Michael Gelsomino

Coincidence of an anterior cerebral artery aneurysm and a glioblastoma: case report and review of literature.

Background The association between glioblastoma and intracranial aneurysm is rare. Treatment guidelines do not exist, and operative mortality and morbidity are significantly high. To our knowledge, no prior cases have employed endovascular therapy for the treatment of these intra-tumor intracranial aneurysms followed by tumor resection. Case presentation A 74-year-old male, history of a left A2 aneurysm, presented after a motor vehicle accident at low speeds. Imaging was concerning for a possible traumatic brain contusion, an aneurysmal hemorrhage given history of left A2 aneurysm, or a hemorrhage from an underlying tumor given profound edema. The patient was discussed at the brain tumor board, where the plan was to address the aneurysm followed by resection of the mass versus close monitoring with subsequent imaging. The high risk of rehemorrhage, given the real possibility of an aneurysmal hemorrhage, motivated prompt treatment of the aneurysm. The patient was taken to the angiography suite; an anterosuperiorly projecting azygous A2 aneurysm, measuring 4.5 mm × 5.5 mm with a neck width at 3.5 mm and a small daughter sac, was completely obliterated with primary coiling. The following day, he underwent a left craniotomy along a forehead skin crease for mass excision. Final pathology revealed glioblastoma. The patient recovered well from both procedures, with a baseline neurological exam. The patient subsequently underwent hypofractionated radiation and temodar. Conclusion To our knowledge, no prior cases have employed endovascular therapy for the treatment of these intracranial aneurysms. We emphasize that efforts to introduce less invasive elements may improve the overall outcomes in this rare patient population.

Granulomatous amebic encephalitis following hematopoietic stem cell transplantation.

Background: Granulomatous amebic encephalitis (GAE) is rare, but often fatal. The infection has been documented predominantly among the immunocompromised population or among those with chronic disease. To date, however, there have only been eight cases regarding the infection following hematopoietic stem cell transplantation (HSCT). Case Description: A 62-year-old female with a history of relapsed diffuse large B-cell lymphoma, recently underwent peripheral blood autologous stem cell transplant after BEAM conditioning (day 0). On day +15, she began to exhibit worsening fatigue, generalized weakness, and fever. Symptoms progressed to nausea, emesis, somnolence, confusion, and frontal headaches over the next few days. Imaging demonstrated multifocal ill-defined vasogenic edema with patchy enhancement. The patient was started on broad antibiotics, antifungals, and seizure prophylaxis. Evaluation for bacterial, fungal, mycobacterial, and viral etiologies was fruitless. Her mental status progressively deteriorated. On day +22, she exhibited severe lethargy and went into pulseless electrical activity arrest, requiring chest compressions. The episode lasted <2 min and her pulse was restored. She was taken to the operating room for a brain biopsy. Postoperatively, her right pupil began to dilate compared to the left; she demonstrated extensor posturing in her upper extremities and withdrawal in her lower extremities. Repeat computed tomography demonstrated progressive edema. Given poor prognosis and poor neurological examination, the family opted for withdrawal of care. Final pathology was consistent with Acanthamoeba GAE. Conclusion: The authors report the third case of GAE after autologous stem cell transplant, and the ninth case overall after HSCT. This case is unusual due to its rapid clinical presentation after HSCT compared to prior literature. The case highlights the need for high suspicion of Acanthamoeba infection in this patient population.

A completely thrombosed, nongiant middle cerebral artery aneurysm mimicking an intra-axial neoplasm.

Background: Few reports exist regarding thrombosed aneurysms where the initial work up was concerning for a neoplasm. To date, no published reports exist regarding a nongiant thrombosed middle cerebral artery aneurysm, where the primary workup and treatment plan was directed toward a preliminary diagnosis of intra-axial neoplasm. Case Description: We report a 43-year-old female who presented with a generalized tonic-clonic seizure attributed to a lesion along the right superior temporal gyrus. The lesion enhanced on initial magnetic resonance imaging (MRI) of the brain, as well as on follow-up MRI. Subsequent vascular studies and metastatic work up were negative. A craniotomy with image guidance was performed and an intraoperative diagnosis was made of a thrombosed aneurysm along a branch of the middle cerebral artery. The aneurysm was trapped and resected as there was no significant flow from the branch as seen on the prior cerebral angiogram. The patient had an uneventful postoperative course. Conclusion: Completely thrombosed, nongiant aneurysms can mimic an intra-axial neoplasm. Typical imaging features for thrombosed aneurysms may be missed, especially if the aneurysms are small, where imaging characteristics of the intraluminal contents is more difficult to appreciate. Although imaging may be consistent with a neoplastic lesion, there should be suspicion for a potential underlying aneurysm.

