Migration of sparganosis from the brain to the cervical spinal cord

Central nervous system (CNS) sparganosis is a rare parasitic infestation caused by ingestion of the raw or inadequately cooked snakes or frogs. Sparganum is well known for its ability of migrating though the tissue, therefore, it can cause various neurological symptoms if it involves neurological systems. A 51-year-old male patient visited our department of neurosurgery complaining of the motor weakness and radiating pain on both upper extremities over 4 months. He had a history of ingesting raw snakes untill his late twenties. The magnetic resonance (MR) images of cervical spine revealed an intramedullary ill-defined enhancing lesion with the aggregated cysts in the upper cervical spinal cord. Under presumptive diagnosis of sparganosis, we took brain MR image. The brain MR images revealed the signal change in right fronto-temporal lobe suggesting the trajectory of parasitic migration via ventricular systems. He underwent a midline myelotomy and granuloma removal followed by the posterior laminoplasty. Pathologic findings showed inflammatory changes and necrosis with keratinized tissue suggesting the CNS sparganosis. We report an uncommon case of CNS sparganosis migrated from the brain to the spinal cord with literature review.     

Relapsing polychondritis with an intracranial granuloma: a case report]

We report a case of relapsing polychondritis (RP) with an intracranial granuloma. A 67-year-old man developed progressive disorientation during the course of RP with left auricular chondritis and episcleritis. He had history of sinusitis and rupture of an aneurysm in middle cerebral artery. Laboratory examinations revealed high erythrocyte sedimentation rate and positive C-reactive protein. Head CT and MRI with contrast enhancement showed a mass adjacent to the falx cerebri and lesions in the frontal skull base. The mass was surrounded by extensive perifocal edema that spread mainly into the frontal white matter on both sides. Histologically, the mass displayed an inflammatory granuloma. By removal of the mass, edema decreased around the granuloma, and his disorientation improved markedly. Surgical findings revealed the granuloma was separated from sinusitis. There are a few reports on RP with an intracranial granuloma.     

The calcified intracorporeal vacuole: an aid to the pathological diagnosis of solitary cerebral cysticercus granulomas

Fifty four cases of single small (<20 mm) enhancing CT lesions (SSECTLs) of the brain that were excised between 1987 and 1995 were reviewed histologically. In 28 cases the entire cysticercus or its parts were found. In the remaining 26 cases, most had a histological picture suggestive of a parasitic granuloma. In six of these 26 cases, small ovoid masses corresponding in morphology to the intracorporeal vacuoles of a cysticercus were seen lying free in the cavitary space of the granuloma. This lends further strength to the contention that SSECTLs of the brain are caused by cysticercus, and that in the event of a surgical excision, absence of obvious parasitic parts should necessitate a closer search, as calcareous residues of the parasite might be the only evidence of the cysticercal aetiology in the granuloma.     

Sparganosis mimicking an intramedullary tumor of the cervical cord

Sparganosis is a rare parasitic infection caused by the migrating plerocercoid larva of the tapeworm Spirometra mansoni that rarely affects the central nervous system. When sparganosis involves the spinal cord, it often affects the thoracic area. Here we report a patient with sparganosis mimicking an intramedullary tumor of the cervical cord. A 51-year-old male presented with slowly progressive paresthesias in all extremities and left-sided motor weakness. MRI of the spinal cord revealed an enhancing lesion from C1 to C4 that was suggestive of an intramedullary tumor. The results of enzyme-linked immunosorbent assays of the cerebrospinal fluid were consistent with infection with Spirometra mansoni, and the larvae were surgically removed. Sparganosis may mimic an intramedullary tumor of the spinal cord and should be considered in the differential diagnosis of a cervical cord mass with an uncertain course.     

