical and radiographic manifestations in 9 of these 11 patients correlated well. In cases of venous angiomas, the venous phase of angiography must be carefully scrutinized, particularly in patients with subarachnoid or intracerebral hemorrhage. Some diagnostic problems related to the angiography of venous angiomas are discussed.