Andreas Schwarz

Psychosocial and neurocognitive performance after spontaneous nonaneurysmal subarachnoid hemorrhage related to the APOE-epsilon4 genotype: a prospective 5-year follow-up study.

OBJECTnIn this study, the authors prospectively evaluated long-term psychosocial and neurocognitive performance in patients suffering from nonaneurysmal, nontraumatic subarachnoid hemorrhage (SAH) and investigated the association between the APOE-epsilon4 genotype and outcome in these patients.nnnMETHODSnAll patients admitted to the authors institution between January 2001 and January 2003 with spontaneous nonaneurysmal SAH were prospectively examined (mean follow-up 59.8 months). The APOE genotype was determined in all patients by polymerase chain reaction from a blood sample. Of the 30 patients included in this study, 11 were carriers of the epsilon4 allele.nnnRESULTSnAll patients showed a good recovery and regained full independence with no persisting neurological deficits. The patients with the epsilon4 allele, however, scored significantly higher on the Beck Depression Inventory (22.1 +/- 6.3 vs 14.1 +/- 5.1). At follow-up, depression was more persistent in the group with the epsilon4 allele compared with the group that lacked the allele. This finding reached statistical significance (p < 0.05). Selective attention was impaired in all patients during the first year of follow-up, with an earlier recovery noted in the patients without the epsilon4 allele. Moreover, there was a tendency toward a linear relationship between the Beck Depression Inventory and the d2 Test of Attention. Two patients who carried the epsilon4 allele did not return to their employment even after 5 years.nnnCONCLUSIONSnThe findings in this study suggest that the APOE genotypes may be associated with the psychosocial and neurocognitive performance after spontaneous nonaneurysmal SAH, even in the absence of neurological impairment. Physicians should consider patient genotype in assessing the long-term consequences of nonaneurysmal SAH.

Renal cell carcinoma and intradural spinal metastasis with cauda equina infiltration: case report--part II.

Study Design. A case report and clinical discussion. Objective. To describe the diagnosis, pathophysiology, and treatment of a papillary renal cell carcinoma that developed an intradural spinal mass with cauda equina infiltration. Summary of Background Data. Cancers that metastasize intradurally to the spinal canal are uncommon, accounting for the 6% of all spinal metastases. Those from renal cell carcinoma are especially unusual. Only 3 reports that describe the spread of metastatic renal cell carcinoma to the cauda equina have been published to our knowledge. Methods. A female patient had undergone nephrectomy for the treatment of the papillary renal cell carcinoma 2 years before, and only 1 localization (at the genital tract) was previously diagnosed. The patient presented with lower back pain irradiated to both legs, vesical incontinence, and severe paraparesis. Results. Preoperative magnetic resonance images of the lumbar spine showed an intradural spinal mass from L3–L5 with infiltration of the cauda equina; the lesion measured 62 mm craniocaudally and 16 mm anteroposteriorly, and thus occupied the majority of the intrathecal space at that level. The magnetic resonance images, surgical treatment, and related pathophysiology are reviewed. Conclusions. The majority of cauda equina tumors are primary tumors, and metastases are very rare. To our knowledge, this is the fourth case described of metastasis of renal cell carcinoma at the cauda equina and the first of papillary type.

Intraneural cavernous malformation of the cauda equina

Spinal cavernous angiomas are rare vascular malformations occurring mainly in the vertebral body with or without an extradural extension. Only 3-5% of these lesions are entirely located in the spinal canal where they can occupy an extradural, intradural-extramedullary or intramedullary position. We present a 75-year-old woman with signs and symptoms of multiple lumbar radiculopathy. The lumbosacral MRI showed an intradural cauda equina lesion with heterogeneous contrast enhancement that was subsequently radically removed through an L3-L4 laminectomy. The microscopic appearance was suggestive of cavernous angioma with intraneural growth. Clinical, radiological, and surgical features of this unusual lesion (to date, only 12 cases are reported) are discussed.

Role of lumbar interspinous distraction on the neural elements

The interspinous distraction devices are used to treat variable pathologies ranging from facet syndrome, diskogenic low back pain, degenerative spinal stenosis, diskopathy, spondylolisthesis, and instability. The insertion of a posterior element with an interspinous device (ISD) is commonly judged responsive to a relative kyphosis of a lumbar segment with a moderate but persistent increase of the spinal canal and of the foraminal width and area, and without influence on low-grade spondylolisthesis. The consequence is the need of shared specific biomechanical concepts to give for each degenerative problem the right indication through a critical analysis of all available experimental and clinical biomechanical data. We reviewed systematically the available clinical and experimental data about kyphosis, enlargement of the spinal canal, distraction of the interspinous distance, increase of the neural foramina, ligamentous structures, load of the posterior annulus, intradiskal pressure, strength of the spinous processes, degeneration of the adjacent segment, complications, and cost-effectiveness of the ISD. The existing literature does not provide actual scientific evidence over the superiority of the ISD strategy, but most of the experimental and clinical data show a challenging potential. These considerations are applicable with different types of ISD with only few differences between the different categories. Despite—or because of—the low invasiveness of the surgical implantation of the ISD, this technique promises to play a major role in the future degenerative lumbar microsurgery. The main indications for ISD remain lumbar spinal stenoses and painful facet arthroses. A clear documented contraindication is the presence of an anterolisthesis. Nevertheless, the existing literature does not provide evidence of superiority of outcome and cost-effectiveness of the ISD strategy over laminectomy or other surgical procedures. At this time, the devices should be used in clinical randomized independent trials in order to obtain more information concerning the most advantageous optimal indication or, in selected cases, to treat tailored indications.

