Development of malignant glioma 15 months after anterior temporal lobectomy in a patient with temporal lobe epilepsy

Summary We report a 36-year-old woman, who had previously undergone anterior temporal lobectomy for intractable temporal lobe seizures; fifteen months later, magnetic resonance (MR) images showed a space-occupying lesion in the temporal lobectomy cavity. After a second operation, a histopathological examination showed a grade III astrocytoma. The fortuitous co-occurrence of temporal lobe epilepsy and a tumour was suspected, but histopathological and immunohistochemical examination of original resected temporal lobe parenchyma did not show evidence of neoplasm. The patient had not undergone postoperative radiotherapy and had not experienced viral infections. We propose that two factors possibly associated with the development of glioma were chemical exposure from anticonvulsant agents and trauma from resection of the anterior temporal lobe during initial surgery.     

Language function following anterior temporal lobectomy

The authors report the results of a prospective investigation that evaluated postoperative changes in language function after dominant (29 cases) or nondominant (35 cases) anterior temporal lobectomy for treatment of complex partial seizures. These patients received conservative resection of lateral temporal cortex but aggressive resection of medial temporal cortex. None of the patients underwent functional mapping of cortical language ability. All patients were assessed with a standardized aphasia battery (Multilingual Aphasia Examination) before and 6 months after surgery. Postoperatively, the dominant anterior temporal lobectomy group did not show any significant losses in language function compared to patients who underwent nondominant anterior temporal lobectomy. In addition, the dominant temporal lobectomy group showed significant postoperative improvement in complex receptive language comprehension compared to the nondominant group. These results suggest that patients with complex partial seizures of medial temporal lobe onset can undergo a conservative resection of lateral temporal cortex without language mapping. Such surgery carries little risk to language function and provides an excellent postoperative surgical outcome.     

Extent of mesiobasal resection determines outcome after temporal lobectomy for intractable complex partial seizures.

The extent of resection was assessed in 94 patients who underwent temporal lobectomy for medically intractable complex partial seizures originating from a unilateral seizure focus in the anteromesial temporal lobe. Postoperative magnetic resonance imaging in the coronal plane was used to quantify the extent of resection of lateral and mesiobasal structures according to a 20-compartment model of the temporal lobe. Successful seizure outcome (greater than or equal to 90% reduction in seizure frequency) was accomplished in 83% of the patients (all followed up for more than 1 year; mean duration of follow-up, 25.2 months) and correlated significantly (P less than 0.05) with the extent of mesiobasal resection, regardless of the extent of resection of lateral structures. Successful seizure outcome was accomplished in 81% of the patients with no structural lesions, and also correlated significantly (P less than 0.05) with the extent of mesiobasal resection regardless of the extent of lateral resection. A successful seizure outcome was accomplished in 90% of the 21 patients with structural lesions documented by neuroimaging studies. Two patients who underwent extensive lobectomy without resection of the structural lesion had no reduction in seizure frequency postoperatively. We conclude that the most important factor in determining the outcome of temporal lobectomy in patients with unilateral anteromesial temporal lobe epileptogenicity is the extent of resection of structures in the mesiobasal temporal lobe. In patients with structural lesions, lesion resection may be an added contributor to successful seizure outcome.     

Insular psammomatous meningioma presenting intractable complex partial seizures

We describe a 30-year-old female with intractable symptomatic epilepsy caused by an insular calcified mass, which was histologically proved as psammomatous meningioma. Seizures were described as consciousness impairment, motionless stare and automatism. After total removal of the tumor with a neuronavigation system and motor evoked potential (MEP) monitoring, seizures completely disappeared without neurological deficit. We emphasize that insular meningioma presents complex partial seizures which mimic medial temporal lobe epilepsy and seizures are controlled by total resection of the tumor.     

Failure of low-dose radiosurgery to control temporal lobe epilepsy.