Primary Eosinophilic Granuloma of Adult Cervical Spine Presenting as a Radiculomyelopathy

We report a case of 29-year-old man diagnosed as a primary eosinophilic granuloma (EG) lesion of the seventh cervical vertebra. He had paresthesia on both arms, and grasping weakness for 10 days. Cervical magnetic resonance image (MRI) showed an enhancing mass with ventral epidural bulging and cord compression on the seventh cervical vertebra. Additionally, we performed spine series MRI, bone scan and positive emission tomography for confirmation of other bone lesions. These studies showed no other pathological lesions. He underwent anterior cervical corpectomy of the seventh cervical vertebra and plate fixation with iliac bone graft. After surgical management, neurological symptoms were much improved. Histopathologic evaluation confirmed the diagnosis of EG. There was no evidence of tumor recurrence at 12 months postoperative cervical MRI follow-up. We reported symptomatic primary EG of cervical spine successfully treated with surgical resection.     

Giant cell reparative granuloma of the pediatric cranium: case report and review of the literature

Purpose

Giant cell reparative granulomas are rare bone tumors. Although benign, these tumors are locally destructive and can be highly vascular. They seldom occur in the cranial vault. We describe a multidisciplinary approach to a case of giant cell reparative granuloma of the cranium in a 3-year-old patient.

Case report

A 3-year-old girl female referred to the pediatric neurosurgery department for evaluation of a retro-auricular mass. She had a history of recurrent otitis media with two subsequent courses of antibiotics without resolution. CT imaging revealed an expansive lesion located in the right mastoid region. Open surgical biopsy revealed a hemorrhagic tumor consistent with a giant cell reparative granuloma. Angiography identified a hypervascular tumor blush that was supplied by the occipital artery. Preoperative transcatheter embolization was performed followed by a multidisciplinary surgical resection and reconstruction. Blood loss was minimal, and the patient recovered well after surgery.

Conclusion

Preoperative endovascular embolization and a multidisciplinary intraoperative approach with primary resection and cranial vault reconstruction is an effective approach to hypervascular giant cell reparative granulomas.     

Granuloma formation and arterial thrombosis following cotton wrapping of an intracranial aneurysm. A case report.

The authors report the case of a patient whose left middle cerebral artery aneurysm was wrapped with cotton. Occlusion of the middle cerebral artery, probably secondary to a foreign-body inflammatory reaction, developed late in the postoperative course. A computerized tomography scan revealed cerebral infarct, and an enhancing expansive lesion at the site of the aneurysm suggesting the formation of a granuloma. These findings are discussed and the literature is reviewed.     

Clinicopathological correlation in a case of painful ophthalmoplegia: Tolosa-Hunt syndrome.

A case of painful ophthalmoplegia due to idiopathic granulomatous involvement of the superior orbital fissure (Tolosa-Hunt syndrome) is described. The clinical features of recurrent pain, ocular motor nerve palsies and proptosis correlated well with the eventual demonstration of an enhancing mass in the region of the cavernous sinus. Removal of the lesion led to a resolution of the clinical picture and demonstration of a non-caseating granuloma with no other detectable cause. The original observation of Tolosa was thus re-affirmed.     

Cerebral sparganosis mansoni--report of two cases

Cerebral Sparganosis Mansoni is a very rare disease caused by a larva of Diphyllobothrium and so far, only two cases have been reported. Another two cases are presented in this paper. Case 1: A 64-year-old man was admitted presenting with hypovolition. He has eaten thunder fishes several years before. CT scan revealed an extensive low density area with an enhanced nodular mass around the right basal ganglia. An operation was carried out on the preoperative diagnosis of brain tumor and a granuloma was completely removed. His postoperative course was excellent. The histological examination confirmed the diagnosis of cerebral sparganosis. Case 2: The patients was 60-year-old male showing hypesthesia in the left half of his face. He has often been to South Korea where patients of Sparganosis Mansoni are often reported. Enhanced CT scan demonstrated a small nodular region in the tip of the left temporal lobe. Sparganum Mansoni was identified during surgery and a granuloma was also extirpated. His postoperative course was also excellent. In cases with cerebral parasitism by Sparganum Mansoni, CT scan shows an extensive low density area with a nodular enhancement, but no calcification nor cyst formation. It is quite difficult to differentiate sparganosis from cerebral tumors on CT and laboratory data preoperatively. The diagnosis is usually confirmed by postoperative histological examination. As for the treatment of this disease, no effective chemotherapy is now available and surgical excision is recommended. Actually, four cases with cerebral sparganosis including two of our own demonstrated a satisfactory prognosis by surgical treatments.     

