Therapeutic irradiation of brain tumor and cerebrovasculopathy

The first case was a 5-year-old girl treated with a total of 6000 rads after total removal of a left temporoparietal tumor extending into the basal ganglia. About 4 years after completion of the radiation therapy, she showed left hemiplegia and deterioration in her level of consciousness. A plain CT scan showed calcification in the region of the bilateral basal ganglia and low density area in the right fronto-parietal region. An enhanced CT revealed gyral enhancements in the pre- and postcentral gyrus of the right hemisphere. Left carotid angiograms showed a narrowing of the horizontal portion and an occlusion of the distal portion of the left anterior cerebral artery. The distal portion of the right anterior cerebral artery was filled through the anterior communicating artery. Right carotid angiograms revealed an occlusion of the terminal portion of the internal carotid artery, retrograde filling of the anterior and middle cerebral arteries by leptomeningeal anastomosis via the posterior cerebral artery, and partial filling of the anterior cerebral artery via the anterior falx artery. Preoperative arteriography did not show occlusion and stenosis of the cerebral arteries. Superficial temporal artery-middle cerebral artery anastomosis in the right hemisphere was performed. Regional cerebral blood flow measured during operation increased from 34 to 72 ml/100 gr/min due to the surgery. About two weeks after surgery, left hemiplegia disappeared completely. The second case was a 67-year-old man who had received radiotherapy, following surgery of a chromophobe pituitary adenoma. About one year after irradiation he began to complain of gait disturbance and dysarthria.(ABSTRACT TRUNCATED AT 250 WORDS)     

Multiple giant aneurysm--a case report

We report a case of five aneurysms, including three giant aneurysms, a pair of symmetric aneurysms, and two fusiform aneurysms. The initial clinical symptom was a cerebral ischemic attack. On admission, the patient complained of sudden onset of speech disturbance. Physical examination showed left hemiparesis. Radiological studies, including computed tomography and cerebral arteriography, revealed multiple low density areas bilaterally in the basal ganglia and three fusiform giant aneurysms bilaterally in the middle cerebral arteries and basilar artery. Considering the difficulty of surgical treatment, the patient was discharged. Six months later, complaining of right hemiparesis and total dysphasia, the patient was readmitted to our department. CT scan on admission revealed no changes except for ischemic changes. During the second admission, another attack of subarachnoidal hemorrhage due to rupture of the left middle cerebral artery aneurysm occurred, and the patient died. Autopsy was performed, and two more aneurysms, not visualized in the former studies, were found in the right anterior communicating artery and the cortical branch of the right middle cerebral artery. The occurrence of aneurysms in such a fashion as seen in the present case is to be very rare in the aspect of the size, the multiplicity and the bilaterally development.     

Basal ganglia germinoma treated with interstitial brachytherapy; case report

A case of primary intracranial germinoma in the left basal ganglia treated with interstitial brachytherapy was reported. A 15-year-old boy was referred to our hospital for evaluation of right hemiparesis. A CT scan showed a slightly hyperdense mass with multiple cystic low density in the left basal ganglia. The mass was heterogeneously enhanced after intravenous administration of contrast material. T1 weighted image showed a slightly hyperintense mass with cystic components and the mass was heterogeneously enhanced with Gd-DTPA. T2 weighted MR image showed a mixed intensity mass and peritumoral edema. Stereotactic needle biopsy and implantation of 3 catheters for interstitial brachytherapy were performed simultaneously using BRW CT guided stereotactic apparatus. After the histological diagnosis was confirmed to be two cell pattern germinoma, 9 iridium-192 seeds were inserted into the catheters and maintained for 10 days to give 35Gy of irradiation at the tumor periphery. Subsequent CT scans showed marked tumor regression and the clinical symptoms were improved. Germinoma originating in the basal ganglia is rare and hard to diagnose previous to biopsy. Histological confirmation is essential before initiation of treatment because germinoma is commonly thought to be radiosensitive tumor. The interstitial brachytherapy enables selective irradiation of the tumor and actually causes no complications such as bone marrow suppression or cerebral atrophy. The neuroradiological findings, especially of CT scan and MRI, were presented and the strategy for treatment of germinoma in basal ganglia was discussed.     