Radiosurgical treatment of intractable epilepsy has emerged as a noninvasive alternative to resection. Although gamma knife surgery (GKS) reportedly is effective when the radiation dose is sufficient to cause a destructive reaction in the targeted medial temporal lobe, the optimal target area and dose distribution are largely unknown. Some investigators have suggested that focused irradiation from a nondestructive dose is also effective. In this article the authors report two cases of medial temporal lobe epilepsy in which the patients underwent GKS performed using a 50% marginal dose of 18 Gy covering the amygdala. hippocampal head and body, and parahippocampal gyrus. In both cases this procedure failed to control seizures. Both patients became seizure free after undergoing anterior temporal lobectomy 30 and 16 months, respectively, after radiosurgery.     

Giant skull base atypical meningioma presenting with rapidly progressive impaired consciousness caused by severe venous congestion: case report

A 43-year-old female presented with a giant skull base atypical meningioma manifesting as rapid progression of impaired consciousness. The meningioma was located in the ethmoid sinus, sphenoid sinus, nasal cavity, and left middle temporal fossa, and the intracranial portion of the tumor involved the left temporal region with massive surrounding brain edema in the left temporal lobe and basal ganglia. She underwent emergent fronto-temporo-parietal decompressive craniectomy, and the intracranial portion of the tumor was resected to control intracranial pressure. She recovered consciousness and neurological function dramatically, and subsequently underwent radical tumor resection via combined extended transbasal and left lateral transzygomatic infratemporal fossa approaches one month after the initial surgery. The extensive brain edema completely disappeared after tumor resection, and the patient fully recovered without neurological deficits except anosmia and small visual field defect. Rapid neurological deterioration and disturbance of consciousness caused by extensive peritumoral brain swelling are unusual in meningioma. In this case, the extemporaneous decompressive craniectomy was highly useful in the management of increased intracranial pressure.     

A case of Sturge-Weber syndrome with severe temper tantrum

We report a case of Sturge-Weber syndrome with intractable epilepsy presenting complex partial seizures(CPSs) and severe temper tantrum successfully treated with anterior temporal lobectomy. A 23-month-old girl without facial angioma presented with seizures from 8 months after birth. Neuroradiological examination demonstrated angioma in the left temporooccipital lobes and calcification in the left occipital lobe. Thus she was diagnosed as having Sturge-Weber syndrome. Her parents sought medical advice because of intractable and more frequent CPSs and a change in temperament manifesting as severe temper tantrums. Interictal electroencephalogram (EEG) showed relatively mild abnormal slow wave discharges in the left temporal region. The patient underwent left anterior temporal lobectomy based on intraoperative electrocorticography (ECoG) findings. Histopathological examination demonstrated gliotic change in the amygdala. After the surgery, she has remained seizure-free for 14 months while taking anticonvulsants and temper tantrums ultimately showed remission 10 months following surgery. This case may indicate that severe temper tantrum was associated with a change in amygdala structures.     

Astrocytic tumorette: microscopic to minute foci of glioma unexpectedly found in autopsy or surgical specimens

Four examples of astrocytic tumorettes (microscopic to minute foci of glioma) are described herein. They include one malignant astrocytoma and three low grade astrocytomas. The first patient, who died of heart failure, was found incidentally to havour a small malignant astrocytoma at the time of autopsy. The other three patients with astrocytomas of low grade in malignancy, ranged from 18 to 25 years in age, and presented with intractable seizures. Electroencephalography defined a temporal lobe focus in all three patients. Subsequently, all three underwent a unilateral temporal lobectomy with resection of the epileptic focus. Careful histological examinations on the removed tissues from each patient revealed that each of them had a minute astrocytoma. The histogenesis of benign and malignant astrocytomas and the importance of surgical exploration in the management of the patients with intractable seizure disorders are discussed.     

Compulsive polydipsia following meningioma resection: an epileptic phenomenon? Case report

The authors report the case of an individual who developed compulsive polydipsia following resection of a left sphenoidal ridge meningioma. The episodic, stereotyped nature of his symptoms, response to treatment, and electroencephalographic and magnetic resonance imaging findings are all highly consistent with temporal lobe-onset epilepsy. The pathophysiology of this underrecognized phenomenon is discussed.     

