Inability to sneeze as a manifestation of medullary neoplasm

A young man with headache was unable to sneeze despite a strong sensory urge to do so. Magnetic resonance imaging revealed a cystic neoplasm in the medulla oblongata that presumably interrupted the efferent arc of the sneezing reflex.

"Angioglioma" and the arteriovenous malformation-glioma association

The term "angioglioma" denotes a highly vascular glioma, most of which are low-grade lesions associated with a favorable prognosis. The authors encountered an example of this pathology, a cystic oligodendroglioma associated with prominent vasculature which both clinically and histologically mimicked an occult arteriovenous malformation (AVM). This case and reports of the association of AVM and glioma prompted a histological review of 1034 surgically resected AVM's, both angiographically occult and visible, among which no oligodendroglial or astrocytic forms of "angioglioma" were found. Eight cases were observed, however, wherein oligodendroglial cells were increased in number within or about the malformation. Two basic histological patterns of oligodendroglial cell excess were seen; one appeared to be malformative in nature with abnormal disposition of oligodendroglial cells being an integral part of the AVM, whereas in the other an apparent increase in cellularity seemed the result of chronic ischemia with condensation of white matter. It appeared that the areas of increased oligodendrocyte content seen in association with AVM are non-neoplastic lesions that exhibit two rather distinct histological patterns of differing origin. In an effort to determine the frequency of "angioglioma," the authors examined Tissue Registry data for several glioma groups in which highly vascular examples are prone to occur. Tumors selected for study included 104 cerebellar-type (pilocytic) astrocytomas, 82 oligodendrogliomas, and 51 supratentorial pilocytic astrocytomas. Histological hypervascularity mimicking a vascular malformation (that is, an "angioglioma") was encountered in 5%, 4%, and 12% of the cases, respectively. Based upon clinical, radiological, and pathological reviews of these cases, as well as a careful review of the literature, it was concluded that 1) "angiogliomas" are neither rare nor represent a distinct clinicopathological entity; 2) in histological but not necessarily angiographic surgical terms, they represent simply highly vascular gliomas, usually of low grade; and 3) the clinicopathological and angiographic features as well as the prognosis of such lesions do not differ from those of similar gliomas without angioma-like vasculature. Finally, "angiogliomas" must not be confused with gliomas of high-grade malignancy which, due to neovascularity, may be highly vascular at angiography and at surgery.

Low-grade astrocytoma of the tectal region as an unusual cause of knee pain: case report

A 12-year-old boy was investigated for knee pain and contractures, and was found to have an intraspinal tumor of a lumbar nerve root and a tumor in the tectal region, both low-grade astrocytomas. We postulated that the tectal region astrocytoma metastasized to the lumbar intraspinal region. After surgery, the child underwent focal irradiation to the posterior fossa supplemented by craniospinal irradiation and a boost dose to the region of the lumbar spinal tumor. A low-grade astrocytoma rarely presents as spinal metastasis. This case may represent the first of a primary tectal low-grade astrocytoma manifesting as a symptomatic spinal mass.

Aphasia in polyglots: report of two cases and analysis of the literature

Two cases of aphasia in polyglot patients who experienced different symptoms in each of the languages they knew are reported. The authors discuss the problem and analyze the available literature in an attempt to formulate a pathogenetic hypothesis of the different involvement of the known idioms sometimes observed in aphasic polyglots. In particular, when time has elapsed between the learning of the mother tongue and other languages, and all the known languages are, consequently, functionally independent, it is possible that the two or more known idioms have distinct anatomical representations, probably localized separately in the two hemispheres. This could explain why, in some polyglots, aphasia affects one of the known languages preferentially. In subjects in whom the different known idioms were learned during early childhood, the anatomical representation of the languages is similar, which explains why, in this kind of polyglot, all the known languages can be equally affected by cerebral damage that causes aphasia.