Case report of traumatic hemorrhage from the anterior choroidal artery

Traumatic hemorrhage from the anterior choroidal artery is very rare. A 74-year-old male was admitted to our hospital immediately after a traffic accident. CT on admission showed right intracerebral hematomas in the posterior limb of the internal capsule and the upper part of the right cerebral peduncle. Neurological examination revealed that the patient had left hemiparesis and transient mute, pseudobulbar sign and peduncular hallucination. The absence of hypertensive asymptomatic microbleeds in other basal ganglia supported the verdict of traumatic injury of the anterior choroidal artery. The tear mechanism of the anterior choroidal artery might have been caused by an impact to the parietal region directed toward the tentorium.     

Xenon-enhanced computed tomographic measurement of cerebral blood flow in patients with chronic subdural hematomas

We compared clinical symptoms with extent of brain shift on computed tomographic (CT) scans and quantitative and three-dimensional measurements of cerebral blood flow (CBF) on xenon-enhanced CT scans in 10 patients with chronic subdural hematomas. Five patients had only headache and minimal or no brain shift on a CT scan. The other five had hemiparesis and/or mental disturbance in addition to headache and moderate or severe brain shift on a CT scan. The mean hemispheric CBF decreased about 7% in patients with headache and about 35% in patients with hemiparesis and/or mental disturbance. It decreased also on the side without the hematoma. The CBF reduction was always more pronounced in the putamen and thalamus than in the cortex. On the contrary, the cortex CBF was mostly preserved or even elevated in both groups of patients. We speculate that CBF reduction in patients with a chronic subdural hematoma occurs initially in central cerebral areas like the basal ganglia and thalamus, and then extends to the entire hemisphere including the cortex as brain compression and displacement progress. Central cerebral area involvement might be more responsible for clinical symptoms than the cortex.     

A case of iatrogenic traumatic intracranial aneurysm

A case of traumatic aneurysm due to an arterial injury during removal of a tuberculum sellae meningioma is reported. A 43-year-old man had undergone craniotomy for removal of the tumor. It was very hard with many feeders from bilateral anterior cerebral arteries (ACA), so the resection between the left ACA and the tumor was difficult. A small artery was accidentally pulled out from the left ACA and bleeding occurred from the small artery in the artery. The ACA was trapped temporarily with two clips and was coated using Oxycell and Biobond. The bleeding was stopped by this procedure and the blood reflowed. This tumor was removed totally, but postoperative CT scan showed an enhancing small lesion in the anterior part of the left basal ganglia 10 days after operation. The angiograms performed next day revealed a fusiform aneurysm of the left proximal ACA near the anterior communicating artery. The skull was reopened to treat the aneurysm. The aneurysm arising from just a bleeding point in the previous operation was oval in shape without neck, so it was trapped by two small aneurysm clips and resected. The patient's condition was uneventful after the second operation. Pathological diagnosis of the aneurysm was confirmed a false aneurysm. Iatrogenic traumatic aneurysms caused by neurosurgical procedure has been reported in 29 cases. Eighteen cases showed bleeding from injured artery during surgery and a half of them showed rupture from the aneurysm within one month after operation. Such doubtful cases of traumatic aneurysm should be diagnosed by angiography and operated as early as possible.     