Multicystic, heterogeneously enhancing meningioma in an octogenerian

A multicystic meningioma in an octogenerian whose tissue diagnosis was ill-defined and misleading on preoperative neuroradiologic imaging is presented. Nauta has described four cyst types that can develop in cystic meningiomas. We report the first case in which three cyst types are demonstrated concurrently, describe the histopathology and surgical management. This case represents a rare variant of a common tumour in an unusual age group, and underscores the need for definitive biopsy and resection as indicated. Furthermore, the diagnosis of multicystic meningioma does not favour an aggressive histopathology in this case.     

Intracranial leptomeningeal metastasis from thymic carcinoma: case report and review

BACKGROUND: Thymic carcinoma is an uncommon malignant tumor of the anterior mediastinum. Meningeal metastasis from this type of neoplasm is extraordinarily rare and the prognosis is abysmal. CASE DESCRIPTION: This article presents the case of a 45-year-old man with known metastatic thymic carcinoma who presented with intractable headaches. An MRI scan was highly suggestive of a meningioma, and it was initially suspected that this patient had 2 primary tumors. Surgical resection of the mass both demonstrated a metastatic thymic lesion and ameliorated the patient's quality of life. CONCLUSION: The authors report a case of intracranial meningeal metastasis from a lymphoepithelioma-like poorly differentiated metastatic thymic carcinoma, which was treated by resection and WBRT. A review of the current literature revealed no other cases of this uncommon alhistologic subtype of thymic carcinoma metastatic to the cranium. The incidence, histologic classification of subtypes, and treatment are discussed. This case also illustrates the importance of maintaining a high degree of suspicion for a metastasis in patients with known primary malignancy who present with an MRI highly suspicious for meningioma.     

Intractable epilepsy following radiosurgery for arteriovenous malformation.

Radiosurgery is often used to treat arteriovenous malformations (AVMs) located in deep brain locations. Most of these procedures are successful not only in obliterating the AVM but also in decreasing the frequency and severity of associated seizures. Although radiosurgery is occasionally associated with the development of easy-to-control seizures immediately postoperatively, there have been no reports of intractable epilepsy developing after radiosurgery. In this report, however, a case is presented in which a patient underwent gamma knife surgery (GKS) for an AVM, after which intractable epilepsy and mesial temporal sclerosis (MTS) gradually developed. A 37-year-old right-handed woman underwent GKS for a right mesial parietotemporooccipital AVM. One year later, the AVM had reduced in size, but the patient began to experience complex partial seizures (CPSs). These CPSs initially occurred at a frequency of one per month, but 6 months later they were occurring every other week. She also started having secondarily generalized tonic-clonic seizures (GTCSs) once per month. Over the next year the frequency of her seizures gradually increased to several CPSs per day and two to three GTCSs per week, despite treatment with various combinations of antiepileptic drugs. By this time her AVM had decreased to one half of its original size. Video-electroencephalography monitoring demonstrated that both the CPSs and GTCSs were arising from the right posterior quadrant. Magnetic resonance imaging revealed not only the presence of the right-sided AVM, but also right-sided MTS. The patient underwent surgical resection of the AVM and right temporal lobectomy. She has been free from seizure for longer than 1 year. Radiosurgery may be associated with intractable epilepsy and MTS.     

Fatal hemorrhagic infarction of posterior fossa meningioma during cardiopulmonary bypass

Few publications address cardiac surgery in the presence of meningioma. Individual complications include transient visual loss from a suprasellar meningioma, hemiparesis after mitral valve replacement with recovery after resection, and non-fatal hemorrhage into a posterior fossa meningioma. The largest report of 16 patients with known meningiomas over 11 years suggested a benign course, with no new neurologic symptoms and no required resection of a meningioma over an average follow-up of 31 months. In 2 cases we report a presumed posterior fossa meningioma led to fatal outcome after cardiac surgery performed on bypass. Possible causes and future considerations are discussed.     