Fourth nerve paresis and ipsilateral relative afferent pupillary defect without visual sensory disturbance. A sign of contralateral dorsal midbrain disease

We describe a patient with a left trochlear nerve paresis and a left relative afferent pupillary defect despite normal visual acuity, color vision, visual fields, and fundus examination. Magnetic resonance imaging revealed a lesion in the right dorsal midbrain extending from the brachium of the superior colliculus to the inferior colliculus. The anatomy and physiology of the pupillary light reflex are reviewed, as are possible mechanisms for the laterality of afferent pupillary defects with midbrain lesions. The presence of a trochlear nerve paresis with an ipsilateral relative afferent pupillary defect and an otherwise normal ophthalmic exam indicates a lesion in the contralateral dorsocaudal midbrain.

Quadrantic visual field defects. A hallmark of lesions in extrastriate (V2/V3) cortex

We report 2 patients with homonymous quadrantic visual field defects. The first patient experienced scintillations in the left lower quadrant, leading to the discovery of an astrocytoma in the cuneus of the right occipital lobe. Postoperatively she had a left lower quadrantanopia that precisely respected the horizontal meridian. The second patient presented with a left lower quadrantanopia, sparing the central 10 degrees of vision that also respected the horizontal meridian. An astrocytoma was resected from the right upper peristriate cortex. We must explain how a lesion in extrastriate cortex produced a homonymous field defect with a sharp horizontal edge in these 2 patients. Areas V2 and V3 are each divided along the horizontal meridian into separate halves flanking striate cortex. Consequently, the upper and lower quadrants in extrastriate cortex are physically isolated on opposite sides of striate cortex. We propose that a lesion involving V2/V3 may be sufficient to create a visual field defect. Although the lesion may have irregular margins, if it crosses the representation of the horizontal meridian in extrastriate cortex, it will produce a quadrantic visual field defect with a sharp horizontal border because of the split layout of the upper and lower quadrants in V2/V3.

[A case of adult pilocytic astrocytoma in the right temporal lobe]

A case of adult pilocytic astrocytoma in the right temporal lobe is reported here. The patient was a twenty-four year old man, who came to the neurological division of our hospital on October 6, 1987 because of repeated consciousness-loss attacks accompanied with uncinate fit. He had no neurological deficits. However, an EEG revealed spike-and-wave complexes in the right temporal region, and a CT scan showed a small cystic lesion in the right temporal lobe. A diagnosis of psychomotor seizure was made, and the administration of anticonvulsants was started. The incidence of attack then decreased, but after approximately two years of drug therapy the attacks increased again. A CT scan was again performed, and revealed that the lesion in the right temporal lobe was enlarging. Also a noticeable enhanced lesion, identified as a mural nodule was found in the post-contrast enhancement study. A brain tumor was then suspected, and he was admitted to the neurosurgical division on October 11, 1989. He had no neurological deficits on admission. An MRI showed a low intensity lesion in the T1 weighted image, and a high intensity lesion in the T2 weighted image. A cystic lesion with a marked enhanced mural nodule was also found in the base of the right temporal lobe, according to the Gd enhancement study. Perifocal edema was not recognized. Cerebral angiography showed no positive findings. Positron emission tomography (PET), using H2(15)O, revealed low perfusion at or around the lesion, and PET using [11C]-methionine revealed an accumulation of methionine at the lesion. A diagnosis of low-grade glioma was made, and a right temporal craniotomy, for the purpose of totally removing the tumor was performed on October 26, 1989.(ABSTRACT TRUNCATED AT 250 WORDS)

Ipsilateral hemi-parkinsonism secondary to an astrocytoma

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Astrocytoma and associated arteriovenous malformation

A case is reported of a cerebral arteriovenous malformation occurring in continuity with an astrocytoma. Possible etiologies of this unusual association are discussed.