Bilateral traumatic hemorrhage in the basal ganglia: report of two cases

Hematomas of the basal ganglia in head injury have long been recognized by pathologists with an interest in head injury but their mechanism has not been revealed clearly. We report two cases of bilateral traumatic hemorrhage in the basal ganglia. Case #1, a 17-year-old male was admitted to our hospital immediately after a traffic accident. Neurological examination revealed that the patient was comatose and had right hemiparesis. CT scan showed bilateral hemorrhage of the basal ganglia and subarachnoid hemorrhage in the perimesencephalic cistern. MRI showed high signal intensity areas in the bilateral basal ganglia, perimesencephalic cistern, cerebral white matter and corpus callosum. The patient was diagnosed as having diffuse axonal injury coinciding with bilateral hemorrhage of the basal ganglia. Stereotactic aspiration for the hematoma of the left basal ganglia was carried out. Case #2, a 75-year-old male was admitted immediately after falling from the roof of his house. Neurological examination revealed no neurological deficit except for headache and nausea. CT scan on the day of injury revealed no abnormality. But CT scan 12 hours following the injury showed bilateral hemorrhage of the basal ganglia. Blood pressure of the patient was within normal range and he was diagnosed as having traumatic bilateral intracerebral hematoma. Conservative treatment was carried out and the patient was discharged 7 days after injury with no neurological deficit. The mechanism of traumatic hemorrhage of the basal ganglia has not been clear. In case #1, diffuse axonal injury (DAI) may have played an important role in the bilateral hemorrhage. But in case #2, non-DAI factor such as vasoparalysis syndrome may have existed.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of bilateral testicular tumor

A case of bilateral germ cell tumor of the testis is reported. In 1988, a 36-year-old male presented with painless swelling of left scrotal contents. Right orchiectomy and retroperitoneal lymph node dissection for embryonal carcinoma had been performed 5 years earlier. Left orchiectomy was performed and its histological finding was seminoma and embryonal carcinoma. Evaluations including CT scan and Ga scintigraphy revealed no metastasis. Postoperatively, the patient was treated with PVB therapy. Previous reports of bilateral germ cell testicular tumor were reviewed, and the age distribution, interval, and histological classification of these cases are discussed.     

Ruptured cerebral aneurysm followed by primary intracranial malignant lymphoma: case report

Reported herein is a case of ruptured anterior cerebral aneurysm followed by primary intracranial malignant lymphoma. A 73-year-old female was admitted to our hospital on October 20, 1986, with a severe subarachnoid hemorrhage. Microsurgery was performed immediately on the day of admission because cerebral angiography revealed bilateral distal anterior cerebral artery aneurysms. Consciousness gradually deteriorated due to cerebral vasospasm from the 3rd day following surgery. To protect the brain, corticosteroid (methylprednisolone 1500 mg, dexamethasone 252 mg) was administered for 26 days after surgery. In spite of treatment, in March 1987 neurological examination revealed akinetic mutism, but CT scan did not reveal any evidence of tumor. CT scan performed on May 2, 1987, revealed a mass lesion in the left frontotemporal lobes and left basal ganglia. Histological diagnosis of malignant lymphoma (diffuse, large-cell type) was obtained by stereotactic biopsy. Radiotherapy (41 Gy of 60Co) was carried out. The CT scan performed on August 26, 1987 revealed that the abnormal enhanced lesion had disappeared. However, neurological findings had not remarkably improved. The patient died of renal failure in February 1988, but tumor recurrence had not been noted in CT scans. Autopsy could not be performed. Whole body CT scan and 67Gd scintigram did not reveal any other tumors except in the brain. Ruptured cerebral aneurysm followed by primary intracranial malignant lymphoma is very rarely reported. In such cases, which have unusual clinical courses and CT findings, we recommend stereotactic biopsy to treat this kind of radiosensitive tumor. The connection between malignant lymphoma and immunosuppression has been considered.(ABSTRACT TRUNCATED AT 250 WORDS)     

Superselective fibrinolysis for a middle cerebral artery embolism caused by a left atrial myxoma: case report

