Jiajing Wang

Malignant intraventricular meningioma with craniospinal dissemination and concurrent pulmonary metastasis

BackgroundMalignant intraventricular meningiomas are quite rare and may spread along the craniospinal axis or extraneurally. However, simultaneous cerebrospinal dissemination and distal extraneural metastasis has seldom been reported.Case presentationA 51-year-old woman presented with recurrent anaplastic meningioma in the trigone of right lateral ventricle over a 1.5-year period. Suggested radiotherapy was refused after each operation. The patient showed a local relapse and dissemination around the previous tumoral cavity and along the spinal canal during the last recurrence. Left pulmonary metastasis was also found. She died despite multiple lesion resections.ConclusionsMalignant intraventricular meningiomas are an uncommon subset of intracranial meningiomas, and have a great potential for intraneural and extraneural metastasis. Systemic investigation for metastasis is required after surgery, especially for those without adjuvant therapies.

Predictors of Surgical Results in Patients with Primary Pontine Hemorrhage.

AIM Prediction of outcome for surgical patients with primary pontine hemorrhage (PPH) is seldom reported although many predictors from clinical and radiological features have been identified in conservative patients. The purpose of this study was to assess the prognostic factors affecting the 30-day mortality and 3-month functional outcome in surgical patients after PPH. MATERIAL AND METHODS Forty-five patients with large PPH ( > 5 ml) and Glasgow Coma Scale (GCS) score < 8 were treated surgically at West China Hospital. The demographic, clinical, imaging and follow-up data were collected retrospectively. Factors affecting the mortality and functional outcome were statistically analyzed. RESULTS Fourteen patients (31.1%) died within 30 days and 7 patients (15.6%) gained a favorable functional recovery within 3 months. A multivariate analysis showed that the hematoma volume, GCS score on admission, age, and type of hemorrhage were all significantly related to the 30-day mortality, while the hematoma volume, GCS score on admission, rostrocaudal extension were associated with the 3-month functional outcome. The presence of hydrocephalus was not found responsible for the surgical outcomes. CONCLUSION The identification of these prognostic factors is helpful for selecting the candidates for surgical treatment. Those with younger age, smaller hematoma without rostrocaudal extension, unilateral hemorrhage, and higher GCS score may benefit from surgery.

Effect of Admission Hyperglycemia on 6-Month Functional Outcome in Patients with Spontaneous Cerebellar Hemorrhage

Background Cerebellar hemorrhage (CH) has a quite different treatment strategy and prognostic factors compared with supratentorial intracerebral hemorrhage (ICH). The prognostic role of hyperglycemia has been discussed mainly in cases of supratentorial hemorrhage; it remains to be elucidated following CH. We aimed to determine the association of hyperglycemia on admission with 6-month functional outcome in CH patients. Material/Methods We retrospectively analyzed 77 patients with acute CH between September 2010 and April 2015 in West China Hospital. Blood glucose level was measured when the patients were admitted. Primary outcome was 6-month functional outcome, which could comprehensively reflect the patient’s recovery of physical and social ability after stroke and was assessed by the modified Rankin scale (mRS). Association of hyperglycemia with functional outcome was identified in logistic regression models. Results There were 50 (64.9%) patients with poor functional outcomes. Patients with poor outcome were much older (P<0.001) and had a significantly higher glucose level on admission (P<0.001), a lower Glasgow Coma Scale score (P<0.001), a larger hematoma (P=0.003), and a higher incidence of intraventricular extension (P=0.002), brainstem compression (P=0.013), and hydrocephalus (P=0.023). Multivariate analysis showed that hyperglycemia (OR 1.50, 95% CI 1.07–2.08, P=0.017 when glucose level was analyzed as a continuous variable; OR 7.46, 95% CI 1.41–39.51, P=0.018 when glucose level was dichotomized by the critical threshold of 6.78 mmol/L) emerged as an independent predictor for adverse functional outcome at 6 months. Conclusions To the best of our knowledge, this is the first study focusing on the relationship between hyperglycemia and long-term functional outcome after CH. The study combined with previous pertinent reports definitely indicates the poor effect of hyperglycemia on both supra- and infratentorial ICH independent of hemorrhage site. Therefore, further controlled trials are urgently needed to evaluate the benefits of glucose-lowing treatment.

