Characterization of a severe parenchymal phenotype of experimental autoimmune encephalomyelitis in (C57BL6xB10.PL)F1 mice

We here describe a novel CD4 T cell adoptive transfer model of severe experimental autoimmune encephalomyelitis in (C57BL6xB10.PL)F1 mice. This FI cross developed severe disease characterized by extensive parenchymal spinal cord and brain periventricular white matter infiltrates. In contrast, B10.PL mice developed mild disease characterized by meningeal predominant infiltrates. As determined by cDNA microarray and quantitative real time PCR expression analysis, histologic and flow cytometry analysis of inflammatory infiltrates, and attenuation of disease in class I-deficient and CD8-depleted F1 mice; this severe disease phenotype appears to be regulated by CNS infiltration of CD8 T lymphocytes early in the disease course.

A case of sarcoidosis presenting as a non-specific intramedullary lesion

Neurosarcoidosis occurs in 5-15% of sarcoidosis cases. Approximately 50% of patients with neurosarcoidosis present with a neurological disease at the time sarcoidosis is first diagnosed. Spinal sarcoidosis is rare. We report the case of a 61-year-old man with a highly aspecific intramedullary lesion as the first manifestation of sarcoidosis. One year after the onset of neurological symptoms, the high levels of angiotensin-converting enzyme and the results of a total body gallium scan and bronchoalveolar lavage supported the diagnosis of sarcoidosis. Isolated single reports indicate that spinal neurosarcoidosis may be the initial manifestation of sarcoidosis. In our case, magnetic resonance imaging of the dorsal spine showed a largely aspecific lesion. Neurosarcoidosis should be considered in the differential diagnosis of intramedullary cord lesion with leptomeningeal enhancement; a systematic search for evidence of sarcoidosis should be mandatory in all cases for a correct diagnosis and early treatment.

Intrathecal enzyme replacement therapy: successful treatment of brain disease via the cerebrospinal fluid

Treatment of brain disease with recombinant proteins is difficult due to the blood-brain barrier. As an alternative to direct injections into the brain, we studied whether application of high concentrations of therapeutic enzymes via intrathecal (IT) injections could successfully drive uptake across the ependyma to treat brain disease. We studied IT enzyme replacement therapy with recombinant human iduronidase (rhIDU) in canine mucopolysaccharidosis I (MPS I, Hurler syndrome), a lysosomal storage disorder with brain and meningeal involvement. Monthly or quarterly IT treatment regimens with rhIDU achieved supranormal iduronidase enzyme levels in the brain, spinal cord, and spinal meninges. All regimens normalized total brain glycosaminoglycan (GAG) storage and reduced spinal meningeal GAG storage by 58-70%. The improvement in GAG storage levels persisted three months after the final IT dose. The successful use of enzyme therapy via the CSF represents a potentially useful approach for lysosomal storage disorders.

Feasibility and limitation of constructive interference in steady-state (CISS) MR imaging in neonates with lumbosacral myeloschisis

INTRODUCTION

The aim of this study was to evaluate three-dimensional Fourier transformation-constructive interference in steady-state (CISS) imaging as a preoperative anatomical evaluation of the relationship between the placode, spinal nerve roots, CSF space, and the myelomeningocele sac in neonates with lumbosacral myeloschisis.

METHODS

Five consecutive patients with lumbosacral myeloschisis were included in this study. Magnetic resonance (MR) CISS, conventional T1-weighted (T1-W) and T2-weighted (T2-W) images were acquired on the day of birth to compare the anatomical findings with each sequence. We also performed curvilinear reconstruction of the CISS images, which can be reconstructed along the curved spinal cord and neural placode.

RESULTS

Neural placodes were demonstrated in two patients on T1-W images and in three patients on T2-W images. T2-W images revealed a small number of nerve roots in two patients, while no nerve roots were demonstrated on T1-W images. In contrast, CISS images clearly demonstrated neural placodes and spinal nerve roots in four patients. These findings were in accordance with intraoperative findings. Curvilinear CISS images demonstrated the neuroanatomy around the myeloschisis in one slice. The resulting images were degraded by a band artifact that obstructed fine anatomical analysis of the nerve roots in the ventral CSF space. The placode and nerve roots could not be visualized in one patient in whom the CSF space was narrow due to the collapse of the myelomeningocele sac.

CONCLUSION

MR CISS imaging is superior to T1-W and T2-W imaging for demonstrating the neural placode and nerve roots, although problems remain in terms of artifacts.

[Sinonasal and cerebral imaging findings in Wegener's granulomatosis]

Sinonasal CT must be studied with both soft tissue and bone algorithms. Sinonasal findings in Wegener's granulomatosis are mucosal thickening, subtotal opacification, air-fluid level, bony destruction (mainly of the nasal septum), and sclerosing osteitis. Orbital MRI helps to define the extent of the disease. Contiguous granulomatous infiltration of the orbit appears dark (hypointense signals) on both T2-weighted-and T1-weighted images, but is enhanced after gadolinium administration. Cerebral MRI findings include diffuse linear dural thickening, enhanced by injection, and local dural thickening contiguous with orbital, nasal and paranasal disease. The remote granulomatous lesions in brain parenchyma are the least common form of central nervous system lesion. The pituitary gland and infundibulum can also be involved in Wegener's granulomatosis. These imaging findings of Wegener's granulomatosis are nonspecific. They should be combined with clinical examination and c-ANCA tests to confirm the diagnosis.