A case of successful treatment by local fibrinolysis of a middle cerebral artery embolism caused by a thrombus from a left atrial myxoma is reported. A 62-year-old woman using a pacemaker and suffering from sick sinus syndrome was admitted on December 29th 1996, complaining of transient restlessness. CT and cerebral angiography revealed no abnormal vascular lesions. Eighteen months after the initial episode, she suffered a sudden onset of left hemiparesis and loss of consciousness. CT scan performed during the second episode revealed no lesions and, in particular, no early CT infarction sign, but emergent cerebral angiography revealed a right middle cerebral artery embolic occlusion. Local fibrinolysis using a tissue plasminogen activator was performed within 3 hours after the beginning of the episode, and partial recanalization was obtained within one hour after initiation of the fibrinolytic therapy. On the first hospital day, though CT revealed a small low-density area in the right basal ganglia, motor deficits gradually improved. Considering the possibility of a cardiac source of the embolism, trans-esophageal echocardiography was performed and revealed a left atrial tumor suspected to be a myxoma. It was removed by surgery on the 34th hospital day. Histological examination proved it to be a myxoma. Nine months after local fibrinolytic therapy, the patient returned to work. The diagnosis of cerebral embolism caused by cardiac myxoma is difficult to make at the time when the patient is first examined after admission. It is also hard to discover during emergent cerebral angiography with fibrinolytic therapy. Therefore, in the case of patients with cerebral embolism for which local fibrinolysis is ineffective, it should be presumed that cardiac myxoma is the source of the embolus. Direct PTA alone may be effective for such tumoral embolism.     

Simultaneous occurrence of renal cell and transitional cell carcinoma in the same kidney and ureter. A case report

An unusual case of 2 concurrent primary renal tumors within the same kidney is reported. A 70-year-old woman presented with gross hematuria when she was in the hospital for cerebral infarction. Excretory urography revealed a marked expansion of the right kidney with no renal function. CT scan showed a mass arising from the right kidney, the hydronephrotic right renal pelvis, and a mass in the lower right ureter. Selective renal angiogram showed marked neovascularity of the mass. There was an encasement of the intrarenal artery to the lower pole. Angiographic findings were highly suggestive of a renal cell carcinoma with a second neoplasm in the renal pelvis. Subsequently, the patient underwent right radical nephroureterectomy and partial cystectomy. Section of the removed specimen revealed a 4.0 X 3.8 cm solid tumor confined to the kidney in the upper pole and a transitional cell carcinoma arising from the renal pelvis. In addition, transitional cell carcinoma was present in the distal ureter.     

Three cases of cryptic arteriovenous malformation in basal ganglia manifested by putaminal hemorrhage

Three cases of histologically proven cryptic arteriovenous (AV) malformation of the basal ganglia are reported. Seventeen cases of patients showing putaminal hemorrhage in the CT scan underwent craniotomy for evacuation of a hematoma between January 1986 and December 1988. The preoperative diagnosis was hypertensive putaminal hemorrhage. In all three cases a network of abnormal vessels around the internal capsule was detected at surgery. Case 1: A 62-year-old male was admitted to our hospital with consciousness disturbance (JCS 20), total aphasia and right hemiparesis. The CT scan showed left putaminal hemorrhage. The volume of the hematoma was 45 ml by CT criteria. Left carotid angiography did not demonstrate any abnormal findings. Case 2: 69-year-old male was admitted with consciousness disturbance (JCS 10) and right hemiparesis. Left putaminal hemorrhage (volume 25 ml) was recognized on the CT scan. Two hours after admission, the consciousness level suddenly deteriorated (JCS 100). At that moment, the volume of the putaminal hematoma had increased to 100 ml. AV malformation was not detected by left carotid angiography. Case 3: A 50-year-old male was admitted with consciousness disturbance (JCS 20), total aphasia and right hemiparesis. The CT scan showed left putaminal hemorrhage of 73 ml. Pathohistological examination proved AV malformation in each case. The three cases described here suggest the following; 1) The incidence of the basal ganglia cryptic AV malformation has been considered low, but meticulous examination shows that among the cases diagnosed as hypertensive hemorrhage, AV malformation is not infrequently the hidden cause.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intracranial germinoma and Down's syndrome--case report.

A germinoma in the basal ganglia developed in a 9-year-old boy with Down's syndrome, presenting as left hemiparesis. An initial computed tomographic (CT) scan demonstrated no notable abnormalities, but serial CT scans followed the entire course of tumor growth. Subtotal removal and irradiation achieved tumor remission. This is the first case reported of intracranial germinoma associated with Down's syndrome.     

