Mahmoud Rayes

Supratentorial neurenteric cysts—A fascinating entity of uncertain embryopathogenesis

The histopathological, immunologic, and ultrastructural findings of neurenteric cysts support an endodermal derivation. These developmental cystic lesions are generally located in the posterior mediastinum, abdomen, and pelvis and may also contain some mesodermal and neuroectodermal elements. In contrast, neurenteric cysts of the central nervous system are very infrequent and occur most commonly in the spinal canal. Intraspinal neurenteric cysts are usually encountered in the cervicothoracic region with an intradural, extramedullary location and are commonly associated with congenital defects of the overlying skin and/or vertebral bodies. Intracranial neurenteric cysts are very uncommon and typically located in the posterior fossa. Several hypotheses have been postulated to explain the origin of intracranial neurenteric cysts. However, the embryologic basis of these fascinating lesions remains incompletely understood. Supratentorial neurenteric cysts are distinctly rare often represent a diagnostic challenge on preoperative neuroimaging. In fact, only 22 cases of supratentorial neurenteric cysts have been reported in the literature including our own patient with a laterally based convexity extraaxial cyst presenting with seizures. In this report, we review the clinical, radiographic, and histological findings of supratentorial neurenteric cysts. We discuss the differential diagnoses and surgical considerations in the management of these intriguing lesions. We also provide an extensive review of normal human embryogenesis and discuss putative mechanisms of embryopathogenesis of supratentorial neurenteric cysts.

Safety and efficacy of intracranial stenting for acute ischemic stroke beyond 8 h of symptom onset

Objective To report our experience with stent supported intracranial recanalization for acute ischemic stroke beyond 8 h of symptoms onset. Background Acute ischemic stroke (AIS) therapy is often limited to an 8 h window using mechanical means. However, recent reports have shown delayed recanalization beyond 8 h might be a viable option in a subset of patients. Methods A retrospective review was performed of our AIS database for patients who underwent stent supported intracranial recanalization beyond 8 h of symptom onset. Clinical and angiographic data were reviewed. Outcome was measured using modified Rankin Scale (mRS) scores at 30 and 90 days. Results 12 patients (11 men and one woman) underwent delayed stenting for AIS. Mean age was 49 years (range 37–73) and mean National Institutes of Health Stroke Scale was 17 (range 8–29, median 15). Mean time from stroke onset to intervention was 66.1 h (range 10–168 h, median 46 h). 10 patients presented with a Thrombolysis in Myocardial Infarction (TIMI) score of 0 and the remaining two had a TIMI of 1. Recanalized vessels included: left middle cerebral artery (n=6), basilar trunk (n=2), vertebrobasilar junction (n=3) and internal carotid artery (ICA)-T (n=1). Four patients had prior attempts of embolectomy/thrombolysis using mechanical and chemical means. Stents used included: six balloon mounted stents, five Wingspan and one Enterprise self-expanding intracranial stent. Recanalization, defined as a TIMI score of 2 or more, was achieved in 11 patients. Two patients (17%) had intracranial hemorrhage. Thirty day mRS of ≤3 was achieved in six patients (50%). Seven patients (58%) had a 90 day mRS of ≤2. Conclusion Stent supported intracranial recanalization is a safe and feasible approach in a selective group of patients presenting with acute ischemic stroke beyond 8 h of symptom onset.

The safety and efficacy of coiling multiple aneurysms in the same session

Objective Multiple intracranial aneurysms are common. While sequential clipping of multiple aneurysms during a single open surgical procedure has been reported, the same is not true for endovascular coiling. We present our experience describing the safe coiling of multiple aneurysms in the same setting. Methods Retrospective review of our coiling log between 2006 and 2009 showed six cases in which multiple aneurysms were coiled in the same session. Results All patients were coiled using the same microcatheter. Distal aneurysms were coiled first. Good occlusion rates were achieved in all cases. There were no thromboembolic events or procedure-related rupture or mortality. Conclusion In addition to safety and efficacy, cost savings are expected when coiling multiple aneurysms in the same procedure.