[Meningoencephalomyelitis as the initial symptom of a brain tumour mimicking encephalitis due to herpes simplex virus: a case report]

INTRODUCTION

Meningoencephalomyelitis can be due to a number of treatable causes. A tumoural aetiology is rare and they are generally malignant tumours with an ominous prognosis. We report a case of meningoencephalomyelitis that initially presented as encephalitis due to herpes simplex virus (HSV) and which was finally seen to be an anaplastic oligoastrocytoma.

CASE REPORT

We describe the case of a 68-year-old male with a history of just strong low back pain during the previous month, who was admitted to hospital because of progressive clinical symptoms involving cognitive impairment and myoclonias. The polymerase chain reaction for the cerebrospinal fluid was positive for HSV and magnetic resonance imaging revealed diffuse compromise of right temporal lobe, the spinal cord and the cervical meninges. The progressive deterioration of the patient despite treatment with acyclovir, anti-tuberculosis agents and with corticoids made it necessary to perform a biopsy study of the cervical meninges, the results of which suggested non-specific macromonocytic meningoencephalitis. The patient's condition continued to deteriorate until he died. The post-mortem examination revealed a grade III oligoastrocytoma in both temporal lobes, which had extended into the adjacent subarachnoid space and the cerebral and cervical leptomeninges.

CONCLUSIONS

Non-specific symptoms of low back pain can conceal a brain tumour. Attention is drawn to how infrequently it manifests clinically and in imaging studies as meningoencephalomyelitis due to direct tumoural invasion. This should be considered as a possibility when faced with a slowly progressing clinical picture that, despite the initial suspicion of encephalitis due to HSV, does not respond to the usual treatment.

Patterns of Contrast Enhancement in the Brain and Meninges

Contrast material enhancement for cross-sectional imaging has been used since the mid 1970s for computed tomography and the mid 1980s for magnetic resonance imaging. Knowledge of the patterns and mechanisms of contrast enhancement facilitate radiologic differential diagnosis. Brain and spinal cord enhancement is related to both intravascular and extravascular contrast material. Extraaxial enhancing lesions include primary neoplasms (meningioma), granulomatous disease (sarcoid), and metastases (which often manifest as mass lesions). Linear pachymeningeal (dura-arachnoid) enhancement occurs after surgery and with spontaneous intracranial hypotension. Leptomeningeal (pia-arachnoid) enhancement is present in meningitis and meningoencephalitis. Superficial gyral enhancement is seen after reperfusion in cerebral ischemia, during the healing phase of cerebral infarction, and with encephalitis. Nodular subcortical lesions are typical for hematogenous dissemination and may be neoplastic (metastases) or infectious (septic emboli). Deeper lesions may form rings or affect the ventricular margins. Ring enhancement that is smooth and thin is typical of an organizing abscess, whereas thick irregular rings suggest a necrotic neoplasm. Some low-grade neoplasms are "fluid-secreting," and they may form heterogeneously enhancing lesions with an incomplete ring sign as well as the classic "cyst-with-nodule" morphology. Demyelinating lesions, including both classic multiple sclerosis and tumefactive demyelination, may also create an open ring or incomplete ring sign. Thick and irregular periventricular enhancement is typical for primary central nervous system lymphoma. Thin enhancement of the ventricular margin occurs with infectious ependymitis. Understanding the classic patterns of lesion enhancement--and the radiologic-pathologic mechanisms that produce them--can improve image assessment and differential diagnosis.

[Cerebral amyloid angiopathy]

Cerebral amyloid angiopathy is characterised by the presence of protein deposits in the wall of the cerebral vessels. Sporadic forms with deposits of Abeta peptide are the most frequent. The diagnosis of cerebral amyloid angiopathy is only certain when amyloid deposits can be visualized on cerebral tissue by biopsy, that appears in most circumstances to carry too many risks for the expected benefits, or post mortem. The clinical diagnostic criteria are advanced age, morphology of the intracerebral hematomas, occurrence of several episodes of intracerebral haemorrhages and presence of dementia. Recent progresses in the field of MRI make the diagnosis of cerebral amyloid angiopathy easier and more accurate. MRI should be more frequently performed in aged patients.

Le méningiome chordoïde. À propos de deux cas

Chordoid meningioma is an uncommon histopathological variant of meningioma frequently confused with chordoma. Recurrence is not uncommon. The aim of our study is to present the clinical and pathological characteristics of this entity and a review of the literature. We report two cases of chordoid meningioma occurring in two women aged 47 and 63 years. Both women presented neurological signs without systemic disease. Radiological findings were temporoparietal and temporofrontal lesions with intense enhancement after contrast injection. Complete surgical resection was performed. Histopathologic findings were consistent with chordoid meningioma.