Atypical meningioma of the sylvian fissure

Meningiomas are meningothelial cell neoplasms that account for approximately 25% of all primary intracranial tumors. Most meningiomas are slow-growing benign lesions, and they are usually attached to the inner surface of the dura mater. Nevertheless, since the first description by of Cushing and Eisenhardt, many meningiomas without dural attachment have been reported. A subgroup located in the sylvian fissure (also called deep sylvian meningiomas) has been described, and these represent a radiological and neurosurgical challenge. We describe an atypical sylvian fissure meningioma in a 23-year-old male with a brief history of headache and mild hemiparesis. We also review the pertinent literature defining the major epidemiological, clinical, radiological and surgical characteristics of these rare tumors.

Primary high-grade B-cell lymphoma of the choroid plexus

Primary central nervous system lymphoma (PCNSL) is an extranodal non-Hodgkin lymphoma arising from and confined to the neuraxis. It represents about 3-4% of all primitive brain neoplasms and is mainly located in deep supratentorial regions. A ventricular involvement is quite frequent, but in the vast majority of cases it is secondary to an extension from a subependymal location. Amongst the primary ventricular forms occasionally reported, a choroid plexus origin is extremely rare; to date, only three cases have been described in the English literature. We report the case of a 71-year-old left-handed woman admitted to our department after a progressive 2-week history of confusion, motor speech disturbances and left hemiparesis. A brain MRI scan displayed an intraventricular lesion located in the right atrium, about 2.5cm in its major axis, homogeneously enhancing after gadolinium administration, surrounded by edema in the homolateral deep hemispheric region; the main diagnostic hypothesis was meningioma. She underwent a parieto-occipital craniotomy and a navigation-assisted posterior parietal transcortical approach, achieving complete removal of the intraventricular lesion originating from the choroid plexus. The histological diagnosis was of high-grade diffuse large B-cell lymphoma. Both an MRI scan of the entire craniospinal axis and a thoracic and abdominal CT scan showed no other neoplastic lesions; a bone marrow biopsy was normal; a final diagnosis of primary central nervous system lymphoma was made. CSF cytological analysis did not show any signs of lymphoma dissemination. Adjuvant chemotherapy with methotrexate was administered, and at the last follow-up (26 months) our patient is clinically and radiologically disease-free. Primary choroid plexus lymphoma is a very rare tumor that should be included in the differential diagnosis of intraventricular neoplasms. It usually occurs in the lateral ventricles (with a predilection for the atrium) of adult people (>50 years of age), apparently with a male prevalence. Generally, the radiological picture mimics that of a meningioma, despite the fact that meningiomas usually reach a greater volume before clinical onset. Surgery is almost always necessary to obtain an adequate tissue sample and frequently leads to a radical removal of the lesion. Low-grade marginal zone B-cell, T-cell and high-grade diffuse large B-cell (present case) forms have been described. With a proper adjuvant therapy a relatively good outcome is observed.

A prospective long-term study of return to work after nontraumatic nonaneurysmal subarachnoid hemorrhage

Patients generally have a good prognosis and develop only occasional neurological complications after nontraumatic, nonaneurysmal subarachnoid hemorrhage (SAH). This prospective long-term study investigated the normal return to work of patients who had experienced nontraumatic nonaneurysmal SAH. From June 2001 to June 2004, all patients presenting with nonaneurysmal nontraumatic SAH were asked to participate in this study. The population was divided in two groups: perimesencephalic (pSAH) and nonperimesencephalic pattern (npSAH). All patients underwent a battery of neuropsychological tests and completed psychological questionnaires assessing their general cognitive and language functions, memory and construction ability, attention, anxiety and depression, and quality of life. The patients were interviewed at the hospital, and neuropsychological assessments were conducted regularly for 7 years. The cognitive assessment after 7 years revealed a statistically significant difference between the pSAH and npSAH groups with respect to the activation and elaboration speed of attention as well as long-term non-verbal memory. Nine patients could not return to their former jobs after nonaneurysmal SAH. Although nontraumatic nonaneurysmal subarachnoid hemorrhage is typically a pathology with an excellent prognosis, there is evidence that this event may influence working life for a long time.

Low-back pain as the presenting sign in a patient with a giant, sacral cellular schwannoma: 10-year follow-up

Giant sacral tumors present unique challenges to surgeons because there is no established consensus regarding the best treatment options. The authors report on the care of and outcome in a patient presenting with low-back pain only, who underwent preoperative biopsy sampling and subsequent embolization of the feeding vessels of a giant, sacral cellular schwannoma. The main procedure was performed via a combined posterior-anterior approach with complete microsurgical removal of the tumor, without the use of instrumentation, bracing, or adjuvant radio- and chemotherapy. At the 10-year follow-up, no evidence of residual tumor, recurrence, or instability was recognizable. Giant, sacral cellular schwannomas can be aggressively completely removed without any significant morbidity, achieving long-term control of the disease.

Primary cerebral alveolar rhabdomyosarcoma in adult

Primary cerebral rhabdomyosarcomas are very rare and malignant tumors that occur predominantly in the posterior fossa of pediatric patients. We report a rare case of primary cerebral rhabdomyosarcoma located in the supratentorial compartment of a 51 year-old woman together with a review of the pertinent Literature especially regarding the histological diagnosis and pitfalls.

Acute Obstructive Hydrocephalus during Chemotherapy in T-Lymphoblastic Lymphoma

Acute obstructive hydrocephalus (AOH) represents a life-threatening event in which clinical presentation is often nonspecific but may include severe headache, vomiting and lethargy. AOH often does not present in onco-haematology. yet, a significant number of case reports have described that patients with acute lymphoblastic leukemia (ALL) do possess such symptoms. The present study reports on the first case of AOH, developed in a patient with lymphoblastic leukemia during induction chemotherapy period.