Recurrent orbitofrontal cholesterol granuloma in pediatric patient: case report and review of the literature

Orbitofrontal cholesterol granuloma is a rare entity which typically involves the lateral part of the supraorbital ridge. It causes progressive expansion and erosion of the inner and outer tables of the frontal bone. We describe a case of recurrent orbitofrontal cholesterol granuloma in a 17-year-old girl. In June 2002 this patient had originally presented to an eye clinic with a small palpable mass in the right superolateral orbit, limitation on upgaze, and progressive proptosis. MRI of the orbit revealed an intraorbital extraconal mass with smooth border, high signal on both T1- and T2-weighted magnetic resonance images. She underwent an anterior orbitotomy via a subbrow incision. The lesion was removed completely, and histopathological examination confirmed a cholesterol granuloma. She remained asymptomatic until her presentation in August 2005. On second admission (3 years later), she complained of a tender palpable mass in the superolateral aspect of the right orbit. Her right eye was 4 mm proptosed and 4 mm inferomedially displaced with limited elevation. The rest of the examination was normal. MRI of the orbit showed a large intraorbital but extraconal mass with smooth border, high signal on both T1- and T2-weighted images without enhancement after gadolinium injection. She underwent complete surgical excision by means of a bicoronal approach. Histopathological diagnosis revealed cholesterol granuloma. No recurrence of the lesion has been observed during the last 6 years following the second operation.     

Pilocytic astrocytoma: unusual feature

Juvenile pilocytic astrocytoma is a well-defined brain tumor. It most often occurs in children and young adults. It is located in the posterior fossa and has typical imaging features, associating cystic and strongly contrast enhancing mural nodule. After complete surgical removal, its prognosis is excellent. Adult cases are seldom observed. They develop almost exclusively within the cerebral hemispheres and share the same imaging and prognostic characteristics as the pediatric forms. We describe the case of a 42-years-old man presenting with a huge heterogenous posterior fossa lesion. Histopathological analysis of the lesion after surgical resection diagnosed a juvenile pilocytic astrocytoma. These peculiar location and imaging features in an adult patient may be misdiagnosed for infectious lesions and must be recognized.     

Fungal granuloma of the brain caused by Cladosporium bantianum--a case report and review of literature

Involvement of the brain by neurotropic, dematiaceous fungi namely Cladosporium bantianum is extremely rare. The disease is very resistant to treatment and prone for frequent relapses despite treatment with amphotericin B and flucytosine, the drugs of choice for the infection. Surgery is often required for resection of the fungal granuloma. Isolation of the fungus from the tissue specimens and its culture, showing dark colored fungal colonies clinches the diagnosis. Animal inoculation studies can provide insights to the portal of entry of the organism. We hereby report a case of fungal granuloma of the brain due to C. bantianum, which responded favorably to intensive antifungal treatment alone, with relevant review of literature.     

A case of calvarial eosinophilic granuloma with rapid expansion and wide skull invasion: immunohistochemical analysis of Ki-67.

A 15-year-old male visited our neurological service with progressive occipitalgia. Computed tomography showed an osteolytic lesion at the occipital cranium, which grew rapidly during a month. Magnetic resonance imaging showed the lesion as low intensity on T1- and high intensity on T2-weighted images. The mass was soft and successfully removed with surrounding cranium. Histological examination revealed an eosinophilic granuloma with wide skull invasion. Immunohistochemical analysis on the specimen disclosed Ki-67 expression with labeling index of 6.2%. Relatively high proliferative activity in the present case indicates that the local replication of Langerhans' cells as well as inflammatory response contributes to the expansion of calvarial eosinophilic granuloma. This is the first report demonstrating the result of Ki-67 expression on calvarial eosinophilic granuloma.     