The relative contributions of brain, cerebrospinal fluid-filled structures and non-neural tissue volumes to occipital-frontal head circumference in subjects with autism

An increased prevalence of macrocephaly defined by occipital-frontal circumference (OFC) is a consistent finding in autism. Several possible mechanisms have been proposed, the most compelling being early brain overgrowth. However, the proportion of non-neural tissues (NNT) that contribute to OFC has not been reported. Using quantitative magnetic resonance imaging (MRI) methods we analyzed the relationships between OFC and total brain (TBV), ventricular, surface cerebrospinal fluid (CSF)/meningeal, and NNT volumes in subjects with autism. Sixty male subjects (34 autistic; 26 controls) seven years of age and older were used in this study. Compared to other measures, NNT volume was most significantly related to OFC (r values > 0.8, p<or=0.001), though NNT volume did not differ between the groups. Ventricular volume was also uniformly related to OFC (r approximately 0.3, p> 0.06). In contrast, the OFC-TBV relationship was less robust in those with autism (r=0.25, p<or=0.09) and only significant in the controls (r=0.58, p<or=0.001). Conversely, subjects with autism had a more robust and significantly different relationship between subarachnoid CSF/meningeal volume than controls (r=0.53 and 0.24; p<or=0.001 and 0.12, respectively). Possible explanations for these findings are discussed in the context of potential OFC differences that may occur in accelerated early brain growth associated with autism.

[Guideline 'Leptomeningeal metastases of solid tumours']

In view of recent progressive insight in the diagnosis and treatment of leptomeningeal metastases of solid tumours, a new guideline has been designed on the initiative of the Dutch Association of NeuroOncology and the Netherlands Society of Neurology, with methodological support from the Dutch Institute for Healthcare Improvement (CBO). - There are no neurological symptoms or signs, nor MRI characteristics that are unique to leptomeningeal metastasis. However, clinical suspicion of leptomeningeal metastasis in a patient known to have cancer, in combination with specific MRI characteristics is sufficient to make the diagnosis. If MRI or CT results are negative or inconclusive cerebrospinal-fluid assessment should be conducted. - Management of care of patients with leptomeningeal metastasis without brain metastases can be based on a series of categories that have been developed using prognostic factors such as Karnofsky performance status, serious encephalopathy or neurological dysfunction, systemic disease, sensitivity of the tumour for chemotherapy or hormonal treatment - In the context of meaningful palliation, systemic treatment, if necessary in combination with radiotherapy to clinically relevant sites, is preferable to intrathecal chemotherapy. - Intrathecal chemotherapy combined with local radiotherapy is recommended if effective systemic treatment is not available, and if the tumour is potentially sensitive to methotrexate, cytarabine or thiotepa. The combination of intrathecal methotrexate and whole-brain radiotherapy should be avoided.

Neurologic complications associated with intrathecal liposomal cytarabine given prophylactically in combination with high-dose methotrexate and cytarabine to patients with acute lymphocytic leukemia

Central nervous system (CNS) prophylaxis has led to a significant improvement in the outcome of patients with acute lymphocytic leukemia (ALL). Liposomal cytarabine (Enzon Pharmaceuticals, Piscataway, NJ; Skye Pharma, San Diego, CA), an intrathecal (IT) preparation of cytarabine with a prolonged half-life, has been shown to be safe and effective in the treatment of neoplastic meningitis. Liposomal cytarabine was given for CNS prophylaxis to 31 patients with newly diagnosed ALL. All patients were treated concurrently with hyper-CVAD chemotherapy (fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone) including high-dose methotrexate (MTX) and cytarabine on alternating courses. Liposomal cytarabine 50 mg was given intrathecally on days 2 and 15 of hyper-CVAD and day 10 of high-dose MTX and cytarabine courses until completion of either 3, 6, or 10 IT treatments, depending on risk for CNS disease. Five patients (16%) experienced serious unexpected neurotoxicity, including seizures, papilledema, cauda equina syndrome (n = 2), and encephalitis after a median of 4 IT administrations of liposomal cytarabine. Toxicities usually manifested after the MTX and cytarabine courses. One patient died with progressive encephalitis. After a median follow-up of 7 months, no isolated CNS relapses have been observed. Liposomal cytarabine given via intrathecal route concomitantly with systemic chemotherapy that crosses the blood-brain barrier such as high-dose MTX and cytarabine can result in significant neurotoxicity.

[Meningiomas: new prognostic factors]

Meningiomas are still defined as benignant tumours although 25% of those tumours will have local recurrance in the follow-up period. The WHO (2000) classification divides meningiomas in three goups: Grade 1 for conventional meningioma. Grade 2 for atypical meningioma and Grade 3 for Anaplastic meningioma. Specific histological variants of meningiomas have been included in grade 2 tumours. Clear cell, rabdoid and papillary meningiomas. We obtained 250 meningiomas from our files and we analyzed 30 inmunohistochemical markers. Several markers can be actually used as prognostic indicators in meningiomas and may allow a more individualized management of patients.

