Chronic intractable epilepsy as the only symptom of primary brain tumor

We identified 39 patients with chronic epilepsy (seizures > or = 2 years) proven to have primary brain tumors. These cases represent approximately 12% of the surgery cases for epilepsy in the same period. Mean age of seizure onset was 13.2 years: mean duration before operation was 10.5 years. Thirty-eight of 39 had normal neurologic examination. Twenty-six tumors were temporal, 7 were frontal, 4 were parietal, and 2 were occipital. Nine of 26 (34.6%) of the temporal group had contralateral interictal EEG spikes. Pathology was 15 ganglioglioma, 13 low-grade astroctoma, 4 oligodendroglioma, 2 low-grade mixed glioma, 1 pleomorphic xanthoastrocytoma, 2 dysembryoplastic neuroepithelial tumor, and 1 ependymoma. Postoperative seizure frequency (minimum follow-up 6 months) ranged from 15 to 16 seizure-free auras only in patients with temporal tumors and total gross tumor removal (mean follow-up 28 months) to 0 of 6 seizure-free in patients with extratemporal tumors who underwent subtotal resection or biopsy.

[A case of low grade glioma with Takayasu disease (aortitis syndrome)]

We experienced a rare case of Takayasu disease with low grade glioma. A 36 year-old female had an episode of right hemiconvulsion. On admission, she complained a slight memory disturbance, urination difficulty and motor weakness of right extremities. CT scan demonstrated a low density lesion in the left frontal lobe. MRI showed an inhomogeneous low intense mass on T 1 WI and a homogeneous high intense mass on T2 WI in the same site. No abnormal contrast enhancement was observed in both CT and MRI. Bilateral carotid angiograms demonstrated a filling defect of the left anterior cerebral artery. An aortogram revealed moderate stenosis of the left carotid artery and the brachiocephalic artery, and complete obstruction of the left subclavian artery. CT-guided stereotactic biopsy was performed using BRW stereotactic system and histological diagnosis was astrocytoma grade II. She was followed by interstitial irradiation of 50 Gy at tumor periphery for 10 days. Her neurological symptoms gradually improved, and she is doing well without neurological deficits at the time of this report. The CT scan obtained 13 months after the brachytherapy revealed a decrease in the extent of low density. Brachytherapy seems to be useful for patients with low grade glioma in the eloquent area of the brain.

Evaluation of the effect of treatment on movement disorders in astrocytomas of the basal ganglia and the thalamus

Twenty patients with movement disorders associated with astrocytomas (grade I-IV according to the WHO tumour classification) of the basal ganglia and the thalamus were evaluated for the effects of treatment. Five patients had more than one movement disorder when the histological diagnosis was verified by stereotactic biopsy. Twelve had tremors, eight hemidystonia, three hemichorea, and one hemichorea/ballismus, and myoclonus respectively. Ten patients died during the follow up period, and for the surviving patients follow up periods ranged from 6-21 years. The movement disorders changed over long periods of time related to therapeutic interventions. CSF shunt operations and percutaneous radiotherapy had no definite effect on the movement disorders. There was a moderate response to medical treatment in a few patients. Stereotactic aspiration of tumour cysts had a marked influence on the movement disorder in two patients, and functional stereotactic surgery abolished tumour induced tremor in one. Interstitial radiotherapy was performed in fifteen patients for treatment of the underlying neoplasm and resulted in different and variable alterations of the movement disorders. These differences may be explained by complex interactions involving structures affected primarily by the tumour, as well as by secondary functional lesions of adjacent structures.

Pontine gliomas causing locked-in syndrome

The terminal phase of pontine glioma is reportedly characterized by disturbance of consciousness. The authors retrospectively reviewed 8 children who died of pontine gliomas in their hospitals. The hospital records were analyzed specifically in regard to neurological status and terminal case. All children became mute and quadriplegic with cranial nerve palsies. The oldest child, 17 years in age, unquestionably showed the classical locked-in syndrome for the last 4 months. Six of the remaining 7 (average 5 years of age), while labeled as semicomatose, responded to calling by blinking and/or vertical eyeball movement. The authors consider that they were indeed awake in the locked-in state until very near death. This would raise a serious ethical problem of whether or not they should be intubated and kept ventilator-dependent at the time of respiratory failure, which often occurs.