Surgical resection of pulmonary metastases from meningioma: Report of a case

Meningiomas rarely metastasize, and little information on pulmonary metastasectomy from meningioma has been documented. We herein report a case of a potentially curative resection for meningioma that metastasized to the lung. A 67-year-old woman was admitted to our hospital because of two masses in the right lung. In 1993, when the patient was 52 years old, she underwent a craniotomy for an atypical meningioma. The meningioma recurred once in the local site and was re-excised in 1997. In 2008, a screening chest X-ray detected two lung nodules in the right lung field. A computed tomographic scan demonstrated round masses with sharp borders, in the right S2 (2.2 cm in diameter) and S4 (1.1 cm in diameter) regions. A whole-body [¹⁸F]2-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography/CT examination revealed intense focal FDG uptake (maximum standard uptake value [SUV_max] = 6.9) in the larger mass, and weak FDG uptake (SUV_max = 2.3) in the smaller mass. A wedge resection of S2 and a middle lobectomy of the right lung were performed, and the final diagnosis was pulmonary metastases from an intracranial meningioma. The patient is presently doing well 20 months after the surgery without any signs of recurrence. Our case demonstrates that surgery should be considered when pulmonary metastases are deemed completely resectable by a preoperative radiological examination, and that a good clinical outcome can be achieved.     

Severe bradycardia during epilepsy surgery.

Several kinds of arrhythmia are known to occur during epileptic seizure, and bradycardia has been reported in patients with temporal lobe epilepsy. The authors review the anesthesia records of patients with intractable epilepsy. Forty-two consecutive patients with intractable epilepsy who underwent epilepsy surgery were examined. Anterior temporal lobectomy was performed on 29 patients, frontal lobectomy on 2 patients, and a subdural electrode was set on 11 patients. Anesthesia was induced with propofol, fentanyl, and vecuronium and maintained with sevoflurane-fentanyl, propofol-fentanyl, or fentanyl-droperidol. Severe bradycardia (13-39 beats/min) was seen in six patients. All six patients recovered within 1 minute of interrupting the surgical procedure and administering intravenous atropine, and the surgeries were completed with no complications. The authors believe the six events were sinus bradycardias. They all occurred during amygdalo-hippocampectomy in cases of temporal lobectomy. This type of hemodynamic change was not seen in any of the patients undergoing temporal lobectomy without hippocampectomy, in patients undergoing frontal lobectomy, or when setting subdural electrodes. Experimentally, it has been shown that stimulation of the limbic system, such as the hippocampus, amygdala, and insular cortex, induces bradycardia and hypotension resulting from increased parasympathetic flow via the vagus nerve. Severe bradycardia may thus occur during surgery for temporal lobe epilepsy, and hemodynamic changes should be watched carefully during amygdalo-hippocampectomy.     

Iterative surgical resections for local recurrent and second primary bronchogenic carcinoma.

OBJECTIVE: To report our experience with repeated pulmonary resection in patients with local recurrent and second primary bronchogenic carcinoma, to assess operative mortality and late outcome. METHODS: The medical records of all patients who underwent a second lung resection for local recurrent and second primary bronchogenic carcinoma from 1978 through 1998 were reviewed. RESULTS: There were 27 patients. They constituted 2.5% of 1059 patients who had undergone lung resection for bronchogenic carcinoma in the same period. Twelve patients (1.1%) (group 1) had a local recurrence that developed at a median interval of 24 months (range 4-83).The first pulmonary resection was lobectomy in ten patients and segmentectomy in two. The second operation consisted of completion pneumonectomy in ten cases, completion lobectomy in one and wedge resection of the right lower lobe after a right upper lobectomy in one. The other 15 patients (1.4%) (group 2) had a new primary lung cancer that developed at a median interval of 45 months (range 21-188).The first pulmonary resection was lobectomy in 12 patients, bilobectomy in one and pneumonectomy in two. The second pulmonary resection was controlateral lobectomy in seven patients, controlateral sleeve lobectomy in two, controlateral pneumonectomy in 1, controlateral wedge resection in four and completion pneumonectomy in one. Overall hospital mortality was 7.4%, including one intraoperative and one postoperative death in group 1 and 2, respectively. Five-year survival after the second operation was 15.5 and 43% with a median survival of 26 and 49 months in groups 1 and 2, respectively (P=ns). CONCLUSIONS: Long-term results justify complete work-up of patients with local recurrent and second primary bronchogenic carcinoma. Treatment should be surgical, if there is no evidence of distant metastasis and the patients are in good health. Early detection of second lesions is possible with an aggressive follow-up conducted maximally at 4 months intervals for the first 2 years and 6 months intervals thereafter throughout life.     

