James Holsapple

Aggressive pediatric meningioma with soft tissue and lymph node metastases: a case report

Metastatic meningioma is extremely rare, occurring in an estimated 0.1% of cases. We report a case of pediatric meningioma metastatic to cervical soft tissue and lymph nodes. An 8-year-old boy presented with headaches, dizziness, and involuntary eye flickering. Magnetic resonance imaging (MRI) revealed a 7.5-cm parasagittal, dural-based mass with venous sinus encasement. Therapeutic embolization was followed by bilateral craniotomy, achieving subtotal resection. Histopathologic examination revealed an atypical meningioma with regions of hypercellularity, small cell morphology, sheeting architecture, increased mitoses, and brain invasion. Surveillance MRI studies showed growth of residual tumor and enlarging cervical soft tissue masses with posterior triangle lymphadenopathy. Radiation and surgical resection were employed for the intracranial tumor burden; resection of the soft tissue masses revealed metastatic meningioma, with soft tissue infiltration and metastasis to 8 lymph nodes. This case demonstrates the aggressive biologic potential of pediatric meningiomas, with potential for distant spread via cerebrospinal fluid leakage and lymphatic invasion.

An enigmatic brainstem posterior fossa ganglioglioma in an adult

Ganglioglioma is a rare central nervous system neoplasm representing 0.4% to 1.7% of all brain tumors and most frequently occurs in the pediatric population with an incidence of 7.6%. These tumors are usually slow-growing and well-circumscribed solid or cystic lesions. Gangliogliomatosis infrequently occurs in the frontal lobe, pineal gland, basal ganglia, hypothalamus, and optic chiasm, with very few reports of brainstem ganglioglioma. We report a case of a 35-year-old female who initially presented with headache, vertigo, ataxia, saccadic dysfunction, dysarthria, and dysmetria for several years due to an unknown etiology. Her brain imaging showed multiple lesions in the pons and the cerebellum with cystic changes and size reduction and enlargement over the next few years while her neurological symptoms continued to worsen. The patient received courses of steroid treatment that improved her neurological symptoms, suggesting an inflammatory component of her disease. Extensive workup for an inflammatory or infectious etiology was unfruitful and two brain biopsies were inconclusive. A third biopsy showed atypical glial nuclei, binucleated cells, and Rosenthal fibers and the presence of BRAF V600E mutation was detected. The diagnosis of gangliogliomatosis was consequently established. This case illustrates that gangliogliomatosis may present with the waxing-and-waning neurological signs and symptoms. It can masquerade inflammatory processes in the central nervous system on brain imaging and deserves careful consideration in the diagnosis of patients with an indolent course of neurological deterioration.

Intraocular Silicone Oil Migration into the Ventricles Resembling Intraventricular Hemorrhage: Case Report and Review of the Literature

BACKGROUND Intracranial silicone migration is a rare complication of ocular silicone oil endotamponade and may resemble intraventricular hemorrhage. The etiology of the phenomenon is challenging to understand. CASE DESCRIPTION In an effort to shed light on this phenomenon, we report a case of a 67-year-old woman with ocular silicone oil endotamponade on the left eye due to retinal detachment who presented with headache to the emergency department. The imaging work-up revealed intraventricular silicone oil migration. CONCLUSIONS The literature is reviewed through the perspective of pathophysiology. The migration of intraocular silicone oil into the ventricular system provides both an important complication for clinicians to be aware of, as well as a paradigm reminding us that cerebrospinal fluid spaces may have more extensive communications with other body compartments than previously thought.

Expanding Endovascular Therapy of Very Small Ruptured Aneurysms with the 1.5-mm Coil.