Surgical treatment of partial epilepsy arising from the insular cortex. Report of two cases

Despite its documented connections with many limbic structures, the role of the insula in the etiology of partial seizures is poorly understood. Two patients are described in whom lesions of the insula were associated with intractable partial seizures. In the first patient, the seizures involved visceral sensory hallucinations followed by motor automatism. Seizures in the second patient began with somatic sensory hallucinations and then produced visceral motor effects. Both patients were found to have low-grade astrocytomas of the insula. In both instances, resection of the lesion and adjacent insular cortex resulted in a cure of the seizures. These cases are placed within the context of the existing literature on the subject.

Effect of cranial irradiation on seizure frequency in adults with low-grade astrocytoma and medically intractable epilepsy

We report the effect of cranial irradiation on seizure frequency in five adults with unresected (biopsy-proven) cerebral hemisphere low-grade astrocytoma and medically intractable epilepsy. Seizures were refractory to standard antiepileptic drugs for 7 months to 27 years. Treatment with 5,400 cGy to 6,120 cGy focal radiation reduced seizure frequency by more than 90% in three patients (one of whom became seizure-free) and by more than 75% (but less than 90%) in one patient. One patient had no response. Brain CT or MRI showed a partial tumor response to radiation in three of the four patients with reduced seizure frequency. In three patients, the reduced seizure frequency continued to the most recent follow-up of 1 to 1.5 years. In the patient who became seizure-free, seizures recurred at 8.2 years and were associated with tumor progression. Irradiation can reduce seizure frequency in some patients with unresected cerebral hemisphere low-grade astrocytoma and medically intractable epilepsy.

Psychotic behavior associated with cerebellar pathology

This report concerns a 27-year-old man in whom psychotic behavior emerged in association with a cerebellar tumor. This presentation supports previous clinical observations which postulate an intimate relationship between cerebellar pathology and the development of schizophrenia.

Coexistence of neoplasia and cortical dysplasia in patients presenting with seizures

Tumors and cortical dysplasia are associated with epilepsy, but few studies have examined the coexistence of neoplasia and dysplasia in these patients. We studied 13 patients (age 4-29 years) with recurrent seizures of 1 month to 21-year' duration (median 72 months). Ten patients were aged < 21 years. Imaging studies localized the lesion to the temporal lobe (10 patients), parietal lobe (2 patients), and frontal lobe (1 patient). Tumors included ganglioglioma (8 patients), dysembryoplastic neuroepithelial tumor (DNT) (3 patients), and low-grade astrocytoma (2 patients). Cortical dysplasia, including atypical aggregates of neurons (6 patients), multifocal loss of the cortical laminar architecture (7 patients), and neurons in the molecular layer of the cortex (3 patients) were observed near but separate from the tumor. Coexistence of certain tumors with cortical dysplasia, most frequently observed in the pediatric population, suggests a hamartomatous/dysplastic nature of the neoplasms.

Epilepsy and low grade gliomas in pediatric neurosurgery

A series of 33 children affected by low grade gliomas and epilepsy is reported. Seizures are often the only symptom of these patients; intracranial hypertension and focal neurological signs may be present too. All children were operated on; tumor removal was performed in 21 cases, tumor removal associated with corticectomy and/or lobectomy was performed in 12 patients. The treatment of epilepsy has been more effective in the first group of patients with only lesionectomy than in the second one, in which neoplasm removal was coupled with nervous system tissue asportation.