Cerebral metabolism of the remote area after epilepsy surgery

To clarify whether epilepsy surgery improves cerebral metabolism, pre- and postoperative positron emission tomography (PET) scans were performed, with special reference to hypometabolism outside the resected epileptogenic zones in nine patients (8 males, 1 female) with medically intractable complex partial seizures and multiple hypometabolic zones. Seven patients underwent unilateral anterior temporal lobectomy, one patient underwent selective amygdalohippocampectomy, and one patient underwent parieto-occipital cortical resection and anterior temporal lobectomy. PET scans were obtained at least 6 months after surgery. Eight patients became seizure-free, and one patient had fewer than three seizures per year. Four patients showed improved glucose metabolism in the formerly hypometabolic zones, which were remote to the surgical site and ipsilateral to the epileptogenic foci. Five patients, who showed bilateral temporal hypometabolism preoperatively, had contralateral temporal hypometabolism after surgery. The relative glucose uptake in four of these patients showed increased metabolism of the adjacent lobes ipsilateral to the surgical site. The lobes that showed increased glucose metabolism after surgery were mostly frontal. Hypometabolism is reversible in the ipsilateral remote area, and may be caused by inhibition via the intercortical pathway. Contralateral temporal hypometabolic zones that persist after surgery may be caused by a different mechanism, and neither indicate the presence of seizure foci nor affect the seizure outcome.     

Temporal lobectomy for seizures associated with unilateral schizencephaly

Schizencephaly is characterized by unilateral or bilateral cerebral clefts associated with neurologic deficits and epilepsy. Most commonly schizencephaly is attributed to abnormal neuronal migration, and these malformations are well visualized by current neuroimaging techniques. This report describes a patient with unilateral schizencephaly and poorly controlled complex partial seizures who was found to have a temporal lobe seizure focus; anterior temporal lobectomy produced nearly complete control of the seizures. Despite the extensive malformation, relatively restricted resection was of significant benefit. The principles of seizure focus localization and resection are applicable to the management of patients with schizencephaly.     

Limited operation of lung cancer: the role of video-assisted thoracic surgery for lung cancer

Lobectomy with systemic nodal dissection is recognized as a standard operation for lung cancer. Partial resection and segmental resection are classified as limited resections for lung cancer to preserve pulmonary function. Minor complications occur more frequently with limited resection than with lobectomy. Partial resection of the lung and simple lobectomy can be performed as video-assisted thoracic surgery (VATS). Systemic hilar and mediastinal lymph node dissection is not yet standardized using VATS. On the other hand, VATS preserves chest wall muscles. The difference between standard thoracotomy and VATS is a difference of approach to the thoracic cavity. It is most important for lung cancer surgery to be performed in the thoracic cavity with the minimum burden on patients.     

Management of empyema cavity with the vacuum-assisted closure device

Management of empyema after pulmonary resection remains a challenging problem. Along with mandatory drainage of the thoracic cavity and investigations to rule out bronchopleural fistula, a reliable method of thoracic cavity closure is needed. The open thoracic window and Eloesser flap techniques rarely represent definitive therapy. Muscle flap and thoracoplasty procedures may provide well-vascularized tissue to close bronchopleural fistula and obliterate the empyema cavity, but they are quite complex and involve significant patient morbidity. We report a case of empyema without bronchopleural fistula after lobectomy in which the vacuum-assisted closure device was used to achieve complete wound healing after open drainage.