A case of mistaken identity: intracranial foreign body reaction after AVM embolisation mimicking a glioma.

Intracranial foreign body granulomas are exceedingly rare. We present the case of an intracranial foreign body granuloma found in a 72-year-old male 10 years after he underwent a successful catheter embolisation of a cerebral arteriovenous malformation (AVM). The patient presented to our unit after a fall. He had symptoms of confusion, change in mental status and expressive dysphasia. On initial inquiry, the patient had no past medical history of note. Plain brain CT showed a space-occupying lesion in the left frontal lobe with calcifications suggesting an oligodendroglioma. MRI of the brain revealed a heterogeneously enhancing lesion with cystic-solid areas. The patient underwent a craniotomy and excision of the tumour. A pathological examination of the specimen confirmed that it was a foreign body granuloma. Upon further probing into the patient's past medical history, his family recalled prior treatment many years ago at another institution. The old records revealed that the patient had undergone catheter embolisation of a frontal lobe AVM 10 years previously. A MEDLINE literature search (1980-2005) revealed a handful of case reports describing intracranial foreign body granulomas secondary to previous intracranial procedures. Although rare, foreign body granulomas should be included in the differential diagnosis of patients who have undergone prior neurosurgical procedures and then present with a space-occupying lesion on imaging.     

Isolated primary Langerhans' cell histiocytosis of central nervous system

Solitary eosinophilic granuloma that involves the CNS is an uncommon lesion and most frequently affects the hypothalamus. We report a new and rare case of solitary eosinophilic granuloma of the left temporal lobe in a patient without systemic disease. The diagnosis was confirmed by electron microscopy and immuohistochemical techniques. The treatment of choice is surgical resection. There is a better prognosis in comparison with cases accompanied by systemic disease.     

The diagnostic difficulties of meningeal and intracerebral plasma cell granulomas—presentation of three cases

Meningeal and intracerebral plasma cell granulomas are uncommon inflammatory lesions of unknown etiology. In this paper the diagnostic difficulties in two patients with meningeal plasma cell granuloma and one patient with intracerebral plasma cell granuloma are described. The first patient had an intracranial extra-axial lesion, which was first diagnosed as a meningioma. One and a half years later she underwent a second resection for recurrent tumor growth and the diagnosis of a meningeal plasma cell granuloma was made. The second patient was treated for a central nervous system B-cell lymphoma but proved to have an intracerebral plasma cell granuloma in retrospect 11 years later. In the third patient tuberculous meningitis was considered to be the most likely diagnosis because infratentorial contrast-enhanced thickened meninges (pachymeningitis) were found together with a high protein level in the cerebrospinal fluid and a positive Mantoux test. However, pathological examination of an extra-axial, cervical lesion that was operated upon revealed a meningeal plasma cell granuloma. These cases show the importance of diagnosing a meningeal or intracerebral plasma cell granuloma correctly, since it has both therapeutical and prognostic implications.     

Intraventricular inflammatory pseudotumor: Report of two cases and review of the literature

Inflammatory pseudotumors (IP) are non‐neoplastic lesions characterized by collagenous stroma and polyclonal mononuclear infiltrates. It is best characterized in the lung, but can occur in the CNS, mimicking a neoplastic process. We discuss the available literature and our cases in order to elucidate best medical practices when confronted with such a lesion. We report on two cases of intraventricular inflammatory pseudotumor in patients who presented with symptoms of CSF obstruction. Both patients were treated surgically with significant clinical improvement. Histopathologically, both specimens revealed a plasma cell granuloma variant of IP. A Medline search for English articles identified 46 cases of CNS IP, only eight of which were located within the ventricle. As with our case, most patients presented due to CSF obstruction or mass effect. Radiographically, the lesions have a variable appearance although most enhanced with gadolinium. Complete resection was achieved in 67% with a 12% rate of recurrence. With incomplete resection or biopsy alone, progression is seen despite steroid or radiation administration. Malignant transformation was only reported once. CNS IP is a rare pathological entity that cannot be diagnosed through clinical presentation or radiographic characteristics, but rather through a careful neuropathological inspection. The available literature suggests that complete resection with close follow‐up is necessary.     