Temporal lobe hypometabolism on PET: predictor of seizure control after temporal lobectomy

To investigate the relationship of temporal lobe hypometabolism demonstrated on PET to surgical outcome and underlying pathology, we reviewed 30 consecutive epilepsy patients who underwent interictal PET studies with 18F fluorodeoxyglucose before temporal lobectomy. Two interpreters blindly reviewed the PET studies and graded them for degree, extent, and location of temporal lobe hypometabolism. Pathologic analysis of en bloc resected tissue showed mesial temporal sclerosis (n = 22), astrocytoma (n = 2), and no pathologic diagnosis (n = 6). Outcome (24 to 40 months' follow-up) was rated as seizure-free (21 patients), significantly improved (five patients), and not significantly improved (four patients). Both the degree and extent of the temporal lobe hypometabolism demonstrated on PET were strongly associated with subsequent seizure control. Pathologic findings, however, did not correlate with degree of PET hypometabolism or subsequent outcome. These data demonstrate that in patients judged to have temporal lobe epilepsy, the presence of temporal lobe hypometabolism is associated with a positive outcome after ipsilateral temporal lobectomy.

Facial myokymia and spastic paretic facial contracture as the result of anaplastic pontocerebellar glioma

The case of a 36-year-old man who sought treatment of right facial myokymia and spastic paretic facial contracture is reported. Computed tomography and magnetic resonance imaging revealed a tumor located in the right cerebellar peduncle and the right dorsal pons bulging into the fourth ventricle. After microsurgical partial resection of the mass, which was verified histologically as an anaplastic glioma, facial myokymia initially ceased. The vermicular rippling movements were less intense upon recurrence and could be controlled by low-dose dexamethasone in the further course, when magnetic resonance imaging showed an interstitial pontine edema after percutaneous radiation therapy. It is assumed that facial myokymia and spastic paretic facial contracture were generated by ectopic activity due to alterations in the microenvironment at the intrapontine portion of the axons of the seventh nerve caused by the compressive effect of the tumor and later by edema.

An uncommon case of brainstem tumor with selective involvement of the respiratory centers

We report a clinical case of a young man with a brainstem tumor with a stable alveolar hypoventilation syndrome as the only symptom of the disease. The ventilatory response to CO2 was almost absent and the ventilatory pattern during tidal breathing was very irregular. The diagnosis was made by magnetic resonance imaging of the brain and confirmed by a stereotactic brain biopsy specimen.

Intracranial EEG monitoring in Landau-Kleffner syndrome associated with left temporal lobe astrocytoma

A 3 1/2-year-old boy developed partial complex seizures with right-sided motor activity, occasionally secondarily generalized at age 18 months. Initial EEG showed left-sided focal epileptiform discharges. Seizures became refractory to antiepileptic drugs (AEDs). At age 3 years, there was severe language deterioration consistent with Landau-Kleffner syndrome (LKS). At that time, an EEG showed almost continual generalized spikes and polyspikes, worse during sleep. Video-EEG showed generalized tonic seizures associated with generalized EEG ictal activity. Magnetic resonance imaging (MRI) showed a cystic and solid lesion of the left hippocampal and parahippocampal gyri without surrounding edema. Subdural strip electrodes under the left temporal and overlying the left frontal lobes demonstrated interictal spikes simultaneously in all recording contacts. Ictal EEG activity occurred in the temporal electrodes 0.2-1 s before appearing in the frontal electrodes. After left temporal lobectomy with subtotal resection of a low-grade astrocytoma, he had an immediate marked decrease in seizures. In 1 month he was seizure-free, and in 6 months had no further seizures and markedly improved language. These findings provide further evidence that left temporal structural epileptogenic lesions may contribute significantly to the pathophysiology of LKS.

[Malignant tumors of the cerebral hemisphere in children. A series of 64 cases]

BACKGROUND

Cerebral hemisphere tumors in children represent about 15% of all tumors of central nervous system. 30 to 40% of them are malignant and have a poor prognosis.

PATIENTS AND METHODS

The files of 64 children (30 boys and 34 girls, less than 15 years old) treated between 1970 and 1989 for malignant cerebral hemisphere tumor were analysed. There were 27 astrocytomas, 20 ependymomas, 7 oligodendroblastomas, 6 sarcomas, 2 neuroblastomas, 1 medulloepithelioma and 1 teratoma. The tumor was located in the frontal area in 18 patients; it was temporal in 9, parietal in 8 and occipital in 2 patients. The tumor infiltrated 2 or several lobes in 27 children. The tumor was excised in 58 patients (completely in 36). Radiotherapy was given in 42 children; 18 of them also received chemotherapy.