Mastoiditis complicated with Gradenigo syndrome and a hypertrophic pachymeningitis with consequent communicating hydrocephalus

We present the clinical, radiological and pathological features of a case of a cranial hypertrophic pachymeningitis that developed in the course of mastoiditis and petrous apex inflammation and responded to immunosuppressive therapy only. Documented by the development of clinical findings, magnetic resonance imaging, cerebrospinal fluid changes, histopathology findings, by otosurgical intervention and finally by the insertion of a ventriculo-peritoneal shunt, the case illustrates a gradual development of pachymeningitis with consequent hydrocephalus and intracranial hypertension. We consider this disease development an example of immune-induced proliferative fibrotic changes in meninges.

Neurosarcoidosis presenting as acute infarction on diffusion-weighted MR imaging: summary of radiologic findings

A 36-year-old woman presented with acute-onset right lower extremity paresthesias, dysarthria, right facial droop, and right hemiparesis. CT and MR imaging of the brain revealed extensive white matter disease and left basal ganglia infarction with dural and leptomeningeal enhancement. Differential considerations included vasculitis, granulomatous disease, and neoplasm. Chest, abdomen, and pelvis CTs were normal. Right temporal lobe biopsy revealed noncaseating granulomatous inflammation consistent with neurosarcoidosis.

BCG vaccination confers poor protection against M. tuberculosis HN878-induced central nervous system disease

Using a rabbit model of tuberculous meningitis (TBM), we compared the protective efficacy of Mycobacterium bovis bacillus Calmette-Guérin (BCG) vaccination against central nervous system infection with the virulent M. tuberculosis clinical isolate HN878 and the laboratory strain H37Rv. Although BCG clearly provided protection against infection with either challenge strain, protection against disease manifestations was significantly poorer in rabbits infected with HN878. BCG was less efficient in protecting against HN878 dissemination to the liver and spleen and against HN878-induced inflammation, loss of body weight, lung and brain pathology, and signs of disease. We suggest that the efficacy of newly developed vaccines should be tested in animal models not only against challenge with M. tuberculosis H37Rv but also with different clinical isolates including the highly virulent strains of the W-Beijing family.

Cerebellopontine angle lipoma with extracranial extension

Lipomas of the cerebellopontine angle (CPA) are rare. A recent literature review identified only 98 reported cases of CPA lipoma. We present here a case of CPA lipoma in a 28-year-old woman who was admitted to our hospital with hearing loss in her left ear. Computed tomography scan and magnetic resonance imaging revealed a CPA mass lesion with extracranial extension around the left internal carotiol artery. The patient was operated on in the sitting position via a right suboccipital craniectomy. The intracranial part of the mass was partially removed. Histopathological examination resulted in a diagnosis of lipoma. Surgical treatment of CPA lipomas is rarely indicated, and the aim of surgery must be decompression of neural structures.

Morphological Changes of the Retrobulbar Optic Nerve and Its Meningeal Sheaths in Glaucoma

This work focuses on the possible remodeling of the intraorbital portion of the optic nerve and its meningeal sheaths in glaucoma. The bulbar segments of the orbital optic nerve portion from 25 donors with glaucoma (M:F = 8:17; mean age +/- SD 85 +/- 11 years) and 25 controls (M:F = 14:11; mean age +/- SD 81 +/- 8 years) were formalin fixed, paraffin embedded and sectioned in series. Sections were stained with PAS, Masson trichrome and CD68, and examined for the following parameters: (1) diameter of the optic nerve; (2) thickness of the pia mater; (3) distance between dura mater and pia mater; (4) occurrence and amount of meningothelial cell nests in the subarachnoid space, and (5) presence and number of corpora arenacea. The mean diameter of the optic nerve was decreased in the glaucoma group when compared to the controls (2.9 +/- 0.5 vs. 3.3 +/- 0.5 mm; p < 0.01). The thickness of the pia mater was increased in the glaucoma group (0.1 +/- 0.04 vs. 0.09 +/- 0.03 mm, p < 0.05). Presence and number of corpora arenacea did not differ between the groups. Occurrence and amount of meningo- thelial cell nests in the subarachnoid space were however significantly increased in glaucoma (p < 0.02). Whether this observation is glaucoma specific deserves further investigation.

New agents for intrathecal administration

Intrathecal administration of chemotherapy, with or without radiation therapy, is the primary treatment modality for the prevention and treatment of central nervous system (CNS) metastases in patients with leukemia or lymphoma. Although this treatment strategy has been very effective for patients with hematological malignancies, currently available intrathecal agents are relatively ineffective for patients with neoplastic meningitis resulting from an underlying solid or CNS tumor effective. This article provides an overview of some of the practical considerations and limitations associated with intrathecal chemotherapy, and is followed by a comprehensive review of some of the preclinical and early phase clinical trials of novel anticancer agents and treatment strategies using the intrathecal route.