Chemotherapeutic treatment of extensive optic pathway tumors in infants

Two infants, ages 14 and 4 months, with extensive optic pathway tumors were treated with intensive chemotherapy called MADDOC: nitrogen mustard, doxorubicin, cis-platinum, dacarbazine, vincristine, and cyclophosphamide. The first child had hydrocephalus with an enhancing mass at the hypothalamus which followed the optic radiation to include the lateral geniculate body and medial temporal lobe. A v-p shunt was placed, and biopsy revealed a Grade II astrocytoma. One month later, the child developed malignant ascites. Intensive induction chemotherapy was then begun with cis-platinum 100 mg/m2 and cyclophosphamide 3 g/m2 for two initial cycles. The ascites resolved within one week, and chemotherapy was continued for 10 courses of the 6-drug MADDOC regimen. CT scans showed a gradual shrinkage of the tumor mass by approximately 70%. The enhancing areas continued to decrease in size through 20 months after completing MADDOC. The child has not received radiation and is well 4 years 7 months post diagnosis. The second infant had massive enlargement of the right optic nerve with an enhancing chiasmatic mass extending into the suprasellar space, hypothalamus, and brain stem. This infant was not biopsied; she also received induction MADDOC chemotherapy for 12 cycles. CT scans showed a definite decrease in the chiasmatic mass by the fifth cycle, with continued reduction by approximately 40% after 10 months. Twenty-three months from diagnosis there was asymptomatic evidence of tumor growth. The child is being treated with carboplatinum and remains ophthalmologically and radiographically stable 43 months from diagnosis.

General protease and collagenase (IV) activity in C6 astrocytoma cells, C6 spheroids and implanted C6 spheroids

Tumor growth is dependent on the ability of neoplastic cells to induce angiogenesis. Remodelling of blood vessels requires reconstruction of the collagen (type IV) and non-fibrous protein components of basement membrane. This study assessed the general protease and collagenase (IV) activities of C6 astrocytoma cells in monolayer and spheroid culture and C6 astrocytoma spheroids growing in vivo. Extracellular release of non-specific proteases and collagenase IV was maximal during early exponential cell growth. Increased spheroid size resulted in enhanced extracellular activity of both enzyme groups assessed. The size of the implanted spheroid influenced the activity measured in vivo. General proteolytic activity was significantly greater in tumor tissue at all spheroid sizes while only the implantation of 750 microns spheroids resulted in significantly increased collagenase type IV activity. The growth of C6 astrocytoma cells in monolayer and spheroid culture in vitro and in vivo is associated with distinct alterations in intracellular and extracellular activity of the proteolytic enzymes assessed. Increased extracellular release of these enzymes may play important roles in tumor-associated angiogenesis, tumor invasiveness, tumor induced hemorrhage and tumor-associated edema.

Management of chiasmal and hypothalamic gliomas of infancy and childhood with chemotherapy

Between March, 1983, and February, 1989, 19 infants or children with chiasmal/hypothalamic gliomas were treated with chemotherapy after either surgical or radiological diagnosis. The patients ranged in age from 15 weeks to 15.6 years (median 3.2 years) at the start of therapy. Twelve patients were treated immediately after diagnosis because of progressive symptoms, and seven received chemotherapy after either radiographic progression or clinical deterioration, including progressive visual loss or intracranial hypertension. Based on biopsy results, seven of these tumors were classified as juvenile pilocytic astrocytomas, two as astrocytomas, two as highly anaplastic astrocytomas, and one as a subependymal giant-cell astrocytoma. There was associated neurofibromatosis in four patients. The two initial patients were treated with either actinomycin D and vincristine or 5-fluorouracil, hydroxyurea, and 6-thioguanine. The remaining patients received nitrosourea-based therapy; 15 evaluable patients were treated with a five-drug regimen that included 6-thioguanine, procarbazine, dibromodulcitol, 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU), and vincristine and one received 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) and 5-fluorouracil. Fifteen of the 18 evaluable patients initially managed with chemotherapy either responded to therapy or their condition stabilized. Median time to tumor progression has not been reached at a median follow-up period of 79 weeks (range 6.6 to 303 weeks), and no tumor-related death has occurred with a median follow-up period of 79 weeks (range 18 to 322 weeks) from the initiation of therapy. The four patients who failed therapy or whose disease progressed after chemotherapy were treated satisfactorily with radiation therapy. Initial improvement or stabilization of visual function was obtained in 16 patients. Endocrine function remained stable in all patients during treatment, although three patients required pharmacological treatment for endocrinopathy that was present at diagnosis. These preliminary results suggest that nitrosourea-based cytotoxic regimens are useful for the initial treatment of children with chiasmal/hypothalamic gliomas, and allow potentially harmful radiation therapy to be deferred until progression of disease.

