Pierpaolo Lunardi

Low-grade primary meningeal lymphoma: case report and review of the literature

Primary meningeal lymphoma is a rare occurrence. We present a case of an immunocompetent patient operated on for a fronto-parietal lesion similar to a meningioma, which the histological examination diagnosed as a mucosa-associated lymphoid tissue (MALT)-type lymphoma. She received no further post-operative treatment and after 36 months showed no evidence of disease. In a review of the literature, we identified 14 similar cases of MALT lymphoma pre-operatively diagnosed as meningioma. Recognition of this rare meningeal location of a lymphoma involving the central nervous system is useful for a proper diagnosis and adequate treatment.

Epidural hematoma after thoracic epidural catheter removal in the absence of risk factors

Background and Objectives The purpose of this report is to enhance awareness that an epidural hematoma can occur even in patients devoid of risk factors. Case Report A 69-year-old, 55-kg male was scheduled for video-assisted thoracoscopic resection of bilateral pulmonary metastases and received combined thoracic epidural and general anesthesia. The epidural catheter insertion was unremarkable. All laboratory values were within normal values. No anticoagulation or antiplatelet drugs were administered. The epidural catheter was removed on postoperative day 2. The patient developed signs of an epidural hematoma a few hours later and was treated by decompressive laminectomy. Full neurologic recovery was observed after a 6-month period. Conclusion Catheter removal is a critical period for epidural hematoma formation even if no risk factors are identified. Early recognition and treatment are essential features for good neurologic recovery after an epidural hematoma.

Calcifying pseudo-tumor of the spine: description of a case and review of the literature

A case of calcifying pseudo-tumor of the thoracic spine, a rare lesion with tumor-like behavior and a probable inflammatory-reactive origin, is described. The clinical-pathological and neuro-radiological aspects of this lesion are discussed in relation to surgical treatment. In accordance with the other cases reported in the literature, the case observed confirmed the benign behavior of the lesion and the effectiveness of surgical treatment for achieving complete resolution of clinical symptoms without any recurrences, even when removal is only subtotal.

Brain Granuloma: Rare Complication of a Retained Catheter

BACKGROUND Ventriculoperitoneal (VP) shunt is the most frequent treatment for hydrocephalus. VP shunt malfunction is a very common problem in neurosurgical practice, often requiring shunt revision procedures. In some cases, complete removal of a VP shunt may present difficulties, leading the surgeon to leave the ventricular catheter in situ. This decision is often made to avoid possible adverse events, primarily risk of life-threatening hemorrhage. However, a nonfunctioning catheter left in the ventricular system may lead to further complications. CASE DESCRIPTION We report the case of an adult man who presented with a tumor-like cystic lesion, with mural and nodular postcontrast enhancement, caused by a huge granuloma formed around the tip of a retained ventricular catheter. CONCLUSIONS This occurrence is extremely rare, and this is the first reported case in the literature. Preoperative differential diagnosis was challenging and included infection, metastasis, dysembryogenetic lesions, and rare reversible porencephalic cysts. According to several physiopathogenetic theories recently reported in the literature, the granuloma may develop as the result of persistent chronic inflammatory reactions between the ventricular catheter left in situ and the brain parenchyma. Application of neuroendoscopic techniques is improving management of VP shunt revisions, allowing safe removal of catheters stuck or lost in the ventricular system. Neuroendoscopy may represent an additional option to avoid possible complications related to retained ventricular catheters.

Pathology of disk degeneration

The intervertebral disk is a proper intersomatic joint between two vertebrae, allowing pluridirectional movements. The disk, composed of the pulposus and gelatinous nucleus with collagen fibers and contained inside a fibrous ring, changes its morphology during movements of the column. The intervertebral disks are maintained in place by the two anterior and posterior longitudinal ligaments, which are also the longitudinal union means of the vertebral bodies.