Delayed posterior fossa epidural hematoma originating from occipital artery after infratentorial craniotomy

Sir, The incidence of postoperative epidural hematoma (EDH) is less than 2 % and most EDHs occur in the supratentorial compartment and produce clinical symptoms within the first 3 days after operation [1, 2]. Different types of EDH respond to different bleeding causes. For regional hematoma which occurred just in the operative area, incomplete hemostasis, hypertension and coagulopathy are regarded as the most important risk factors [1]. Delayed posterior fossa epidural hematoma (PFEDH) is usually associated with occipital trauma as a result of oozing from the fracture edges or a lacerated venous sinus [3, 4]. PFEDH originating from occipital artery (OA) with a long delay after suboccipital craniotomy has not been reported in the English literature. A 51-year-old normotensive male was diagnosed of multiple mass lesions in the bilateral cerebellar hemispheres, vermis and left cerebellopontine angle region with hydrocephalus (Fig. 1a). Decompressive resection of left cerebellar lesion was performed via suboccipital retrosigmoid approach. The surgical procedure was uneventful. Postoperative CT at 1 day and magnetic resonance imaging (MRI) at 3 days showed no bleeding in the surgical region (Fig. 1b, c). Pathological diagnosis of specimen was anaplastic glioma. On the fifth postoperative day, the patient underwent ventricular external drainage as hydrocephalus worsened. Later, he experienced intracranial infection. On the tenth day, sudden incision pain followed by huge hemorrhage from wound occurred without any warning and the patient fell into coma within minutes. Urgent CT revealed a large fresh epidural hematoma of the surgical area (Fig. 1d). The timely hematoma evacuation was performed and an active source of bleeding was identified from the proximate broken end of the occipital artery (Fig. 1e). Despite the total hematoma removal (Fig. 1f), the patient died of intracranial infection and pneumonia. PFEDH after suboccipital craniotomy occurs uncommonly, representing approximately 1 % of all infratentorial craniotomies usually within three postoperative days [5]. Delayed PFEDHs are rarely reported with most of them caused by trauma [3, 4]. To our knowledge, no delayed PFEDH of occipital artery (OA) origin after craniotomy was published. In this case, OA was cut off together with suboccipital muscles by monopolar electrocoaglulation during craniotomy. Although the hemostasis of the broken ends of OA was enhanced by an additional bipolar electrocautery, the risk of rebleeding is possible because the end may contract by its own elasticity into muscle leading to incomplete or C. Tao H. Feng C. You (&) Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu 610041, Sichuan, China e-mail: tcywjj106@163.com

Hemorrhagic Epidermoid Cyst in Cerebellar Vermis.

Intracranial epidermoid cysts are usually located in the paramedian regions with characteristic imaging features. Intracystic hemorrhage is rarely reported with most in the cerebellopontine angle area. We described a case of hemorrhagic epidermoid cyst in cerebellar vermis. The patient was a 21-year-old male presenting with a first episode of convulsive seizure attack as the initial and sole symptom. Head computed tomography showed a mass lesion in the cerebellar vermis with high density and nodular low density in the back of the lesion. Magnetic resonance imaging revealed most of the lesion was hypointense to isointense, extremely hypointensity on T1-, T2-weighted imaging respectively. The nodule was hyperintense on both T1- and T2-weighted images. The atypical clinical presentation, location and radiological features of intracranial epidermoid cyst make accurate diagnosis quite challenging. In such cases, scrutinized histopathological examination is necessary to exclude the malignancy that may need radio/chemotherapy.

Predictors of Acute Vertebrobasilar Vasospasm following Tumor Resection in the Foramen Magnum Region

Objective Cerebral vasospasm can occur after skull base tumor removal. Few studies concentrated on the posterior circulation vasospasm after tumor resection in the posterior fossa. We aimed to identify the risk factors associated with postoperative vertebrobasilar vasospasm after tumor resection in the foramen magnum. Methods We retrospectively reviewed the data of 62 patients with tumors in the foramen magnum at our institution from January 2010 to January 2015. The demographic data, tumor features, surgical characteristics were collected. Vertebrobasilar vasospasm was evaluated by bedside transcranial Doppler before surgery and on postoperative day 1, 3, 7. Univariate and multivariate analyses were performed to determine the predictors of postoperative vasospasm in the posterior circulation. Results Vertebrobasilar vasospasm was detected in 28 (53.8%) of the 62 patients at a mean time of 3.5 days after surgery. There were 5 (8%) patients with severe vasospasm according to the grading criteria. Age, tumor type, tumor size, vertebral artery encasement, and surgical time were significantly related to vasospasm in the univariate analysis. Further multivariate analysis demonstrated that only age and vertebral artery encasement were independent risk factors predicting the occurrence of postoperative vertebrobasilar vasospasm. Conclusions The incidence of acute vertebrobasilar vasospasm is not uncommon after foramen magnum tumor resection. Age and vertebral artery encasement are significantly correlated with postoperative vasospasm. Close monitoring of vasospasm should be given to patients with younger age and the presence of vertebral artery encasement on the preoperative imaging to facilitate early diagnosis and intervention.