Tumors Presenting as Multiple Cranial Nerve Palsies

Glomus jugulare tumors treatment by gamma knife radiosurgery: A single center study

Objective

Glomus jugulare tumor are benign vascular tumors and surgical resection is almost impossible. We have treated these tumors by Gamma knife radiosurgery and share our experience.

Methods

This study was conducted at the Neurospinal and Cancer Care Institute, Karachi from January 2010 to May 2020. Thirty-four patients with glomus jugulare tumors treated with gamma knife radiosurgery were included in the study. The comprehensive clinical and demographic characteristics of all patients were collected through a manually designed questionnaire. Computed tomography, digital subtraction angiography and magnetic resonance imaging were used to make the diagnosis. Data was incorporated and analyzed by SPSS version 26.

Results

A total of 34 patients were included in the study of which 16(47%) were males and 18(53%) were females with first follow up after 6-month up to two year clinical and radiological follow-up. The mean age of the patients was 42.5±13.5 with a minimum age of 20 years and maximum age of 65 years. The KPS scale was 2.09±0.45 and the volume of the tumor was 33.8±22.5 cm3. The improvement was shown in 27 patients of which 14 were males and 13 were females showing insignificance post radiation change. Of all 34 patients, the outcome was recorded as 3(9%) for excellent, 22(64%) for good, 6(17%) for fair and 3(9%) were poor results.

Conclusions

Gamma Knife radiosurgery is a safe and effective primary therapy and salvage therapy for residual and recurrent cases of glomus jugulare and tympanicum tumors.

Clinical Presentation and Prognosis

Over the past three decades, the care for patients with meningioma has steadily improved as a result of a better understanding of the natural history, molecular biology, and classification of these tumors. Surgical frameworks for management have been established and validated with more options for adjuvant and salvage treatment available for patients with residual or recurrent disease. Overall these advances have improved clinical outcomes and prognosis.Alongside the improved clinical management has come an increase in biological understanding of these tumors. The number of publications within the field of meningioma research continues to expand and biological studies identifying molecular factors at the cytogenic and genomic level offer exciting potential for more personalized management strategies. As survival and understanding have increased, treatment outcomes are moving from traditional metrics, which describe the morbidity and mortality to more patient-centered measures. The subjective experiences of patients with meningioma are gaining interest among clinical researchers and it is recognized that even supposedly mild symptoms arising from meningioma can have a significant effect on a patient's quality of life.This chapter reviews the varied clinical presentations of meningioma, which in the modern era of widespread brain imaging must include a discussion of incidental meningioma. The second part examines prognosis and the clinical, pathological, and molecular factors that can be used to predict outcomes.

Neuro-Ophthalmic Manifestations of Intracranial Space Occupying Lesions in Adults

Objectives

The purpose of this study is to evaluate the epidemiology, neuro-ophthalmic, and clinical characteristics of intracranial space occupying lesions (ICSOLs) in adult patients.

Methods

All patients above 16 years presenting with brain tumors confirmed by magnetic resonance imaging and treated surgically in our institute were included in this study. Epidemiology of the patients along with neurological and ophthalmic manifestation was evaluated.

Results

A total of 252 patients were included in the study ranging from 18 years to 79 years. Supratentorial location was more common than infratentorial location. The most common neurological symptom in our study was headache followed by seizures. Ophthalmic manifestations were present in (73.4%) of patients. The most common visual symptoms and signs were visual loss, strabismus, papilledema, and visual field defects. The most common histopathological diagnosis seen in our study was meningiomas followed by high-grade gliomas.

Conclusion

Ocular signs and symptoms can be considered as a window to the brain through which ICSOLs can be detected. The most common neurological manifestation of ICSOL in our study was headache with or without true localizing signs and symptoms. More frequently, these patients present to an ophthalmologist before a neurosurgeon with related ocular manifestations. Hence, through our study, we emphasize the importance of a detailed ophthalmological examination in these patients which can aid in early diagnosis and prompt management of such lesions.