[Changes in regional meningeal immunity in local immunomodulating therapy in patients with acute traumatic intracranial hematomas]

A clinicomorphological study of 660 patients with acute traumatic intracranial hematomas has shown that pneummonia develops in 56% of cases, intracranial complications (purulent meningitis) in 14%.Pyoinflammatory complications were 1.5-1.7 times less common in small-sized hematomas, their total rate and the rate of pneumonias was twice higher in left cerebral hemispheric lesion. On the contrary, intracranial complications were twice more common in right cerebral hemispheric lesion. The structural bases of the regional meningeal immunity system were as follows: the pathways of blood and spinal fluid circulation and dural arachnoidal intercellular fluid; cellular cooperation of the meninx and tissue of the brain; the network of lymph vessels of the dura mater encephali and adventitia of large blood vessels and middle and inferior jugular (regional) lymph nodes. Morphodunctional changes in the local meningeal immunity system in patients with hematomas point to the development of secondary immunodeficiency. Inclusion of regional immunotherapy with T-activin into multimodality treatment decreases the incidence of extra- and intracranial pyoinflammatory complications and mortality.

Clinicopathologic Features of Aggressive Meningioma Emphasizing the Role of Radiotherapy in Treatment

BACKGROUND AND PURPOSE

Although meningiomas are typically benign, they occasionally behave in an aggressive fashion and carry a less favorable prognosis. The aim of this study was to review the clinical, radiologic and histopathologic features of these aggressive variants as well as the outcome after multimodality therapy.

PATIENTS AND METHODS

16 patients with atypical meningiomas (n = 11) and anaplastic meningiomas (n = 5) were treated in the Departments of Neurosurgery and Radiation Oncology at the University Hospital of Philipps University Marburg, Germany, between 1997 and 2003. Tumor grading was based on new WHO criteria. There were eleven men and five women with a mean age of 54 years. The median follow-up period was 34 months.

RESULTS

A total of 24 surgical procedures were performed for these 16 patients. Only seven patients underwent postoperative fractionated stereotactic radiotherapy. Patients with atypical meningioma received radiotherapy only for the recurrent disease. Six patients (37.5%) experienced tumor recurrence after a mean period of 27.2 months in spite of gross total resection. Radiographic findings suggestive of aggressiveness were observed mostly with WHO grade III meningiomas. By comparing the proliferation rate in four cases with atypical meningioma operated twice, the recurrent tumor had a higher proliferation rate than the first tumor in three cases. A special proliferation pattern was noticed in MIB-1 with anaplastic meningiomas. The mean overall survival period was 66.5 months. There was no mortality among patients with atypical meningioma, while four out of five patients with anaplastic meningioma died during follow-up.

CONCLUSION

Considering the higher rate of recurrence in aggressive meningiomas even after radical surgical excision and the possibility that the recurrent tumor is more aggressive than the original one, surgery should be combined with postoperative fractionated radiotherapy to improve local tumor control. The peculiar focal expression patterns of anaplastic meningioma in MIB-1 might be a marker of such malignant development.

Superficial siderosis due to papillary glioneuronal tumor

Superficial siderosis of the central nervous system is a rare, progressive, irreversible and debilitating neurological disease characterized by the deposition of haemosiderin in the leptomeninges and the subpial layers of the brain and spinal cord. The main clinical findings are progressive bilateral sensorineural hearing loss, cerebellar ataxia and pyramidal tract signs. The present report describes a 49-year-old woman who presented with intermittent headache of 5 years duration. The pain had become more severe in the previous 6 months. Neurological examination revealed nothing abnormal. Computed tomography showed a cystic mass with apparent internal haemorrhage in the right frontal lobe and T(2)-weighted magnetic resonance imaging showed material of low signal intensity coating the entire surface of the brain. The mass was completely excised via craniotomy. A histopathological study identified the mass as a papillary glioneuronal tumour. The patient recovered well and is still neurologically normal 1 year later. This is the first documented case of superficial siderosis caused by this type of tumour.

Localized basal meningeal enhancement in tuberculous meningitis

BACKGROUND

Focal basal meningeal enhancement may produce a confusing CT picture in children with suspected tuberculous meningitis (TBM).

OBJECTIVE

To demonstrate the incidence, distribution and appearance of localized basal meningeal enhancement in children with TBM.

MATERIALS AND METHODS

CT scans of patients with definite (culture proven) and probable (CSF suggestive) TBM were retrospectively evaluated by two observers. Localized basal enhancement was documented as involving: unilateral cistern of the lateral fossa (CLF), unilateral sylvian fissure, unilateral CLF and sylvian fissure in combination, unilateral CLF and sylvian fissure with ipsi- or contralateral ambient cistern and isolated quadrigeminal plate cistern.

RESULTS

The study included 130 patients with TBM (aged 2 months to 13 years 9 months). Focal basal enhancement was seen in 11 patients (8.5%). The sylvian fissure was involved most commonly, followed by the lateral fossa cistern. The ambient cistern was involved in three patients and the quadrigeminal plate cistern in one. Focal areas of enhancement corresponded to the areas of infarction in every patient.

CONCLUSION

Focal basal meningeal enhancement is common (8.5%) in paediatric TBM. This must be kept in mind when evaluating CT scans in children presenting with focal neurological findings, seizures or meningism in communities where TBM is endemic.