RESULTS

The time between the first clinical manifestation and diagnosis was longer than 6 months in 20% of cases. Symptoms of increased intracranial pressure were present at onset of the disease in 56% of patients and at admission in 73%. Convulsions revealed the tumor in only 30% of cases. Nine children died during the first post-operative month. The actuarial survival rate was 39 +/- 13% at 5 years and 29 +/- 13% at 10 years. This rate was better for ependymomas (48 +/- 23% at 5 years and 41 +/- 23% at 10 years) than for astrocytomas (25 +/- 18% and 13 +/- 16%). Three of the 27 astrocytomas developed in children who had been treated 6 to 7 years earlier for acute lymphoblastic leukemia. One infant developed acute lymphoblastic leukemia 2 years after surgery and chemotherapy for astrocytoma and one patient, treated at 5 months of age for retinoblastoma, developed an astrocytoma 13 years later.

CONCLUSIONS

Increased intracranial pressure is more frequently the first symptom than are convulsions in malignant cerebral hemisphere tumors. The long interval between the first manifestations and diagnosis suggests degeneration of benign tumors in 20% of cases. The development of a second malignant neoplasm is not exceptional in children. The better prognosis for ependymomas than for astrocytomas indicates that cerebral ependymomas should be excised and irradiated regardless of their grade.

Fahr's disease associated with astrocytic proliferation and astrocytoma

This report documents the neuropathological findings of astrocytic proliferation and astrocytoma in a patient with Fahr's disease. At autopsy, there was extensive bilateral symmetrical calcification involving basal ganglia, sulcal depth of the cerebral cortex, and dentate nuclei of the cerebellum. A large low-grade astrocytoma was identified in the left parietal lobe. Astrocytic proliferation was also noted in the areas of early calcification and at the margins of large calcareous deposits, away from the tumor.

Peripapillary hemorrhage

On routine examination, a 61-year-old man was found to have a deep peripapillary hemorrhage surrounding his left optic nerve head. Further examination revealed a left sixth nerve paresis, a subtle right homonymous quadrantanopia, and jerky pursuit to the left. The diagnostic work-up was delayed by the patient because of business commitments. He returned confused and obtunded. Neuro-imaging showed a large frontal mass, which turned out to be an anaplastic astrocytoma. Diagnosis of the lesion had been obscured by three false localizing signs. Discussion deals with the definition of Terson's syndrome and the occurrence of peripapillary hemorrhages. Other causes of peripapillary hemorrhages are illustrated.

[Indications for shunting in children with tumours of posterior fossa]

Between 1980-1987 in the Neurosurgery Department we treated 113 patients with cerebellar astrocytoma, 52 children with medulloblastoma and 30 patients with ependymoma. Before operation shunting was used in 10 patients and after operation in 15 patients, generally shunting was necessary in 22% patients with cerebellar astrocytoma. In cases of medulloblastoma before operation shunting was used in 6 children and after in 15 patients, generally shunting was necessary in 21 (40%) patients. In cases of ependymomas shunting was used in 6 patients before operation and 5 cases after operation, generally shunting was necessary in 11 (36%) patients.

Cytomorphology of subependymal giant cell astrocytoma. A case report

Cytologic smears made from minute fragments of tissue removed during neurosurgical procedures are a useful alternative to frozen sections for rapid diagnosis. We describe the cytomorphologic features of a rare brain neoplasm, subependymal giant cell astrocytoma (SEGA). On cytologic grounds this neoplasm is difficult to separate from gemistocytic astrocytoma. The clinical presentations of the two neoplasms, however, are quite distinct, with SEGA an intraventricular neoplasm mostly seen in young adults with tuberous sclerosis, whereas gemistocytic astrocytoma occurs in the cerebral hemisphere of older adults.

