Yoshiteru Soejima

Severe Subarachnoid Hemorrhage Associated with Cerebral Venous Thrombosis in Early Pregnancy: A Case Report

BACKGROUND Cerebral venous thrombosis (CVT) rarely induces subarachnoid hemorrhage (SAH). During late pregnancy and puerperium, CVT is an uncommon but important cause of stroke. However, severe SAH resulting from CVT is extremely rare during early pregnancy. OBJECTIVE We report on a rare case of severe SAH due to CVT, and discuss the potential pitfalls of CVT diagnosis in early pregnancy. CASE REPORT A 32-year-old pregnant woman (9th week of pregnancy) presented with slight head dullness. Initial magnetic resonance imaging (MRI) revealed focal, abnormal signal intensity in the left thalamus. Nine days later, the patient developed a generalized seizure and severe SAH was detected with computed tomography (CT) scan. MRI and cerebral angiography revealed a completely thrombosed superior sagittal sinus, vein of Galen, straight sinus, and right transverse sinus. Transvaginal sonography indicated a missed abortion. The day after admission, the patient presented again with a progressive loss of consciousness and signs of herniation. The patient underwent emergency decompressive craniotomy, followed by intrauterine curettage. Two months later, she made an excellent recovery except for a slight visual field defect. CONCLUSIONS A rare case of severe SAH due to CVT is reported, with emphasis on the potential pitfalls of CVT diagnosis in early pregnancy.

Clinical features and surgical management of intracranial meningiomas in the elderly

Meningioma accounts for ~25% of all primary intracranial neoplasms and the incidence increases with age. Prvios population-based studies demonstrated that the annual incidence of intracranial meningiomas was 1.2-3.1/100,000 population. In particular, the incidence of this disease among the elderly is high. Recently, increased life expectancy and greater use of diagnostic radiological imaging led to an increased incidence in the diagnosis of intracranial meningiomas, both symptomatic and asymptomatic, in the elderly. Thus, neurosurgeons may be increasingly confronted with the management of intracranial meningiomas in the elderly. In practice, it is often difficult for physicians to determine whether traditional surgical resection is the optimal management strategy for intracranial meningiomas in the elderly. However, reported clinical studies about the outcome of surgical resection of intracranial meningiomas in the elderly are limited. Increased risk of mortality and morbidity associated with surgical treatment for intracranial meningiomas in the elderly compared with younger patients have been controversial. In the present study, the clinical features of intracranial meningiomas in 70 consecutive intracranial meningioma patients that underwent surgical treatment at the affiliated hospital of University of Occupational and Environmental Health between 2007 and 2013 were assessed. In addition, patient selection and surgical management of intracranial meningioma in elderly patients was discussed. Preoperative factors, including symptoms, tumor location, tumor size, Karnofsky Performance Scale (KPS) score and American Society of Anesthesiology (ASA) score, and postoperative factors, including pathological diagnosis, tumor proliferation index (Ki-67), resection rate (Simpson grade), length of hospital stay and discharge destination were retrospectively analyzed in patients aged ≥75 years (n=16; elderly group) and <75 years (n=54; younger group). Outcomes were assessed 6 months after surgery. Multivariate logistic regression revealed that tumor resection rate (Simpson grade III-V) was an important predictor of surgical complications (odds ratio, 5.662; 95% confidence interval, 1.323-24.236; P=0.0194). Perioperative morbidity was not correlated with age (>75 years), tumor location, tumor size, KPS score or ASA score. Thus, the present study indicated that age is not associated with surgical outcome in elderly meningioma patients. Regardless of patient age, the decision to perform surgical resection should be made on an individual basis wherein tumor characteristics and the general health of the patient are considered.

Pilocytic astrocytoma presenting with atypical features on magnetic resonance imaging

Pilocytic astrocytoma, which is classified as a grade I astrocytic tumor by the World Health Organization, is the most common type of glioma in children and young adults. Pilocytic astrocytoma generally appears as a well-circumscribed, contrast-enhancing lesion, frequently with cystic components on magnetic resonance imaging (MRI). However, it has been reported that the MRI appearance of pilocytic astrocytoma may be similar to that of high-grade gliomas in some cases. We here report on 6 cases of pilocytic astrocytoma with atypical MRI findings, including small cyst formation, heterogeneously enhancing tumor nodules, irregularly enhancing tumor nodules, and enhancing tumor nodules with internal hemorrhage. All tumors were successfully resected, and the histological diagnoses were pilocytic astrocytoma. When the tumor is located near a cerebral cistern or ventricle, the risk of leptomeningeal dissemination is increased. Furthermore, partial resection has also been associated with a higher risk of recurrence and leptomeningeal dissemination. To date, all but one patient are alive and recurrence-free. Because the preoperative diagnosis influences the decision on the extent of resection and because of the high risk of leptomeningeal dissemination associated with these tumors, careful and correct diagnosis by MRI is important.

Multiple Intracranial Nodules Associated with Rheumatoid Arthritis: Case Report

A 71-year-old woman with active rheumatoid arthritis (RA) was referred to our department because of multiple intracranial nodules. On admission, the RA disease activity was very high even after the treatment of methotrexate in other hospital. She underwent open biopsy to confirm a histopathological diagnosis of the intracranial lesions. Surgical specimen mainly consisted of necrosis surrounded by epithelioid cells. The masses were reduced spontaneously in size without additional treatment. Eleven month later, the lesions were relapsed. She underwent treatment with corticosteroid, and the lesions were remarkably regressed. The clinical course and histological examination were compatible with rheumatoid nodule (RN). Intracranial RN is extremely rare and its clinical course is not completely understood. In active RA patients, RNs should be considered, and histological diagnosis is inevitable for following suitable treatment.

Intrasyrinx hemorrhage associated with hemangioblastoma in epiconus

BACKGROUND CONTEXT Hemangioblastomas in the central nervous system are highly vascular lesions, but have low risk of hemorrhage. In spinal lesions, there are a few rare cases of intramedullary hemorrhages associated with hemangioblastoma, and their prognoses were very severe. PURPOSE This is the first case of an intrasyrinx hemorrhage associated with hemangioblastoma in epiconus. We report this rare case and discuss the clinical manifestations of intrasyrinx hemorrhage caused by hemangioblastoma in epiconus. STUDY DESIGN A case report. METHODS This case report presents a 45-year-old woman with intrasyrinx hemorrhage caused by hemangioblastoma in epiconus. The patient presented with a sudden onset of burning bilateral leg pain and rectal/bladder dysfunction, indicating conus medullaris syndrome. Initial magnetic resonance imaging revealed an intramedullary nodular lesion in the epiconus and holocord syringomyelia. However, follow-up magnetic resonance imaging showed intramedullary hemorrhage. RESULTS The patient underwent surgery, and an intrasyrinx hematoma was evacuated and the tumor was completely removed. Histological diagnosis was hemangioblastoma. Three months after surgery, the patient recovered from neurological deficits. CONCLUSIONS We present this rare case, and emphasize hemangioblastoma as the differential diagnosis in hemorrhagic spinal lesion.

Primary intraosseous meningioma in the calvaria: morphological feature changes on magnetic resonance images over several years

Primary intraosseous meningiomas (PIMs) are rare, and their pathogenesis remains unclear. We report the case of a sizable PIM in the calvaria that progressively enlarged over several years and presented temporal changes in the morphological features on magnetic resonance images. Along with discussing the case, we further emphasize the potential pitfalls of diagnosing a PIM in the calvaria.