Isolated Oculomotor Nerve Palsy as Presenting Symptom of Bilateral Chronic Subdural Hematomas: Two Consecutive Case Report and Review of the Literature

BACKGROUND Isolated oculomotor nerve palsy (ONP) is caused most commonly by vascular disease, posterior circulation aneurysms, and inflammatory or traumatic injury. ONP usually occurs in chronic subdural hematoma (CSDH) as a common sign of cerebral herniation that typically is associated with a deterioration of consciousness. CASE DESCRIPTION We report 2 cases of bilateral CSDH who presented with ONP without deterioration of consciousness. An extensive literature review revealed this is an extremely rare finding. We also investigated all the possible pathogenic mechanisms producing nerve impairment and found a strong association with bilateral subdural hematoma. Vascular compression between posterior circulation arteries and tentorial edge abnormalities also could be involved. Vulnerability of the oculomotor nerve seems to be a necessary condition leading to clinical onset and is caused by predisposing factors to nerve damage, including vascular disease, head trauma, or herpes zoster infection. CONCLUSIONS Although isolated ONP is a very rare presentation of CSDH, a differential diagnosis is absolutely necessary, because surgical treatment allows good recovery of third nerve palsy in most of the cases.

Hypertrophic Pachymeningitis and Hydrocephalus—The Role of Neuroendoscopy: Case Report and Review of the Literature

BACKGROUND Hypertrophic pachymeningitis (HP) is a rare primary or secondary inflammatory disorder that manifests with thickening of dura mater involving predominantly the tentorium and falx in the focal form. Hydrocephalus has not been reported in association with secondary HP. CASE DESCRIPTION A 61-year-old woman presented with intracranial HP of the posterior fossa secondary to Wegener granulomatosis not responsive to corticosteroid therapy. Owing to the association of noncommunicating hydrocephalus, endoscopic third ventriculostomy was performed. There was immediate improvement of neurologic symptoms and no postoperative complications. The patient had very good clinical and radiologic outcome at 1-year follow-up. CONCLUSIONS In a case of noncommunicating hydrocephalus related to focal HP of the posterior fossa, endoscopic third ventriculostomy was effective in resolving symptoms related to increased intracranial pressure. The physiopathogenetic mechanisms and therapeutic strategies were discussed along with a review of the most relevant literature.

Supratentorial embryonal tumors in elderly: diagnostic pitfalls and clinical prognosis

Supratentorial embryonal tumors are very rare malignant tumors of neuroectodermal origin, characterized by an aggressive clinical behavior. They occur prevalently in children. They have been sporadically described in adults and represent an even rarer occurrence in elderly patients, raising many issues on the diagnostic pitfalls and their appropriate management. We present an unusual case of embryonal tumor in a 62-year-old man who presented with speech disorder, and partial deficit of the left 3rd and 5th cranial nerves secondary to a left temporo-insular embryonal tumor: the clinico-radiological features, histopathological insights, therapeutic options and results are discussed along with a review of the most relevant literature, addressing the specific issue of differential diagnosis and the expected results in the elderly population.

Vascular malformations of the central nervous system

Vascular malformations or “angiomas” of the central nervous system consist in a pathological tangle of arteries, veins, capillaries and/or canals of a presumably congenital nature. They are “dynamic” lesions, being characterized by a continuous change in diameter and appearance. The incidence of angiomas in Europe and North America is about 4000–5000 cases per year, one-tenth of the incidence of intracranial aneurysms.

Spinal cord vascular malformations

These dysembryogenetic malformations, also called medullary angiomas, are dilations or anomalies of the arterial, venous or capillary vascular compartment. We distinguish: the raceme-venous angioma (exclusively of venous nature), formed by bluish pial vein conglomerates, sinuous, not pulsating, containing venous blood, and sometimes an ample more or less tortuous vein; and the arteriovenous angioma, formed by arteries and veins communicating between them through a tangle of abnormal vessels, without capillary interposition. This angioma appears as a turgid group of pulsating arteria vessels, containing high pressure arterial blood and by ample, tortuous, venous vessels, pulsating as well; the arterial angioma, purely arterial, is very rare in the spinal cord; the cavernous angiomas or cavernomas are tumor-like malformations of small dimensions, without intervascular tissue, often they are surrounded by coagulated venous blood; the telangectasias are dilations of capillary vessels separated by normal tissue. They can have cavernomatous aspect due to progressive dilation of the vasal walls and secondary disappearance of intervascular tissue.