J. Bradley White

Rate of spontaneous hemorrhage in histologically proven cases of pilocytic astrocytoma.

OBJECT Spontaneous intracerebral hemorrhage is an uncommon but recognized initial presenting sign of both primary and metastatic brain tumors. The rate of tumor-related intracranial hemorrhage is variably reported from <1 to 14.6%. Hemorrhage in primary gliomas occurs in 3.7-7.2% of gliomas, mainly in glioblastoma muliforme and oligodendroglioma with low-grade astrocytomas accounting for <1%. Hemorrhage associated with pilocytic astrocytomas (PAs) is only sporadically reported. The authors report on a series of patients in whom PAs presenting as hemorrhages prompted them to examine the incidence of bleeding in these tumors. METHODS Cases involving a confirmed tissue diagnosis of PA from 1994-2005 were reviewed retrospectively. The authors included only patients with evidence of hemorrhage on computed tomography and/or magnetic resonance imaging seen prior to biopsy or resection and in the absence of trauma or other vascular pathological entities. RESULTS In 138 patients with histologically proven PAs, the mean age at diagnosis was 23 years. In 11 patients (8%; 5 male and 6 female) there was evidence of hemorrhage at presentation. There were no locations more susceptible to hemorrhage than any other, although no bleeding occurred within the cerebellum. All but 1 patient was treated with a gross-total resection. CONCLUSIONS Hemorrhage in association with PAs likely results from the frequently observed abnormal vasculature in these tumors, occurs with a greater frequency than previously thought, and should be considered in the differential diagnosis of spontaneous intracerebral hemorrhage.

Nonenhancing tumors of the spinal cord

OBJECT Enhancement of pathological entities in the central nervous system is a common finding when the blood-brain barrier has been compromised. In the brain, the presence or absence of gadolinium enhancement is often an indicator of tumor invasiveness and/or grade. In the spinal cord, however, contrast enhancement has been shown in all tumor types, regardless of grade. In this study the authors explore the incidence of nonenhancing tumors of the spinal cord and the clinical course of patients with these lesions. METHODS A retrospective analysis was conducted in which investigators examined the patterns of enhancement of histologically proven intramedullary spinal cord tumors that had been evaluated at the Mayo Clinic between 1998 and 2002. The tumors that did not enhance were the subject of this report. RESULTS A total of 130 patients with intramedullary tumors were evaluated. Of those, 11 patients (9%) had tumors that did not enhance. Histologically, a majority of tumors were astrocytomas (eight low-grade and two high-grade lesions); one tumor was a subependymoma. Morphologically, most of the tumors were diffuse and none had associated cysts. Tumors spanned from two to seven levels and were located throughout the spinal cord (four cervical, three cervicothoracic, one thoracic, and three thoracolumbar). Biopsy procedures were performed in eight patients, subtotal resection was performed in two, and gross-total resection in one. After a mean follow-up period of 19 months, tumors remained stable in eight patients but progressed in three, two of whom died. CONCLUSIONS A number of intramedullary spinal cord tumors will not enhance after addition of contrast agents. The absence of enhancement does not imply the absence of tumor.

Recurrence of dysembryoplastic neuroepithelial tumor following resection

Dysembryoplastic neuroepithelial tumor (DNT) is an increasingly recognized surgically curable tumor that characteristically presents with seizures in children. We report a case of a patient who underwent resection of a histologically proven DNT at 6 years of age. The resection was thought to be total at the time of surgery, and this impression was confirmed on postoperative imaging. Following the initial resection, the patient underwent surveillance imaging at regular intervals. Six years following the initial surgery, surveillance imaging demonstrated an enlarging area of signal abnormality at the site of the prior resection. The patient underwent a second resection with pathological confirmation of DNT recurrence. Although recurrence of DNT following resection is rare, this case suggests that surveillance imaging may have a role in patients with DNT, even following resections that are thought to be complete.

Utility of the "buddy" wire in intracranial procedures

Patients undergoing neurointerventional procedures with excessively tortuous vascular anatomy often have limited treatment options. The ability to pass and maintain the stability of micro-guidewires, catheters, and interventional devices is often a product of guide catheter steadiness. A companion wire passed through the lumen of the guide catheter to increase the guide catheter’s stiffness can overcome the challenges associated with tortuous anatomy; this companion wire is referred to as a “buddy” wire. We demonstrate the technical success of this system by presenting a patient whose endovascular treatment would have otherwise been impossible without a “buddy” wire.

Balloon-assisted coiling through a 5-French system

IntroductionWe present a catheter technique that utilizes a 5F system for the purpose of balloon-assisted coiling in the setting of intracranial aneurysms.MethodsA standard 5F short sheath is placed in the common femoral artery, and a 5F diagnostic catheter is placed through the sheath and used for selective vessel angiography. When endovascular intervention is pursued, the diagnostic catheter is placed in the appropriate vessel and systemic heparinization is ensured. Over an exchange length wire, the 5F vertebral catheter and 5F short sheath are exchanged for a 5F Shuttle (Cook) sheath. We then routinely place a 10, 14 or 18 microcatheter over an appropriately gauged microguidewire into the aneurysm. As needed, balloon catheters are then placed across the neck of the aneurysm for remodeling purposes. During the course of the procedure, control angiography is performed through the Shuttle sheath. Following the placement of coils, the microcatheter and balloon catheter are removed and a final biplane image is obtained via the 5F Shuttle sheath.ResultsThis technique has been employed in 15 patients who required balloon-assisted coiling of an intracranial aneurysm. There were no technical difficulties or arterial access site complications from the procedures. Catheter mobility and torque were not affected, nor was the quality of our imaging.ConclusionWe conclude that this small-diameter system provides ample “room” for catheter placement and interventional treatment while reducing the known risks of postprocedural complications. Angiographic images remain excellent and are comparable to those obtained by larger catheters.