Leptomeningeal carcinomatosis associated with oesophageal adenocarcinoma: two case reports and review of the literature

Leptomeningeal carcinomatosis (LC) is a rare complication of solid tumours. We report two cases of leptomeningeal carcinomatosis in patients with oesophageal adenocarcinoma. Diagnosis of LC can be overlooked without a high index of suspicion. Multifocality of symptoms and signs is the hallmark of LC. The combination of cerebrospinal fluid cytology and magnetic resonance imaging has a high diagnostic accuracy. The prognosis remains poor and therefore all therapies are still palliative.

Subacute aseptic meningitis as neurological manifestation of primary Sjögren's syndrome

Sjögren's syndrome (SS) is an autoimmune disease characterized by inflammatory infiltration and secondary chronic dysfunction of exocrine glands. Systemic (extraglandular) manifestations of the disease occur in one-third of the patients, including a wide spectrum of peripheral and central neurological disorders. We report a case of subacute afebrile aseptic meningitis (AM) as neurological manifestation of primary SS. The neurological symptomatology presented gradual onset and progression, including diplopia, mild headache, pain and stiffness of the neck. The clinical examination pointed out xerostomia and xerophthalmia. Diagnosis of SS was confirmed by Schirmer's tear test and histopathology of the labial salivary glands. The neurological involvement was highlighted by gadolinium-enhanced magnetic resonance imaging of the brain which displayed an increased diffuse leptomeningeal enhancement. Cerebrospinal fluid (CSF) analysis showed moderate pleocytosis with prevalence of polymorphonuclear leukocytes and increased protein level but no evidence of Ig intrathecal synthesis. A cycle of intravenous steroid therapy led to a complete disappearance of the neurological symptomatology and to normalization of the CSF inflammatory pattern. Given the unusual presentation of this case of AM, which resembled the characteristics of a chronic meningitis rather than those of an acute form, in patients affected by SS we must stress the importance of cephalic symptoms such as headaches and cervical stiffness (even if mild and without fever) as possible signs of central neurological involvement of the disease.

Comparison of the inflammatory responses of human meningeal cells following challenge with Neisseria lactamica and with Neisseria meningitidis

The rationale for the present study was to determine how different species of bacteria interact with cells of the human meninges in order to gain information that would have broad relevance to understanding aspects of the innate immune response in the brain. Neisseria lactamica is an occasional cause of meningitis in humans, and in this study we investigated the in vitro interactions between N. lactamica and cells derived from the leptomeninges in comparison with the closely related organism Neisseria meningitidis, a major cause of meningitis worldwide. N. lactamica adhered specifically to meningioma cells, but the levels of adherence were generally lower than those with N. meningitidis. Meningioma cells challenged with N. lactamica and N. meningitidis secreted significant amounts of the proinflammatory cytokine interleukin-6 (IL-6), the C-X-C chemokine IL-8, and the C-C chemokines monocyte chemoattractant protein 1 (MCP-1) and RANTES, but it secreted very low levels of the cytokine growth factor granulocyte-macrophage colony-stimulating factor (GM-CSF). Thus, meningeal cells are involved in the innate host response to Neisseria species that are capable of entering the cerebrospinal fluid. The levels of IL-8 and MCP-1 secretion induced by both bacteria were essentially similar. By contrast, N. lactamica induced significantly lower levels of IL-6 than N. meningitidis. Challenge with the highest concentration of N. lactamica (10(8) CFU) induced a small but significant down-regulation of RANTES secretion, which was not observed with lower concentrations of bacteria. N. meningitidis (10(6) to 10(8) CFU) also down-regulated RANTES secretion, but this effect was significantly greater than that observed with N. lactamica. Although both bacteria were unable to invade meningeal cells directly, host cells remained viable on prolonged challenge with N. lactamica, whereas N. meningitidis induced death; the mechanism was overwhelming necrosis with no significant apoptosis. It is likely that differential expression of modulins between N. lactamica and N. meningitidis contributes to these observed differences in pathogenic potential.

Breast carcinoma metastasis and meningioma. A case report

BACKGROUND

The simultaneous occurrence of meningioma and breast cancer with or without brain metastasis is an unusual but well-known event. However, contiguous occurrence of meningioma and brain cancer metastasis is a less rare evidence and we are aware of only one previously published case in the literature.

CASE DESCRIPTION

A 72-year-old woman presented with headache, nausea and vomiting, and diminished mentation and memory. Seven years ago, she had had simple mastectomy at another hospital. Histopathologic examination had been reported as breast carcinoma. The patient had not gone to the controls and was unaware of the diagnosis. Cranial MRI examination of the patient showed two extraaxial masses. Histopathologic examination of the lesion at the frontal convexity, which was reported as en plaque meningioma radiologically, revealed meningioma but the other tumor at the sylvian fossa resembling the other meningioma was reported as breast carcinoma metastasis at histopathologic examination.

CONCLUSIONS

Although meningiomas have well-known radiological features, the other pathologies like breast metastasis may simulate them. A possible hormonal relationship between breast cancer and meningioma has not been clarified. We are not sure that this has played a role in dissociation of both tumor cells in our case.