Evaluation of diplopia as a vital and remarkable ocular finding among cancer patients

BACKGROUND

Diplopia is an important and debilitating symptom of malignancies due to different pathogenetic mechanisms. Data is lacking in the literature because of the rarity of the diplopia in patients with cancer.

AIMS

We aimed to evaluate the etiological and clinical factors of diplopia in patients with different types of cancer.

METHODS

We retrospectively investigated 22 cancer patients with diplopia who were admitted between 2018 and 2021. The diagnosis of primary cancer, the underlying factors causing diplopia, and the life expectancy after diplopia were evaluated.

RESULTS

Among available data of 620 cancer patients applied to our ophthalmology department, 22 (3.55%) had diplopia. Paralytic strabismus was found in 19 patients and restrictive strabismus was found in 3 patients. Among the paralytic cases, 6th nerve palsy was found to be the most common with a rate of 68%. In 18 of 22 (82%) patients, the cause of diplopia was due to orbital or brain metastasis or local invasion. Two patients had diplopia secondary to radiotherapy and 2 had diplopia due to chemotherapy.

CONCLUSION

Metastasis is the most common cause of diplopia in patients with cancer and screening for metastasis is crucial as soon as diplopia begins for a better life expectancy.

Detecting causes of pulsatile tinnitus on CT arteriography-venography: A pictorial review

Pulsatile tinnitus (PT) can be a mild or debilitating symptom. Following clinical examination and otoscopy, when the underlying aetiology is not apparent, radiological imaging can be used to evaluate further. CT arteriography-venography (CT A-V) of the head and neck has recently been introduced as a single 'one catch' modality for identifying the many causes of PT including those which are treatable and potentially serious whilst also providing reassurance through negative studies or studies with benign findings. CT A-V is performed as a single phase study allowing both arterial and venous assessment, hence limiting radiation exposure. Additional multiplanar reformats and bone reconstructions are desirable. Understanding the limitations of CT A-V is also required, with an awareness of the scenarios where other imaging modalities should be considered. The causes of PT can be divided into systemic and non-systemic categories. Non-systemic aetiologies in the head and neck should be carefully reviewed on CT A-V and include a variety of vascular causes (arteriovenous malformations/fistulas, venous or arterial aetiologies) and non-vascular causes (tumours and bony dysplasias). Venous causes (dominant, aberrant, stenosed or thrombosed venous vessels) are more common than arterial aetiologies (aberrant or stenosed internal carotid artery, aneurysms or a persistent stapedial artery). Glomus tumours that are not visible on otoscopy and osseous pathologies such as bony dehiscence and otospongiosis should also be excluded. Careful assessment of all the potential vascular and non-vascular causes should be reviewed in a systematic approach, with correlation made with the clinical history. A structured reporting template for the reporting radiologist is provided in this review to ensure all the potential causes of PT are considered on a CT A-V study. This will help in providing a comprehensive radiological evaluation, hence justifying the radiation dose and for patient assessment and prognostication.

Autoimmune disorders and paraneoplastic syndromes in thymoma

Thymomas are counted among the rare tumour entities which are associated with autoimmune disorders (AIDs) and paraneoplastic syndromes (PNS) far more often than other malignancies. Through its complex immunological function in the context of the selection and maturation of T cells, the thymus is at the same time highly susceptible to disruptive factors caused by the development and growth of thymic tumours. These T cells, which are thought to develop to competent immune cells in the thymus, can instead adopt autoreactive behaviour due to the uncontrolled interplay of thymomas and become the trigger for AID or PNS affecting numerous organs and tissues within the human body. While myasthenia gravis is the most prevalent PNS in thymoma, numerous others have been described, be they related to neurological, cardiovascular, gastrointestinal, haematological, dermatological, endocrine or systemic disorders. This review article sheds light on the pathophysiology, epidemiology, specific clinical features and therapeutic options of the various forms as well as courses and outcomes of AID/PNS in association with thymomas. Whenever suitable and backed by the limited available evidence, the perspectives from both the thymoma and the affected organ/tissue will be highlighted. Specific issues addressed are the prognostic significance of thymectomy on myasthenia gravis and other thymoma-associated AID/PND and further the impact and safety of immunotherapies on AID and PND relating to thymomas.