Dysembryoplastic Neuroectodermal Tumor: An Analysis from the Surveillance, Epidemiology, and End Results Program, 2004–2013

BACKGROUND Dysembryoplastic neuroectodermal tumor (DNT) is a rare neoplasm. Though the pathology is commonly considered benign, there have been various reports documenting rapid growth, recurrence/progression, sudden death, and malignant transformation. Most studies have addressed outcomes regarding seizure control, but limited data exist regarding incidence and survival. Consequently, we explore the Surveillance, Epidemiology, and End Results (SEER) database to explore the epidemiology of DNT. METHODS From the SEER-18 registry database, information from all patients diagnosed with intracranial DNT between 2004 and 2013 was extracted, including age, sex, race, marital status, tumor location, tumor size, receipt of surgery, extent of primary surgery, receipt of radiation, and follow-up data. Age-adjusted incidence rates and overall survival (OS) were calculated. A Cox proportional hazards model was used to assess relationships between various demographic/treatment variables and OS. RESULTS A total of 381 cases were identified in the SEER-18 database. The incidence of DNT within the large subset of the United States population represented by SEER was 0.033 per 100,000 person-years (95% confidence interval [CI], 0.030-0.037). The median duration of follow-up was 50 months. The median OS was not attained. The 3-, 5-, and 9-year OS was 99.363% (95% CI, 97.428%-99.844%), 97.993% (95% CI, 95.168%-99.174%), and 96.296% (95% CI, 91.834%-98.341%), respectively. Seven of the 381 patients passed at their last follow up. Of all demographic/treatment factors, only receipt of radiation demonstrated a significant relationship with OS (hazard ratio, 0.051; 95% CI, 0.01-0.267; P < 0.01). CONCLUSIONS Although the prognosis for DNT is generally favorable, the pathology can lead to poor outcomes in rare cases. Common demographic factors, treatment with surgery, and the extent of surgical resection did not show significant associations with OS. In contrast, treatment with radiation was associated with poorer OS.

Good outcomes in a patient with a Duret hemorrhage from an acute subdural hematoma

Background Secondary brain stem injury is associated with transtentorial herniation, and manifests as “Duret” hemorrhages. Such an injury has been considered a terminal brain stem event with a high morbidity and mortality, sometimes discouraging continuation of care. However, there have been rare instances where patients have had reasonable recovery. We report another case, emphasizing that such an injury by itself should not deter aggressive measures, as good outcomes remain a possibility. Case presentation A 37-year-old male sustained a right subdural hematoma after a mechanical fall while intoxicated. He presented initially with a Glasgow Coma Scale 15. Three days later, he exhibited acute neurological deterioration to Glasgow Coma Scale 4, requiring intubation and mannitol. Repeat scan demonstrated enlarging right subdural hematoma with worsening shift; brain stem hemorrhage was noted at pontomesencephalic junction. Patient was immediately taken for subdural hematoma evacuation. The following day, patient was able to sluggishly follow commands in all four extremities. He had a short stay for inpatient rehabilitation and underwent autologous cranioplasty at 3 months. On examination, he was awake, alert, and oriented to self, time, and location; he exhibited dysarthric speech, right ptosis, but followed commands in all four extremities with no focal motor weakness. Conclusion In contrast to the common belief, patients suffering from a “Duret” hemorrhage can still have a good outcome. “Duret” hemorrhages may not represent a fatal injury. The finding from this paper suggests the finding of “Duret” hemorrhages on imaging should not deter aggressive measures especially in patients with lesions causing significant mass effects. Overall clinical status should drive surgical options and clinical course.

Patients with Blunt Traumatic Brain Injury: A Role for Computed Tomography Angiography of the Head to Evaluate Nontraumatic Causes?

BACKGROUND In the setting of trauma, the cause of intracranial hemorrhage (ICH) is frequently attributed to the physical, traumatic event. Caution should still be directed toward nontraumatic (or spontaneous) causes responsible for the trauma, such as hypertension, cerebral amyloid angiopathy, aneurysms, vascular malformation, and hemorrhagic infarcts. The role for immediate computed tomography angiography remains controversial to evaluate for nontraumatic causes. METHODS A systematic review of the available literature in the Medline PubMed database. RESULTS In the available literature, only 12 patients with traumatic brain injury underwent computed tomography angiography of the head that either showed a vascular malformation and/or altered clinical management because of concerns of a vascular malformation. The ICH in 11 patients was attributed to rupture of a cerebral aneurysm; the other patient received a diagnostic angiogram that was negative. CONCLUSIONS ICH in patients with traumatic brain injury seems to be vastly associated with the traumatic event. Only rare cases have been attributed to aneurysmal rupture. None has been associated with arteriovenous malformation. Nevertheless, clinical vigilance remains reasonable, especially in younger patients and those with hemorrhage within the subarachnoid cisterns or sylvian fissure.

