Yasumasa Makita

Intracranial double teratomas

A case of double teratomas located in the pineal region and the fourth ventricle is presented. A simultaneous occurrence from nonmetastatic, separate origins seems rare in cases of mature teratomas. Computerized tomographic scans led to detection of another asymptomatic teratoma. Surgical treatment produced good results.

Chemodectoma of the Glomus Jugulare with Multiple Metastases

A relatively rare case of chemodectoma of the glomus jugulare with multiple metastases is reported. Ten years ago, a 37-year-old male was seen because of dysphagia and a mass in the right retro-auricular region. The mass in the right jugular foramen was partially resected and irradiated. Histological examination revealed a chemodectoma. Five years thereafter the patient was readmitted with an epidural mass involving the left eighth cervical nerve root. One year later he developed a chest pain and lumbago. A bone scan revealed multiple skeletal metastases. Histologically, specimens from the right parietal bone and the right 10th rib showed a chemodectoma. He was again irradiated. He was again admitted with paraplegia, 9 years after the first admission. With repeated irradiation with a total dose of 16, 700 rads in 10 years, he died with cachexia and aspiration pneumonia at the age of 47. The autopsy revealed multiple metastases of chemodectoma to bone, spinal epidural space, lung, and pancreas. Although chemodectoma of the glomus jugulare is generally considered to be a rare benign tumor, slow metastatic spread to various organs is not uncommon. A careful search for metastatic lesions, possibly for years is essential when following up the patient.

Spontaneous Extrusion of Peritoneal Tubes after Ventriculoperitoneal Shunting

Migration of peritoneal tubes was observed in two cases of ventriculoperitoneal (VP) shunting. The first patient had undergone revision of VP shunting for hydrocephalus at the age of 7 months. He had been well until the age of 16 months, when umbilical erosion was noted. Physical examination revealed that the distal tip of the peritoneal tube (non-spiral wire type) was protruding through the umbilicus. However, the patient was well, and the tube was replaced. The removed tube was contaminated with Staphylococcus aureus, but administration of antibiotics prevented postoperative infection. The second patient, an 8-month-old boy, was brought in because of failure to thrive and feeding difficulty 5 months after VP shunting for hydrocephalus. Physical examination disclosed that the distal tip of the peritoneal tube (again, a non-spiral wire type) was protruding through the anus. The cerebrospinal fluid obtained by puncture of the fontanelle yielded a turbid fluid. There was no evidence of peritonitis. The distal tube was removed, and ventricular drainage, along with administration of antibiotics, was maintained for 1 month. The shunting system was then revised. There have been 53 reported cases of migration of shunting tubes, most of which were located in the bowel. Transumbilical migration has been previously reported only once. In that case as well as ours, Pudenz peritoneal tubes without a spiral wire were used. However, several authors have noted an increased incidence of spontaneous extrusion of the Raimondi type peritoneal tube with a spiral wire. Meningitis and/or ventriculitis carried the worst prognosis. Patients with VP shunts should be regularly examined to avoid the sort of rare complication described here.

Etiological Consideration of Spontaneous Carotid-cavernous Fistula Based on Clinical and Histopathological Studies

Clinical manifestations including the angiographic findings suggest that the spontaneous carotid-cavernous fistulae (CCF) are more likely considered etiologically to be one type of the dural arteriovenous fistulae in the cavernous region. This concept have been elaborated by Newton and Hoyt (1970) and also by us (1971) . However, this is not beyond working hypothesis. Recently we have encountered an autopsied case of spontaneous CCF. This 54-year-old female was expired from incidental apopletic complication two weeks after the selective external carotid ligation combined with embolization by polyurethane foam. At autopsy the sphenoid bone was removed including the sella turcica. After fixation, micropaque solution mixed with Evans blue was injected through the internal carotid artery. Blocks were cut in coronal section and stained with HE and Elastica van Gieson. Cavernous sinuses were divided into several sizes of small venous lakes, whose septa of connective tissues contained small arteries and veins. Injected dye not only was found in the arterioles in the septa, but also leaked out into the veins, connective tissues of the septa and also into the venous sinus. Walls of the arterioles running in the septa were partly thick and partly thin due to proliferation and interruption of the internal elastic lamina, and their lumina were irregularly narrowed and obstructed with concomitant organized thrombi. In addition, there were vessels which were hardly called either arteries or veins, and which had the appearance of venous or capillary angioma. Another interesting findings were observed in the thickened septa of the sinus wall, which are characterized by proliferation of elastica especially around the thrombosed small arteries. These histological features are reasonably considered to be that of arteriovenous malformation. Discussions were made from the histopathological standpoint on atherosclerosis, moya-moya disease, fibromuscular hyperplasia and Ehlers-Danlos syndrome. From the clinical point of view, spontaneous CCF can be differentiated from the traumatic one. The former were commonly seen amongst the middle aged female and frequently accompanied by headache. Multiple feeders mostly of external carotid artery contribute to the fistula. Furthermore, except for a few cases, they were rarely cured with surgery but rather cured or improved either spontaneously or in the process of the angiographic examinations. According to these clinical, angiographic and histological observations, it should be reasonably said that the spontaneous CCF is one type of dural arteriovenous fistula in nature and is the result of the rupture of the arteriovenous malformation of the dural vessels in the septa of the cavernous sinus directly into the cavernous sinus or via bleeding into the connective tissue of the septa.