Fatal hemorrhage in a cerebral pilocytic astrocytoma-adult type

A 69-year-old female presented with a 6-week history of left-sided weakness and a large cerebral mass on computed tomographic scan and magnetic resonance imaging. The patient subsequently had an acute intracerebral hemorrhage with uncal and tonsillar herniation. Postmortem examination revealed an acute cerebral hemorrhage from a pilocytic astrocytoma-adult type. These cerebral neoplasms are rarely associated with hemorrhage.

Sturge-Weber-Dimitri disease? In association with an astrocytoma

A patient with parieto-occipital cortical calcification characteristic of Sturge-Weber-Dimitri disease (SWDD) is of interest in that she lacked the facial portwine lesion and almost all other features of the disease. She subsequently developed an astrocytoma in the underlying white matter. Although the absence of the facial lesion in SWDD has previously been described, there has been no report of a glioma developing in such a patient. The association of SWDD and astrocytoma in this case most likely has been fortuitous.

Unilateral hydrocephalus in adults

The authors report 14 cases of unilateral hydrocephalus in adults. Headache was the most common presenting symptom. Unilateral hydrocephalus was documented in each patient with computed tomography scans; magnetic resonance imaging was also used in seven patients in the latter part of the series. Unilateral hydrocephalus was caused by tumor (seven patients), venous angioma (one patient), ependymal cyst (one patient), postinflammatory gliosis (one patient), and was idiopathic in four patients. The primary surgical treatment was craniotomy with fenestration of the septum pellucidum, which relieved symptoms in eight of nine patients for whom long-term follow-up data were available.

Photocoagulation for serous detachment of the macula secondary to retinal astrocytoma

Retinal astrocytomas are rare, usually asymptomatic, hamartomatous retinal tumors that are most commonly seen in patients with tuberous sclerosis. Serous detachment of the macula is a rare complication of retinal astrocytomas. The first successful treatment with laser photocoagulation of two eyes (two patients) with decreased vision due to a serous detachment of the macula from a retinal astrocytoma is described. Laser photocoagulation should be considered for retinal astrocytomas causing persistent or increasing exudation that is threatening the macula or causing visual loss.

Aqueductal (pencil) glioma presenting as neurogenic pulmonary edema: a case report

A case of neurogenic pulmonary edema due to hydrocephalus, without initial neurological deficit, is described. Computed tomography demonstrated a ring enhancing lesion in the tectum of the mesencephalon obstructing the aqueduct of Sylvius. The lesion, on autopsy, was a rare mesencephalic glioma described in the literature as a "pencil glioma" of the aqueduct.

Central neurogenic hyperventilation: pharmacologic intervention with morphine sulfate and correlative analysis of respiratory, sleep, and ocular motor dysfunction

Central neurogenic hyperventilation (CNH), for which there is no effective therapy, can eventually result in respiratory fatigue and death. This report describes a patient with CNH due to a brainstem anaplastic astrocytoma who also exhibited disturbances of sleep and ocular motor function. The CNH responded clinically to morphine sulfate and methadone. Analysis of ventilatory response to CO2 before and after morphine demonstrated a depression of ventilatory response (49 to 53% of baseline) and occlusion pressure response (35 to 50% of baseline) to CO2, with a requirement for high doses of naloxone (10 mg IV) to reverse the effect. Polysomnography revealed sustained hyperventilation, elevated O2 saturation, and low end-tidal CO2 throughout all stages of non-rapid eye movement (NREM) sleep, and absence of rapid eye movement (REM) sleep. Ocular motor evaluation disclosed absence of horizontal and reflexive saccades with compensatory head thrusts. Correlation of the clinical and physiologic data with the MRI abnormalities suggested that the lesion responsible for CNH in this patient might reside in the medial tegmental parapontine reticular formation. Since recurrent episodes of hyperventilation responded in a sustained fashion to IV and oral opiates, this treatment may warrant consideration in other patients with CNH.

Focal nodular hyperplasia of the liver

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