Stenting of acute and subacute intracranial vertebrobasilar arterial occlusive lesions

Background and objective The outcome of failed recanalization in patients with acutely symptomatic intracranial vertebrobasilar (VB) artery occlusive disease is poor. This paper reports the recanalization rate and safety of VB artery stenting in acutely symptomatic patients presenting >8 h after onset of symptoms. Methods A retrospective review of a prospectively maintained database of stent-supported endovascular treatment of intracranial circulation was carried out to identify patients with VB artery occlusive disease who were acutely revascularized >8 h after symptom onset. Results Of 12 patients (mean age 61 years), nine had acute stroke and three had recurrent transient ischemic attacks. The median time to intervention was 59 h (range 8–80). The median National Institute of Health Stroke Scale score was 11.5 (range 1–40). Angiography showed thrombolysis in myocardial infarction (TIMI) 0 flow in six patients and TIMI 1 flow in the other six. Stents were placed in the basilar artery in six and at the VB junction in the other six. Mechanical and/or intra-arterial thrombolysis was used in three patients before stenting. Nine patients had self-expanding stents and three had balloon-expandable stents. The recanalization rate was 100%. Procedure-related and 3-month mortality was zero. Two patients had asymptomatic intracranial hemorrhage. At 3-month follow-up a favorable outcome with a modified Rankin score ≤2 was achieved in eight. A follow-up angiogram in eight patients showed mild re-stenosis in three. Conclusion Stent-supported VB artery revascularization can be a viable option with an acceptable safety profile in acute VB occlusion or unstable intracranial atherosclerotic arterial disease (ICAD) in carefully selected patients.

Middle cerebral artery pseudoaneurysm formation following stereotactic biopsy.

Trauma accounts for less than 1% of all intracranial aneurysms.1 Based on the underlying mechanism of injury, traumatic intracranial aneurysms (TICA) can be classified into four categories: penetrating head injury, missile injury, blunt head injury, and iatrogenic injury.1-3 Histologically, there are two types of TICAs: true and false. The majority of TICAs are false aneurysms and are also referred to as pseudoaneurysms.2,4,5 Establishing a diagnosis of pseudoaneurysms remains difficult and requires a high index of suspicion. In the absence of timely diagnosis and treatment, a mortality rate of up to 50% has been reported in patients harboring a cerebral pseudoaneurysm.3 We present a case of distal middle cerebral artery (MCA) pseudoaneurysm following a stereotactic needle biopsy of a right temporal lobe mass. To our knowledge, only one other report in the literature describes the formation of pseudoaneurysm following stereotactic brain biopsy. Our case is the only reported case where the diagnosis of iatrogenic pseudoaneurysm following stereotactic biopsy was made prior to definitive surgery.

Synchronous meningioma and anaplastic large cell lymphoma

Synchronous primary brain tumors are exceedingly rare. When they occur, most cases are associated with metastatic disease. To the best of our knowledge, we report the first case of an atypical meningioma infiltrated by a T‐cell‐primary central nervous system lymphoma (PCNSL), specifically anaplastic large cell lymphoma (ALCL). We present a novel, unifying, plausible mechanism for its origin based on theories in the current literature. A 65‐year‐old man with a history of near‐total resection of atypical meningioma presented with a complaint of progressive headaches. Imaging revealed recurrent tumor. Left frontal‐temporal craniotomy with near‐total tumor resection followed by radiation was performed. Recurrent symptomatic tumor led to repeat left frontotemporal craniotomy with tumor resection and partial anterior temporal lobectomy. Part of the specimen showed predominantly fibrotic neoplasm composed of nests and whorls of meningothelial cells, highlighted by epithelial membrane antigen (EMA) staining. The remainder of the specimen consisted of densely cellular neoplasm centered in connective tissue, including areas involved by meningioma. This tumor was composed of moderately large lymphoid cells with large nuclei, prominent nucleoli, and amphophilic cytoplasm. These cells were strongly immunoreactive for CD3 and CD30 but remained unstained with EMA, anaplastic lymphoma kinase‐1 (ALK‐1), CD15 or cytotoxic associated antigen TIA‐1. Smaller mature lymphocytes, chiefly T‐cells, were intermixed. The morphologic and immunohistochemical features were considered typical of anaplastic large T‐cell lymphoma. The pathogenesis of this association may have been due to radiation‐mediated breakdown of the blood–brain barrier with subsequent T‐cell infiltration and proliferation. We advocate aggressive resection and long‐term surveillance for individuals with metastasis, especially higher‐grade neoplasms that receive radiotherapy.