Isolated oculomotor nerve palsy as a manifestation of diffuse large B cell lymphoma: A case report

An isolated third nerve palsy presenting as the primary manifestation of a lymphoma is rare, with only few cases having been described. The present study reports an unusual case of a healthy 67-year old male diagnosed with isolated right oculomotor nerve palsy (ONP), who was found to have an underlying B cell lymphoma. The patient's medical records were accessed upon consent. A thorough physical examination, including stroke and infections work-ups were performed. A chest computerized tomography (CT), brain magnetic resonance imaging and positron emission tomography (PET) scans and a mediastinal tissue biopsy, were performed as part of systematic diagnostic evaluations. The current report suggests that a PET fluorodeoxyglucose study or a CT scan of the chest, abdomen and pelvis (with contrast) may help in the early diagnosis of a cancer responsible for ONP, particularly if brain vessel imaging does not show a posterior cerebral artery aneurysm as a cause for the defect.

Peripheral nervous system involvement in lymphomas

The peripheral nervous system may be involved at any stage in the course of lymphoproliferative diseases. The different underlying mechanisms include neurotoxicity secondary to chemotherapy, direct nerve infiltration (neurolymphomatosis), infections, immune-mediated, paraneoplastic or metabolic processes and nutritional deficiencies. Accordingly, the clinical features are heterogeneous and depend on the localization of the damage (ganglia, roots, plexi, and peripheral nerves) and on the involved structures (myelin, axon, and cell body). Some clinical findings, such a focal or diffuse involvement, symmetric or asymmetric pattern, presence of pain may point to the correct diagnosis. Besides a thorough medical history and neurological examination, neurophysiological studies, cerebrospinal fluid analysis, nerve biopsy (in selected patients with suspected lymphomatous infiltration) and neuroimaging techniques (magnetic resonance neurography and nerve ultrasound) may be crucial for a proper diagnostic workup.

The aetiologies of the unilateral oculomotor nerve palsy: a review of the literature

Oculomotor nerve palsy (ONP) is an important and common clinical diagnosis. Its main features are diplopia and ptosis. Its aetiologies are various and complex. A number of different conditions have been reported to cause ONP, such as diabetes mellitus, aneurysm, tumours, painful ophthalmoplegia, pituitary lesions, cavernous sinus lesions, central nervous system infections, and subarachnoid haemorrhage. A patients needs to undergo several tests in order to establish the correct underlying pathology. In this review, we have summarized the aetiologies of the unilateral ONP, and discussed their relative clinical features, pathogenesis, diagnostic criteria, treatment options, and prognosis. We searched PubMed for papers related to ONP and its aetiologies, and selected the publications, which seemed appropriate.

Multiple Cranial Neuropathies in a Patient with Diffuse Large B-cell Lymphoma: Case Report and Review of Literature

Neuropathies can occur in patients with diffuse large B-cell lymphoma (DLBCL) at any stage of the disease as a presenting symptom or during later stages of illness. A wide spectrum of neurological association is known to occur with DLBCL, ranging from cranial nerve palsies to peripheral neuropathies. Evaluation of cranial and peripheral neuropathies in patients with DLBCL requires meticulous clinical, imaging, and electrodiagnostic testing. A 75-year-old right-handed female with a known history of multiple cranial neuropathies and DLBCL presented with acute dysphagia and upper extremity weakness of one-week duration. On evaluation, she was found to have right vagal nerve palsy. Cerebrospinal fluid (CSF) analysis along with flow cytometry testing showed CD19 and CD20 positive B cells, confirming neoplastic infiltration of CSF. We describe the case and review the literature of the association of cranial nerve palsies with DLBCL.