Orasa Chawalparit

A 29-Year-Old Man with Progressive Short Term Memory Loss

Brain MRI revealed a 5.7x4.3x4.2 cm in the third ventricle with isosignal intensity on T1W, heterogeneous signal on T2W and FLAIR (not shown). The mass showed intense heterogeneous enhancement on T1W after gadolinium injection. Extension to the suprasellar cistern was demonstrated on sagittal T1W after gadolinium injection (Figure 1a). There was also thickening and enhancement of the pituitary stalk, suggestive of involvement or origin of hypothalamus. The coronal T1W after gadolinium injection showed separation of the mass from lateral ventricle (Figure 1b). The inferior wall of the lateral ventricle was displaced upward as well as the septum pellucidum.

Interventional Neuroradiology in Thailand: 1989–1997:

In 1979 the Siriraj team in Bangkok began exploring a field that was then new in Thailand, i. e. interventional neuroradiology. This first phase consisted mostly in self-training and foreign exposure. It included experimental work with animal models, as well as early clinical trials designed to assess our skills in particle embolisation and the ligated and detachable balloon techniques. In 1990 a new phase started. Essential techniques were acquired in collaboration with the neurovascular unit of Bicêtre Hospital in France during a three year training programme. Throughout this period, the support of the Association Médicale Franco-Asiatique (AMFA) and the French foreign affairs department proved vital. Our department progressively became a referral centre for the different techniques used in embolisation (balloons, glue…) and for various vascular lesions of the brain, the head and neck region, and spinal cord diseases. Within Mahidol University, the Ramathibodi and Prasat Hospital centres started the same interventional neuroradiology training program in 1995; they benefited from the same tutors and connections as Siriraj. In 1996, the newly acquired biplane DSA machines in both centres enabled us to improve the treatment of arteriovenous malformations - using the glue technique –, intracranial aneurysm - using GDC-coils -, clot lysis, angioplasty… etc. According to international recommendations, the critical mass we reached in 1997 in terms of number of patients and interventions, allows us to offer training in endovascular techniques to junior neuroradiologists at Mahidol university.

A 53-year-old woman with progressive headaches.

A 53-year-old woman presented with a 1-month history of severe headache and intractable vomiting. Physical examination revealed left facial palsy and generalized weakness of the extremities (grade IV/V all extremities) without other localizing signs. She had no known underlying disease and there was no significant family history. MRI of the brain disclosed multiple ill-defined high signal lesions in T2W at left lower pons, left thalamus, subcortical regions of temporal, parietal, and frontal lobes bilaterally, and periventricular white matter. Nodular enhancement was noted in the left frontal lobe lesion (Figure 1a), left thalamus (not shown) and left pons (Figure 1b). Irregular leptomeningeal enhancement was also noted diffusely. The largest mass present at the left frontal lobe was 2 cm in largest dimension and showed marked peritumoral vasogenic edema (Figure 1a). High resolution chest CT revealed an ill-defined mass at the posterior basal segment of the right lower lobe, 3.2 cm in greatest dimension (not shown). There were also multiple small nodules involving both lungs, ranging from 0.4 to 0.5 cm. Stereotactic biopsy of the left frontal lobe lesion was performed. MICROSCOPIC PATHOLOGY

Moyamoya syndrome: post cranial irradiation of pineal gland tumor.

A right-handed eight-year-old boy, with headache, vomiting and positive parinauds sign was diagnosed as having a pineal gland tumor which histopathological section from surgical biopsy revealed to be a germinoma. The patient underwent ventriculoperitoneal shunt for obstructive hydrocephalus. Thereafter, he received cranial irradiation as definitive treatment. He was well and went back to school until five years later he developed a transient ischemic attack. Cranial magnetic resonance imaging showed a complete cure of the pineal tumor without any other specific abnormality. Eight months later he had an episode of stroke which was demonstrated by cranial computed tomography as acute left cerebral infarction in the middle cerebral artery territory. Cerebral angiography showed Moyamoya syndrome.