[Unusual symptoms in brain tumors in childhood]

Headache, nausea, ataxia and diplopia are leading symptoms of brain tumors in children. We report of 3 children with unusual symptoms and findings. Patient 1 complained of occasional headaches. Clinical examination showed neurological deficits and uveitis. Lumbar puncture revealed a pleocytosis and the oligoclonal banding study was positive. Cranial MRI demonstrated an enlarged pons. Under treatment with cortisone a clinical improvement was seen, but no change of the abnormalities in MRI. Several weeks later a biopsy was performed, which verified an astrozytoma. The second child developed a torticollis, following an accident, and later a refractory constipation was noted. A clinical evaluation was within normal limits. Several weeks later the patient complained of bladder disturbances. Patient 3 had a lateralized tic disorder without any neurologic deficits. CT showed an infratentorial tumor above the 4th ventricle. The tic disorder vanished only after the tumor was completely resected in the second operation. The reported cases demonstrate the fact that in an individual patient a brain tumor can cause unusual symptoms and findings which do not make the diagnosis obvious.

Retinal phakomata associated with cerebral astrocytoma. An incomplete form of Bourneville-Pringle disease?

We report on a 21-year-old, male patient with unilateral retinal phakomata associated with histologically proved cerebral astrocytoma. The patient had presented with bilateral loss of vision and a left-sided hemiparesis. Ophthalmoscopy showed bilateral optic nerve atrophy, multiple punched-out areas of depigmentation and astrocytic hamartomata in the right eye. Despite the absence of classic signs of Bourneville-Pringle disease such as adenoma sebaceum, epilepsy and mental retardation, a strongly presumptive diagnosis of tuberous sclerosis could be made. This unusual case demonstrates that retinal phakomata can be the solely visible manifestation of Bourneville-Pringle disease.

Seizures as the presenting symptom of brain tumors in children

Epileptic seizures caused by tumors in children have been regarded as uncommon. We have studied 99 consecutive cases of brain tumors during the period 1980-1987. In 20 cases the tumor was localized to one of the hemipheres and 10 of the cases had seizures, in 9 as the only initial symptom. Details of the clinical picture and the course are presented. Delay from initial symptoms to correct diagnosis was considerable in 4 cases--more than six years. The factors mainly responsible for this delay were: initial EEG normal or soon normalized, misinterpretation of computerized tomography and seizure freedom with or without antiepileptic drug treatment. We conclude that regional slowing in the EEG is a common, although not obligatory, finding. Computerized tomography should be performed in all children with newly presented epilepsy of partial type, except for those with benign partial epilepsy with centro-temporal spikes.

Giant cell astrocytoma of the retina in tuberous sclerosis

The clinical and pathologic features of an unusual retinal glioma that was the only clinically overt manifestation of tuberous sclerosis in a 27-year-old woman are reported. The tumor was composed predominantly of large pleomorphic cells with glassy eosinophilic cytoplasm. Immunologic staining yielded positive results for gamma enolase, but not for glial fibrillary acid protein. The histologic and immunopathologic features of this tumor were essentially identical to the subependymal giant cell astrocytoma found in tuberous sclerosis. This case illustrates the large overlap in dysplastic astrocytic and neuronal differentiation that can occur in the retina of patients with tuberous sclerosis. Giant cell astrocytoma of the retina can be mistaken for a malignant tumor histologically by persons unfamiliar with this entity.

Knee-chest position as a sign of increased intracranial pressure in children

In three young children a newly acquired clinical sign--the knee-chest position--was associated with increased intracranial pressure. This sign may serve as an additional marker to suggest increased intracranial pressure in young children.

[Infantile spasms associated with a brain tumor]

BACKGROUND

Infantile spasms are exceptionally associated with a focal cerebral lesion such as a brain tumor.

CASE REPORT

A 15 month-old girl was treated with hydrocortisone and valproic acid for infantile spasms that had appeared a few days earlier. Her psychomotor development was considered normal and the CT scan was normal. Clinical symptoms disappeared within 10 days and the EEG became normal except for a few epileptiform discharges in the frontal areas. The girl developed partial seizures at the age of 5 years. Imaging techniques showed a brain tumor in the right frontal lobe. Surgical excision was followed by radiation therapy. Analysis of the tumor showed an astrocytoma. The girl is normal 18 months after intervention.

CONCLUSION

It is difficult to determine a relationship between the infantile spasms and the brain tumor in this case. The moderately asymmetrical pattern of the EEG after infantile spasms, the fact that these spasms appeared relatively late and the persistence of discharges, lead to repeated specialized investigations.