A case of Rathke's cleft cyst with apoplexy

We report a case of Rathke's cleft cyst associated with cholesterin granuloma in an 8-year-old girl with apoplexy. She was admitted to our hospital in April 1996 because of repeated headache and deep ophthalmic pain, without any visual disturbance. Computed tomography (CT) of the pituitary demonstrated an intrasellar isodense mass extending to the suprasellar cistern. Magnetic resonance imaging (MRI) showed a high-intensity mass on both T₁- and T₂-weighted images. The preoperative diagnosis of this lesion was Rathke's cleft cyst associated with a craniopharyngioma and/or hemorrhage. Transsphenoidal microsurgery was performed, and a bloody coffee-like serous and mucinous-yellowish substance was evacuated. Curettage of the wall removed the yellowish hard mass and soft membranous tissue. Histological examination of this tumor revealed a Rathke's cleft cyst with cholesterin granuloma. Received: 28 April 1997 Revised: 25 August 1997     

A case of high‐grade astrocytoma with BRAF and ATRX mutations following a long‐standing course over two decades

Pediatric high‐grade gliomas are rare and occasionally hard to classify. These tumors often feature a well‐demarcated histology and are expected to have a better outcome than ordinary diffuse high‐grade gliomas in adults. We herein report a case of circumscribed high‐grade glioma that showed a distinct molecular profile and followed an excellent course for 26 years. The patient, a 3‐year‐old boy at onset, presented with a contrast‐enhancing mass in the right temporal lobe and underwent resection. Histologically, the tumor mainly consisted of compact bundles of GFAP‐positive spindle cells. With its malignant features including brisk mitotic activity and pseudopallisading necrosis, a diagnosis of high‐grade astrocytoma was made and adjuvant chemoradiotherapy was administered. After a disease‐free period of two decades, the tumor recurred locally. The resected tumor was histologically identical to the primary tumor and additionally contained pleomorphic cells, but lacked eosinophilic granular bodies and reticulin networks. The primary and recurrent tumors both harbored the BRAF V600E mutation, and the recurrent tumor was immunonegative for ATRX. Combined BRAF and ATRX mutations are rare in gliomas, with only a pediatric case of glioblastoma being reported in the literature. However, our case cannot be regarded as glioblastoma because of its well‐demarcated histology and excellent course. The distinction of either a diffuse or localized nature in gliomas is important, particularly in children, for predicting prognoses and selecting adjuvant therapies that consequently affect life‐long health care. The present case provides novel insights into pediatric high‐grade astrocytomas.     

Dysplastic gangliocytoma of the cerebellum (Lhermitte-Duclos disease).

Dysplastic gangliocytoma of the cerebellum is a rare disorder requiring surgical resection. During surgical exploration, the margin with normal cerebellar tissue is often not distinct. We present here a case in which we surgically treated a patient with Lhermitte-Duclos disease, and discuss radical resection of the tumour. The patient was first admitted at the age of 34 years. A MRI scan revealed a large left cerebellar mass typical of dysplastic gangliocytoma. Postoperatively the patient developed severe cerebellar syndrome with only partial recovery after 4 years. MRI revealed no impairment of cerebrospinal fluid circulation; the mass in the left cerebellum had been removed, and no recurrent disease was visible. Clinical problems after gross total or complete removal of Lhermitte-Duclos lesions have not been reported in the literature, but herein we stress the importance of extreme caution in removing these lesions in cerebellar areas that have no distinct border between the tumour and normal tissue.