Pure tentorial subdural hematoma from rupture of aneurysm along the transmastoid branches of the occipital artery.

Background: Pure subdural hematoma (without subarachnoid, intraventricular, or intraparenchymal hemorrhage) due to a ruptured intracranial aneurysm is rare. Most reported cases involve an aneurysm along the internal carotid artery, posterior communicating artery, or middle cerebral artery. No reports have described an aneurysm along the transmastoid branches of the occipital artery. Case Description: A 70-year-old female presented with sudden-onset, excruciating headaches, associated with dizziness, nausea, and emesis. There was no history of trauma. Computed tomography (CT) head demonstrated a pure tentorial subdural hematoma. Vascular imaging revealed bilateral aneurysms along the transmastoid branches of the intracranial portion of both the occipital arteries. Consequently, these branches were embolized, with no residual filling of the aneurysms. After the procedure, the patient remained neurologically well. The patient was monitored appropriately for vasospasm, and was discharged home 10 days after presentation. Conclusion: Rupture of aneurysms along intracranial branches of the occipital artery can lead to pure subdural hematoma along the tentorium.

Central cord syndrome in a patient with systemic sclerosis and cervical calcinosis: case report and review of literature

Systemic sclerosis, or scleroderma, rarely involves the cervical spine. The disorder can induce dystrophic calcinosis that can cause spinal canal stenosis and spinal instability. An association between this pathology with acute traumatic central cord syndrome and dural erosion is rare. This case report highlights such an association and postulates the underlying mechanisms. A 57-year-old female, with a history of chronic obstructive pulmonary disease (COPD), schizophrenia and systemic sclerosis, presented with weakness in all extremities after a minor fall. Imaging demonstrated a calcified soft-tissue mass at C4/5 causing severe cord compression, cord edema spanning C3–C6, calcified soft-tissue masses at right C2/C3 facet joint and bilateral C4/5 facet joints, and significant subluxation at C4/5. Patient underwent C4–C7 laminectomies, and C3–T1 fixation and fusion. The calcinosis appeared to erode through the dura, which necessitated dura repair once the calcionsis was carefully debulked. The patient recovered well, and improved clinically with rehabilitation. Dystrophic calcinosis from underlying systemic sclerosis can cause significant chronic cervical stenosis, which may reduce the threshold for acute traumatic cervical cord syndrome under minor trauma. Moreover, dystrophic calcinosis may exhibit a propensity for dural erosion, possibly through chronic adhesions secondary to chronic inflammation. Aggressive removal of the calcinosis may breach the dura. Consequently, subtotal debulking may be reasonable if the spinal canal is adequately decompressed after laminectomies.

A rare remarkable recovery in a pediatric patient with the bi-hemispheric, transventricular trajectory craniocerebral gunshot wound.

The gunshot wound to the head (GSWH) is associated with a mortality rate of 20–90% in adults and 20–65% in the pediatric population. Due to the high rates of mortality and morbidity, the management of these patients has been a topic of high interest in the neurosurgical community. We present an 18-year-old male suffering a GSWH with the bullet following a transventricular trajectory and crossing the midsagittal plane, creating extensive intracranial injuries. Despite a calculated mortality rate of >97% from these devastating injuries, the patient survived the GSWH and made a remarkable recovery. The young adult brain still maintains a high potential for neurological plasticity. This may partially explain why the young adult population with a severe GSWH can have a better than expected recovery course. Bifrontal GSW injuries may have much better outcomes than more posterior injuries as has been demonstrated in this patient in this case.

Co-presentation of a subdural empyema and an infected ventriculoperitoneal shunt in an adult patient: A rare complication with review of literature.

Background: The occurrence of a subdural empyema as a complication of a ventriculoperitoneal (VP) shunt infection is rare. Only three articles have been published on this topic. Moreover, the available literature only involves pediatric patients. Case Description: The authors present a 38-year-old male with a preexisting right frontal subdural hygroma that developed into a subdural empyema in the presence of an infected right occipital VP shunt. A brief literature review is provided, and the pathogenesis is discussed. Conclusion: This is the first known report regarding an adult patient with a subdural empyema and a VP shunt infection. Although a magnetic resonance imaging (MRI) brain is not typically ordered during diagnosis of a shunt infection, the authors advocate a low threshold to employ MRI brain to evaluate for other sources of infection, especially in an immunocompromised patient or in a patient with a history of a subdural hematoma or hygroma that can be easily overlook as being stable on computed tomography of head.