A case of posttraumatic delayed cerebral arterial spasm; case report and review of the literature on the pathogenesis]

A case of posttraumatic delayed cerebral arterial spasm is presented. A 71-year-old man was admitted to our hospital with head injury. Neurological examination on admission only revealed consciousness disturbance (Japan Coma Scale 30). CT scan 19 hours after the injury demonstrated a contusional hematoma in the right frontal lobe, faint subarachnoid hemorrhage in the left sylvian fissure and subdural hematoma in the interhemispheric fissure. His consciousness was disturbed on the 14th day. CT scan demonstrated a left subdural effusion, which was surgically evacuated. However, from the next day the patient developed left hemiparesis. Right carotid angiogram on the 17th day after the injury revealed multiple segmental arterial narrowing in the right anterior cerebral artery (ACA) and middle cerebral artery (MCA). We diagnosed a posttraumatic delayed cerebral arterial spasm. CT scan revealed low density areas in the right ACA and MCA territory. The pathogenesis of posttraumatic delayed arterial spasm is not yet well known. Now, four theories have been suggested as follows: (1) Subarachnoid hemorrhage, (2) Direct mechanical injury to the arterial wall, (3) Hypothalamus dysfunction, and (4) Disturbed autoregulation. In our case, three important factors are suggested. The first is direct injury to the artery, the second is cerebral contusion, and the third is subdural effusion.     

A case of large basal ganglia AVM totally removed by staged operation

Large basal ganglia AVMs have been deemed inoperable because of their location in critical structures. Nonetheless, the unfavorable natural history of an untreated ruptured AVM in a young patient induced us to approach these lesions. We presented a case of a large basal ganglia AVM totally removed by a three-staged operation. A 26-year-old man who had twice experienced intracranial hemorrhage was admitted for examination. On admission, mild left hemiparesis, hypesthesia and left hemianopsia were disclosed. CT scan showed the AVM was located in the posterior thalamus with the hematoma cavity laterally. Right carotid and vertebral angiograms demonstrated a large AVM, 5cm in diameter, supplied by the anterior choroidal artery (AchoA), the lateral lenticulostriate arteries (I-LSAs), the lateral posterior choroidal artery (LPchoA) and the thalamo-perforating artery. Drainage was via the internal cerebral vein and the basal vein of Rosenthal. MRI demonstrated more clearly the anatomical relationship of the nidus and surrounding structures. The patient underwent a three staged operation. At the first operation AchoA was interrupted in the inferior horn of the lateral ventricle (IHL) via the hematoma cavity using the trans-sylvian approach. The anterior part of the nidus was dissected with all except one of the I-LSAs being disconnected. At the next operation by occipital interhemispheric approach, some feeders from the posterior cerebral artery were coagulated and disconnected. The medial and posterior part of the nidus was dissected from the thalamus along with the choroid plexus of the trigone of the lateral ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)     

Three cases of internal carotid artery dissection due to trivial trauma

Three cases of internal carotid artery (ICA) dissection due to trivial trauma were reported. A 14-year-old, previously healthy, girl developed left hemiparesis after jogging. MRI sh owed cerebral infarction in the right basal ganglia and the MR angiography (MRA) revealed luminal narrowing of the right ICA as well as pseudolumen at the origin of the right ICA. She was treated with antithrombotic therapy. Follow-up MRA demonstrated normal signal in the right ICA. A 23-year-old woman admitted to the hospital because of minor facial injury due to a traffic accident. Although she had no apparent symptom, follow-up CT, one day after presentation,. showed cerebral infarction in the right basal ganglia. Angiography showed diminished luminal diameter of the right ICA. She was treated with antithrombotic therapy and follow-up angiography showed reconstitution of normal lumina of the right ICA. A 34-year-old woman was referred to our hospital because of transient ischemic attack following swimming. Neurological examination was normal and MRI did not show any ischemic lesion. MRA revealed diminished signal in the left ICA as well as string and pearl sign at the origin of the left ICA. She was treated with antithrombotic therapy, and follow-up angiography showed normalization of the left ICA. Cervical ICA dissection due to trivial trauma usually appears as an eccentric tapered stenosis arising at the origin of the ICA and resolves with complete or excellent recovery in most cases. Surgical or endovascular treatment should be reserved for patients who have persistent symptoms of ischemia despite adequate antithrombotic treatment.     