Histopathological study of five cases with sporadic meningioangiomatosis

We report five cases of sporadic meningioangiomatosis, three males and two females, ranging in age from 12 to 36 years at diagnosis. The lesion was found incidentally by MRI after a head trauma in one case; the other four subjects had a seizure disorders, which improved following surgical resection of the cortical lesions. Grossly, the lesionectomy specimens were of a whitish color and firm consistency. Histological examination revealed that the lesions were confined to the cortex with focal involvement of the overlying leptomeninges, and revealed unifying features of meningioangiomatosis, such as proliferating microvessels with perivascular cuffs of spindle-cell proliferation within the cortex. Two cases had numerous calcifications; one was associated with a prominent fibrocalcifying component. Immunostaining results were variable among the cases. Only vimentin was consistently positive. Some of the spindle cells were weak positive for EMA in two cases. Immunoreactions with anti-CD34 detected within the cytoplasm of the spindle cells were observed in three of the five cases. The Ki-67 proliferation index of all the cases was very low, less than 0.1%. Neurofibrillary tangles were identified in only one of the five cases using the Bodian and immunostaining methods. These findings indicate that meningioangiomatosis lesions show a wide range of clinicopathological features, making diagnosis difficult. A histopathological spectrum and differential diagnoses were discussed with a review of the literature. Since this lesion is a distinct clinicopathological entity and hamartomatous in nature, it is important to make a correct diagnosis in order to avoid further aggressive treatment.

Adult intranasal meningoencephalocele presenting as a nasal polyp

We present an isolated purely intranasal meningoencephalocele, presenting as a nasal polyp in an adult, which is uncommon. Based on a review of the literature, we emphasize that nasal obstruction may be the only presenting symptom of an intranasal meningoencephalocele.

Heavy water inhibiting the expression of transforming growth factor-beta1 and the development of kaolin-induced hydrocephalus in mice

OBJECT

The authors investigated the effects of heavy water (D2O) on intrameningeal fibrosis and on the expression of cytokine production in mice with kaolin-induced hydrocephalus.

METHODS

Mice in which kaolin was injected into the cisterna magna were divided into two groups: 1) Group H, which had free access to H2O as tap water; and 2) Group D, which had free access to 30% D2O as tap water before and after kaolin injection. A distilled water-injected group, which had free access to H2O as tap water was designated the sham-operated group. The authors examined the effects of D2O within 28 days after injection on the development of hydrocephalus and intrameningeal fibrosis, as well as on the expression levels of several inflammatory and fibrogenic cytokines: transforming growth factor-beta1 (TGFbeta1), fibroblast growth factor-2 (FGF2), platelet-derived growth factor (PDGF)-BB, and interleukin (IL)-6. The cerebral ventricles were less expanded, and intrameningeal fibrosis was milder in Group D than in Group H. The proliferation of fibroblasts was assessed by applying the bromodeoxyuridine labeling index, which was lower in Group D than in Group H. Expression of TGFbeta1 in the macrophages, choroid plexus, and meninges was inhibited in Group D but not in Group H. The serum level of total TGFbeta1 was significantly lower in Group D than in Group H on Day 14, whereas the levels of FGF2, PDGF-BB, and IL-6 did not differ significantly among the groups.

CONCLUSIONS

Administration of D2O prevented the development of kaolin-induced hydrocephalus in mice and inhibited intrameningeal fibrosis and upregulation of TGFbeta1.

Both nasal cerebral heterotopia and encephalocele in the same patient

OBJECTIVE AND PATIENT: Both nasal cerebral heterotopia and encephalocele are rare congenital benign masses of neurogenic origin caused by an embryonic developmental abnormality. It is generally accepted that nasal heterotopia is a sequelae to encephalocele. This report presents an unusual case of nasal cerebral heterotopia and encephalocele arising in the same patient. The patient had a firm, solid mass measuring 1.5 x 1.0 cm on the bridge of the nose covered with normal skin and another mass in the nasal cavity obstructing the right nasal cavity. Computed tomography (CT) demonstrated that the nasal bone separated these masses. CT also showed a bony defect at the skull base. Surgery consisted of dividing the encephalocele and closure of the skull base fistulae, along with nasal subcutaneous mass enucleation.

RESULTS

Intraoperative examination indicated the existence of a pit on the nasal bone where the pedicle of the nasal subcutaneous mass connected. Microscopic examination of the nasal cavity mass demonstrated meningoencephalocele, and examination of the nasal subcutaneous mass demonstrated nasal cerebral heterotopia, which was confirmed by immunohistochemical staining. After 10 months, complete removal of the subcutaneous nasal mass was recognized and there was no evidence of recurrence.

CONCLUSION

Findings in this case suggest that the nasal cerebral heterotopias will result from encephalocele.

Primary diffuse multinodular leptomeningeal gliomatosis: case report and review of the literature

BACKGROUND

Primary diffuse leptomeningeal gliomatosis is an exceptional neoplasm, and only 30 cases have been reported in the literature. We report a recent case and compare data with previously published observations.

METHODS

A 50-year-old man was admitted to the neurosurgery department for a previous 4-month history of headache, associated with nonspecific neurological signs. Biologic data and cerebrospinal fluid examination suggested an inflammatory process. The patient was given an antituberculous therapy. Magnetic resonance imaging revealed a multinodular enhancement of spinal nerve roots. A biopsy of sacral rootlets was performed. Histological examination revealed an anaplastic astrocytoma. Patient's status worsened, and death occurred 7 months later.