Background: Very small ruptured aneurysms (≤3 mm) demonstrate a significant risk for procedural rupture with endovascular therapy. Since 2007, 1.5-mm-diameter coils have been available (Micrus, Microvention, and ev3), allowing neurointerventionalists the opportunity to offer patients with very small aneurysms endovascular treatment. In this study, we review the clinical and angiographic outcome of patients with very small ruptured aneurysms treated with the 1.5-mm coil. Methods: This is a retrospective cohort study in which we examined consecutive ruptured very small aneurysms treated with coil embolization at a single institution. The longest linear aneurysm was recorded, even if the first coil was sized to a smaller transverse diameter. Very small aneurysms were defined as ≤3 mm. Descriptive results are presented. Results: From July 2007 to March 2015, 81 aneurysms were treated acutely with coils in 78 patients presenting with subarachnoid hemorrhage. There were 5 patients with 3-mm aneurysms, of which the transverse diameter was ≤2 mm in 3 patients. In all 5 patients, a balloon was placed for hemostatic prophylaxis in case of rupture, and a single 1.5-mm coil was inserted for aneurysm treatment without complication. Complete aneurysm occlusion was achieved in 1 patient, residual neck in 2, and residual aneurysm in 2 patients. Aneurysm recanalization was present in 2 patients with an anterior communicating artery aneurysm; a recoiling attempt was unsuccessful in 1 of these 2 patients due to inadvertent displacement and distal coil embolization, but subsequent surgical clipping was successful. Another patient was retreated by surgical clipping for a residual wide-neck carotid terminus aneurysm. One patient died of ventriculitis 3 weeks after presentation; all 4 other patients had an excellent outcome with no rebleed at follow-up (mean 21 months, range 1-62). Conclusion: The advent of the 1.5-mm coil may be used in the endovascular treatment of patients with very small ruptured aneurysms, providing a temporary protection to the site of rupture in the acute phase. If necessary, bridging with elective clipping may provide definitive aneurysm treatment.

Resection of Primary Brachial Plexus Tumor via a Modified Supraclavicular Approach

Benign peripheral nerve sheath tumors are generally considered curable lesions, and surgical resection is recommended as the primary line of treatment. When these tumors occur in the brachial plexus, they are most frequently accessed via the supraclavicular approach. Traditional descriptions of this approach have included either transection of sternocleidomastoid (SCM) muscle fibers or disarticulation of the clavicular head of the SCM muscle. This report presents a simple and easy-to-adapt modification of the supraclavicular approach that offers greater preservation of the SCM muscle. The modification primarily consists of the creation of an intramuscular window between the sternal and clavicular heads of the SCM via the splitting and dilation SCM muscle fibers. This technique minimizes the disruption of SCM muscle tissue compared with previous descriptions and may be associated with improved postoperative pain and return to function.

A Waveform Archiving System for the GE Solar 8000i Bedside Monitor

OBJECTIVES Our objective was to develop, deploy, and test a data-acquisition system for the reliable and robust archiving of high-resolution physiological waveform data from a variety of bedside monitoring devices, including the GE Solar 8000i patient monitor, and for the logging of ancillary clinical and demographic information. MATERIALS AND METHODS The data-acquisition system consists of a computer-based archiving unit and a GE Tram Rac 4A that connects to the GE Solar 8000i monitor. Standard physiological front-end sensors connect directly to the Tram Rac, which serves as a port replicator for the GE monitor and provides access to these waveform signals through an analog data interface. Together with the GE monitoring data streams, we simultaneously collect the cerebral blood flow velocity envelope from a transcranial Doppler ultrasound system and a non-invasive arterial blood pressure waveform along a common time axis. All waveform signals are digitized and archived through a LabView-controlled interface that also allows for the logging of relevant meta-data such as clinical and patient demographic information. RESULTS The acquisition system was certified for hospital use by the clinical engineering team at Boston Medical Center, Boston, MA, USA. Over a 12-month period, we collected 57 datasets from 11 neuro-ICU patients. The system provided reliable and failure-free waveform archiving. We measured an average temporal drift between waveforms from different monitoring devices of 1 ms every 66 min of recorded data. CONCLUSIONS The waveform acquisition system allows for robust real-time data acquisition, processing, and archiving of waveforms. The temporal drift between waveforms archived from different devices is entirely negligible, even for long-term recording.