Bilateral ophthalmic origin of the middle meningeal artery

The origin of the middle meningeal artery (MMA) may vary although it can arise from the ophthalmic artery (OA) with a 0.5% prevalence. We report the exceptional bilateral asymmetric origin from the OAs that has not previously been reported in the literature. Surgeons should be aware of this variation as it could be crucial in the setting of an endovascular approach for meningeal lesions, as in our observation. A 50-year-old male underwent a preoperative cerebral digital subtracted angiography that incidentally revealed MMAs arising from the OA on both sides. In fact, the origin was asymmetric because it was complete on the right side with the anterior and posterior branches of the MMA arising from the OA, whereas it was partial on the left side, with only the anterior branch arising from the OA. The CT scan showed the absence of the foramen spinosum only on the right side. This paper discusses the unique anatomic variation in the light of MMA embryology and its different origins. Knowledge of this variation may have a practical impact in cases of cerebral embolization.     

Unusual intrathoracic location of a primary germ cell tumour.

The primary location of non-metastatic germ cell tumours of the chest is the anterior mediastinal compartment. Germ cell tumour arising from lung parenchyma is one of the rarest conditions in human and only a few cases of choriocarcinomas and yolk sac tumour have been reported to date. Here we report a case of intrapulmonary mixed type germ cell tumour, containing embryonal carcinoma, choriocarcinoma and yolk sac tumour elements. Diagnosis of the lesion was achieved by open thoracotomy and bulk of the tumour was resected by right upper lobectomy.     

Coexistence of multiple metastatic brain tumors from thyroid carcinoma and cerebral aneurysms

A 73-year-old woman was admitted with coexistence of multiple metastatic brain tumor and cerebral aneurysm. She has been operated on for a tumor of the thyroid gland 3 years before. Computed tomography (CT) scan revealed well-defined, homogeneously enhanced masses in the left frontal and right posterior temporal region. Right carotid angiography showed a tumor stain supplied by the branch of the fronto-polar artery. Left carotid angiography showed an aneurysm at the anterior communicating artery and a tumor stain supplied by the posterior temporal artery. Total removal of the bilateral tumor and aneurysmal neck clipping were performed simultaneously with bi-frontal craniotomy and right temporal craniotomy in April of 1988. Histology of tumor was papillary carcinoma. The surgical indication and treatment for patients with coexistence of multiple brain tumor and cerebral aneurysm were discussed.     

Intraparenchymal epidermoid cyst of the right frontal lobe: a case report

Epidermoid cysts are most likely to occur at the cerebellopontine angle or in the suprasellar region. Intracerebral epidermoid cysts are rare and only 18 cases have been reported in the literature. This report presents a case of epidermoid cyst which developed in the right frontal lobe. A 24-year-old woman was admitted to our clinic on April 24, 1983 because of generalized convulsions. On admission no neurological abnormalities were found except for absence of the venous pulsation in an ophthalmoscopic study. A plain roentgenogram revealed a crescent shaped calcification in the right frontal lobe. An X-ray CT scan showed a round low density area (Hounsfield units + 12) surrounded by irregular ring-like high density spots in the right frontal lobe. Right carotid angiography showed round shift of the anterior cerebral artery to the left. The horizontal portion of the middle cerebral artery was stretched and lenticulostriate arteries were shifted laterally. Abnormal vascularization was not found. On May 11th 1983 a right fronto-temporal craniotomy was performed. Partial corticotomy was done along the cortical sulcus and the tumor was resected. The histological diagnosis was epidermoid cyst. In general an X-ray CT scan shows a low density area with irregular margin. Usually the low density area revealed -8 approximately +30 of Hounsfield units. Neither perifocal low density area nor enhancement by contrast medium is observed.