RESULTS

Complete neuraxis postmortem examination revealed no intraparenchymatous glioma and was conclusive for the diagnosis of primary leptomeningeal gliomatosis (astrocytic, World Health Organization grade III), with a multinodular pattern in the spinal cord, the brainstem, and the brain base with diffuse extension into the cerebellar subarachnoid spaces.

CONCLUSIONS

Our case illustrates the diagnostic difficulties in making the premortem diagnosis. The review of the literature indicates that there are no specific clinical or biologic signs. Magnetic resonance imaging using T1-weighted images with gadolinium enhancement and biopsy material may be useful diagnostic tools. In most cases, autopsy evaluation alone permits definitive primary diffuse leptomeningeal gliomatosis diagnosis. Whatever the histological characteristics of proliferating cells are, the prognosis remains poor. No prognostic factors have been shown to be correlated with survival time. Unfortunately, no routine treatment has been yet proposed.

Supratentorial meningeal melanocytoma mimicking a convexity meningioma

OBJECTIVE AND IMPORTANCE

Meningeal melanocytomas are rare benign neuro-ectodermal tumors arising from melanocytic cells in the leptomeninges. These leptomeningeal melanocytes are found at highest density underneath the brain stem and along the upper cervical spinal cord. Thus, most reported cases of meningeal melanocytomas are located in the posterior fossa and the spinal cord, respectively.

CLINICAL PRESENTATION

We report on the rare case of a 55-year-old male patient with a large supratentorial meningeal melanocytoma mimicking a convexity meningioma and a smaller, similarly dura based lesion in the posterior fossa.

INTERVENTION

Tumor control to date was achieved by surgery of the large lesion and radiosurgery of the small lesion.

CONCLUSION

Complete tumor resection may be advantageous and second or recurrent lesions may be managed by repeat surgery or stereotactic radiosurgery.

Kinetics of cerebral amyloid angiopathy progression in a transgenic mouse model of Alzheimer disease

Cerebral amyloid angiopathy (CAA), the deposition of cerebrovascular beta-amyloid (Abeta) in the walls of arterial vessels, has been implicated in hemorrhagic stroke and is present in most cases of Alzheimer disease. Previous studies of the progression of CAA in humans and animal models have been limited to the comparison of pathological tissue from different brains at single time points. Our objective was to visualize in real time the initiation and progression of CAA in Tg2576 mice by multiphoton microscopy through cranial windows. Affected vessels were labeled by methoxy-X04, a fluorescent dye that selectively binds cerebrovascular beta-amyloid and plaques. With serial imaging sessions spaced at weekly intervals, we were able to observe the earliest appearance of CAA in leptomeningeal arteries as multifocal deposits of band-like Abeta. Over subsequent imaging sessions, we were able to identify growth of these deposits (propagation), as well as appearance of new bands (additional initiation events). Statistical modeling of the data suggested that as the extent of CAA progressed in this vascular bed, there was increased prevalence of propagation over initiation. During the early phases of CAA development, the overall pathology burden progressed at a rate of 0.35% of total available vessel area per day (95% confidence interval, 0.3-0.4%). The consistent rate of disease progression implies that this model is amenable to investigations of therapeutic interventions.

Neuroradiologic and clinicopathologic features of oculoleptomeningeal type amyloidosis

OBJECTIVE

To clarify the pathogenesis of leptomeningeal amyloidosis in familial amyloidotic polyneuropathy amyloidogenic transthyretin Y114C (FAP ATTR Y114C).

METHODS

The authors analyzed eight FAP ATTR Y114C patients. Six patients showed CNS symptoms associated with leptomeningeal amyloidosis. To examine the function of the blood-CSF barrier and blood-brain barrier (BBB), the authors performed CSF and MRI studies. The authors also performed a histopathologic study of autopsy specimens to examine the distribution of amyloid deposition in the CNS.

RESULTS

CSF study showed high total protein concentrations and increased albumin CSF/serum concentration quotients (Qalb; an indication of blood-CSF barrier function). MRI with gadolinium (Gd) revealed enhancement from brainstem to spinal cord. Serial brain MRI studies with FLAIR images after Gd administration showed Gd leakage into the subarachnoid space (two patients). These findings suggested the blood-CSF barrier and BBB dysfunctions. Constructive interference in steady state (CISS) three-dimensional Fourier transformation (CISS-3DFT) sequence analysis demonstrated amyloid-induced funiculus structures joining the spinal cord and dura mater (one patient). Histopathologic study revealed intense amyloid deposition in leptomeninges, vessel walls, and parenchyma in spinal cord and the brain. These distributions of amyloid deposition are unique compared to other TTR related leptomeningeal amyloidosis.

CONCLUSIONS

Patients with familial amyloidotic polyneuropathy amyloidogenic transthyretin Y114C had CNS disorders related to amyloid deposition in leptomeninges, vessel walls, and parenchyma in spinal cord and the brain. The pathogenesis of CNS disorders may reflect disruption of the blood-CSF barrier and blood-brain barrier by amyloid deposition.