VANISHING ANEURYSM IN PRETRUNCAL NONANEURYSMAL SUBARACHNOID HEMORRHAGE

Pretruncal, nonaneurysmal subarachnoid hemorrhage is generally a benign entity with an unknown etiology.1 A ruptured vein, cryptic arteriovenous malformation, perforating artery, or intramural hematoma have all been implicated as potential sources for hemorrhage in these patients.2,3 We present a patient who had the typical clinical and radiographic course associated with pretruncal, nonaneurysmal subarachnoid hemorrhage but in whom, based on serial, three-dimensional rotational angiograms (3DRA), we uncovered a transient microaneurysm near the basilar apex. We posit that such self-limited microaneurysms might be the cause of some proportion of the patient population that presents with pretruncal, “nonaneurysmal” subarachnoid hemorrhage, but that, prior to the advent of 3DRA, we simply were unable to diagnose these lesions. We present this case not only to inform other practitioners who might encounter these microaneurysms, but also to raise the possibility that these lesions represent yet another important source of pretruncal nonaneurysmal subarachnoid hemorrhage. ### Case report. A 47-year-old woman developed the worst headache of her life while exerting herself during weightlifting. She reported to the emergency department where a noncontrast head CT demonstrated acute, subarachnoid hemorrhage in a perimesencephalic pattern, consistent with a pretruncal nonaneurysmal subarachnoid hemorrhage. Clinically, she was a Hunt-Hess and WFNS grade 1. A cerebral angiogram was performed, including …

Use of the Perclose ProGlide device with the 9 French Merci retrieval system

IntroductionClosure devices are commonly used in neurointerventional procedures to achieve groin hemostasis. These devices are particularly useful in procedures requiring anticoagulation and larger catheters. The suture-mediated Perclose ProGlide device is intended for use with 5F to 8F sheaths. We describe the use of the ProGlide device with 9F sheaths in acute stroke treatment using the Merci retrieval device.MethodsThe ProGlide device is advanced over a wire until the wire exit port is at the skin surface. The wire is removed and the device is advanced until pulsatile blood flow is encountered. The footplates are opened and the stitch is deployed. The footplates are then closed and the device is removed. After advancing the suture to the vessel, it is locked and trimmed. Firm pressure is necessary during deployment to prevent oozing around the device. If continued bleeding is encountered, direct manual pressure is used to achieve hemostasis.ResultsWe have successfully used the Perclose ProGlide device in four patients following the Merci retriever without groin or extremity complication. The Perclose ProGlide device can be successfully used after placement of a 9F system in patients who have undergone mechanical thrombectomy.ConclusionThis technique may be of interest to endovascular surgical neuroradiologists because it affords fast hemostasis in large access sites following mechanical thrombectomy with the Merci retrieval device. Compared to the “Preclose” technique, it saves valuable time at the beginning of the case.

A Case of Infertility in a Patient with a Ventriculoperitoneal Shunt

Objective and Importance: Complications arising from the placement of ventriculoperitoneal (VP) shunts are well documented. A case of infertility is presented that was thought to result from factors related to the distal end of a VP shunt residing within a patient’s abdomen. Clinical Presentation: A 30-year-old female with a 3-year history of infertility was referred for fallopian tube blockage. An exploratory laparoscopy revealed multiple adhesions adjoining the distal end of her fallopian tubes. The distal portion of a VP shunt placed at childhood (with subsequent revisions) was found entangled among grossly inflamed and densely adhesive pelvic viscera. Intervention: Laparoscopic adhesiolysis was performed and the patient’s fallopian tubes were reconstituted. The distal portion of the VP shunt was freed from the surrounding viscera and was not revised. Conclusion: VP shunts may produce adhesive disease and complicate fertility via mechanical, chemical, and/or infectious processes.

Disseminated enterogenous cells at the cervicomedullary junction causing communicating hydrocephalus

The authors present a unique case of a patient with communicating hydrocephalus and repeated ventriculoperitoneal shunt obstructions resulting from mucin-secreting enterogenous cell deposits at the cervicomedullary junction. Pathological examinations revealed that these cellular deposits lacked characteristic cystic architecture and the patient had no history of previous cyst with dissemination. Because of the repeated shunt obstructions and inability to surgically resect the lesion in its entirety, the authors elected radiation therapy to the cervicomedullary junction, encompassing the radiological abnormality. As of this writing, the patient has remained at neurological baseline and has not required further shunt revisions for obstruction.

Sudden onset weakness in an immunocompromised patient.

Toxoplasmosis is an infection caused by the intracellular parasite Toxoplasma gondii. Human infection usually occurs via an oral or transplacental route. In adults, most infections are subclinical, but severe infection can occur in patients who are immunocompromised, particularly those with AIDS or a history of transplantation. In our patient, a steroid-induced immunosuppression was likely to blame for her susceptibility to the pathogen. Imaging with a non-contrast CT scan often depicts an isodense lesion with surrounding edema and mass effect. On MRI, T2-weighted FLAIR images reveal a hyperintense signal consistent with the underlying mass and edema. On T1-weighted MRI the lesion is often hypo/isodense to gray matter with ring enhancement following the administration of contrast. Diffusion-weighted images often show restricted diffusion (Fig. 1). Histology demonstrated an area of necrosis with scattered cysts (arrow) containing basophilic bradyzoites consistent with toxoplasma micro-organisms (Fig. 2). In our patient, a mild perivascular lymphoplasmacytic infiltrate with scattered cells positive for Epstein-Barr virus (EBV) was present raising the possibility of an early EBV-associated lymphoproliferative disorder. The primary treatment consists of a regimen of pyrimethamine and sulfadiazine.