Outcome of brain abscess by Clostridium perfringens

OBJECTIVEDespite the aggressive infection of soft tissue caused by Clostridium perfringens (gas gangrene-necrotizing fasciitis), a brain abscess with this bacteria treated by early surgical excision, debridement of necrotic tissue, and antibiotic coverage may be expected to have a good recovery. Long-term follow-up has not been well established in this group of patients. We report this case to show the outcome at 3 years post surgical and antibiotic treatment for C. perfringens brain abscess and stress the need for urgent intervention to achieve good outcome. We also present a literature review of Clostridial brain abscesses since the 1960s. CLINICAL PRESENTATIONA 53-year-old man was brought to the emergency room after having a witnessed seizure status postassault 3 days before admission. On presentation, he was febrile, disoriented, lethargic, and demonstrated right upper extremity weakness. A computed tomographic scan of the head showed a left frontoparietal depressed cranial fracture complicated with gas and intraparenchymal air fluid level cavity. INTERVENTIONEmergent surgery for debridement and excision of necrotic tissue was performed. Empiric intravenous antibiotic therapy was started and penicillin G was added for 6 weeks after C. perfringens was demonstrated. CONCLUSIONDespite the severe infection and effect of C. perfringens in soft tissues in the brain, it appears that emergent surgical debridement and antibiotic coverage will yield an excellent outcome for these patients.

Good outcome in HELLP syndrome with lobar cerebral hematomas

BackgroundHELLP syndrome is associated with high morbidity and mortality which is attributed most commonly to intracranial hemorrhage (ICH) and/or stroke. The presence of other complications further worsens the prognosis.MethodsWe present a rare case of HELLP syndrome which presented with ICH and further complicated by seizures, disseminated intravascular coagulation, and acute renal failure.ResultsAggressive surgical and medical management of her ICH, HELLP syndrome and associated complications resulted in good functional recovery. Hypothermia seems to be a good adjunctive in treatment.ConclusionICH associated with HELLP syndrome when managed aggressively can have meaningful neurological recovery.

Endovascular management of a giant aneurysm through saphenous vein graft after extracranial–intracranial bypass: case report and literature review

It is known that giant intracerebral aneurysms have a high rupture and mortality rate. Furthermore, their optimal treatment method is not straightforward. While traditionally they have been managed with surgical clipping, it is not always possible. A unique case is presented in which a patient with multiple intracranial aneurysms was treated using a multimodality approach. After an intracranial–extracranial bypass, the left internal carotid artery ophthalmic aneurysm continued to grow on follow-up angiogram. Thus it was decided to go ahead with coiling of the aneurysm. The coils were delivered through the saphenous vein graft. The patient tolerated the procedure well and there were no procedural complications.

Peripheral ophthalmic artery aneurysm associated with multiple intracranial aneurysms: a case report

Peripheral intraorbital ophthalmic artery aneurysms are rare. We here present a case of intraorbital ophthalmic artery aneurysm, associated with multiple anterior circulation aneurysms. The asymptomatic ophthalmic artery aneurysm was not treated. However, the symptomatic ones were embolized.