Primary glioblastoma multiforme of the oculomotor nerve. Case report

Glioblastoma multiforme with oculomotor nerve involvement: case report and literature review

Gliomas involving the cranial nerves III-XIII are rare. Even rarer are glioblastomas multiforme (GBMs) with only 10 cases previously reported. Oculomotor nerve involvement was described in only 2 patients. The mechanisms proposed so far include an origin from the nerve itself or an extension within the nerve of a midbrain tumor. We report the case of a 69-year-old man who presented with an isolated left oculomotor nerve palsy. He was found to have a left temporal GBM extended to the frontal lobe. Diagnostics and intraoperative and pathological findings clearly demonstrated a massive infiltration of the cisternal portion of the left oculomotor nerve. We suppose this could be the first case of direct oculomotor nerve invasion by exophytic spread of a supratentorial GBM or by subarachnoid seeding from a temporal tumor. Less probably, it could be the first case of an oculomotor nerve GBM with a temporal lobe invasion.

An integrative survival analysis and a systematic review of the cerebellopontine angle glioblastomas

Glioblastomas presenting topographically at the cerebellopontine angle (CPA) are exceedingly rare. Given the specific anatomical considerations and their rarity, overall survival (OS) and management are not discussed in detail. The authors performed an integrative survival analysis of CPA glioblastomas. A literature search of PubMed, Scopus, and Web of Science databases was performed per PRISMA guidelines. Patient data including demographics, clinical features, neuroimaging, management, follow-up, and OS were extracted. The mean age was 39 ± 26.2 years. The mean OS was 8.9 months. Kaplan-Meier log-rank test and univariate Cox proportional-hazards model identified hydrocephalus (log-rank, p = 0.034; HR 0.34; 95% CI 0.12-0.94; p = 0.038), chemotherapy (log-rank, p < 0.005; HR 5.66; 95% CI 1.53-20.88; p = 0.009), and radiotherapy (log-rank, p < 0.0001; HR 12.01; 95% CI 3.44-41.89; p < 0.001) as factors influencing OS. Hydrocephalus (HR 3.57; 95% CI 1.07-11.1; p = 0.038) and no adjuvant radiotherapy (HR 0.12; 95% CI 0.02-0.59; p < 0.01) remained prognostic on multivariable analysis with fourfold and twofold higher risk for the time-related onset of death, respectively. This should be considered when assessing the risk-to-benefit ratio for patients undergoing surgery for CPA glioblastoma.

Leptomeningeal Spread at the Diagnosis of Glioblastoma Multiforme: A Case Report and Literature Review

Approximately two-thirds of glioblastoma (GBM) patients progress to leptomeningeal spread (LMS) within two years. While 90% of LMS cases are diagnosed during the progression and/or recurrence of GBM (defined as secondary LMS), LMS presentation at the time of GBM diagnosis (defined as primary LMS) is very rare. ¹⁸F-fluorodeoxy glucose positron emission tomography computed tomography (¹⁸F-FDG PET/CT) study helps to diagnose the multifocal spread of the malignant primary brain tumor. Our patient was a 31-year-old man with a tumorous lesion located in the right temporal lobe, a wide area of the leptomeninges, and spinal cord (thoracic 5/6, and lumbar 1 level) involvement as a concurrent manifestation. After the removal of the right temporal tumor, the clinical status progressed rapidly, showing signs of increased intracranial pressure and hydrocephalus caused by LMS. He underwent a ventriculoperitoneal shunt a week after craniotomy. During management, progression of cord compression, paraplegia, bone marrow suppression related to radiochemotherapy, intercurrent infections, and persistent ascites due to peritoneal metastasis of the LMS through the shunt system was observed. The patient finally succumbed to the disease nine months after the diagnosis of simultaneous GBM and LMS. The overall survival of primary LMS with GBM in our case was nine months, which is shorter than that of secondary LMS with GBM. The survival period after the diagnosis of LMS did not seem to be significantly different between primary and secondary LMS. To determine the prognostic effect and difference between primary and secondary LMS, further cooperative studies with large-volume data analysis are warranted.

Neuro-Ophthalmic Manifestations of Intracranial Malignancies

BACKGROUND

To describe the various neuro-ophthalmic presentations, key exam features, and clinical findings associated with 5 common primary and secondary intracranial malignancies.

EVIDENCE ACQUISITION

Retrospective PubMed search and review of published case reports, case series, observational studies, book chapters, and review articles examining the neuro-ophthalmic features of intracranial malignancies including primary glial neoplasms (e.g., glioblastoma multiforme), primary and secondary lymphoma, intracranial metastases, carcinomatous/lymphomatous meningitis, and intracranial germ cell tumors. The search strategy used to perform the retrospective review included the aforementioned tumor type (e.g., glioblastoma multiforme) and the following terms and Boolean operators: AND ("visual loss" OR "papilledema" OR "diplopia" OR "ophthalmoplegia" or "neuro-ophthalmology" OR "proptosis").

RESULTS

The rate of growth and the location of an intracranial tumor are essential factors in determining the neuro-ophthalmic presentation of certain intracranial malignancies. Primary malignant brain glial neoplasms commonly present with visual afferent complaints (e.g., unilateral or bilateral visual acuity or visual field defects, bitemporal or homonymous hemianopsia), pupil abnormalities (relative afferent pupillary defect), and optic atrophy or papilledema. Primary intraocular lymphoma (with or without central nervous system lymphoma) typically presents as a painless bilateral vitritis. Secondary intracranial malignancies have variable afferent and efferent visual pathway presentations. Carcinomatous/lymphomatous meningitis is associated with diplopia (e.g., multiple ocular motor cranial neuropathies with or without vision loss from papilledema or compressive/infiltrative optic neuropathy). Intracranial germ cell tumors can present with a chiasmal syndrome or dorsal midbrain syndrome.

CONCLUSION

Intracranial malignancies can present with neuro-ophthalmic symptoms or signs depending on topographical localization. Specific neuro-ophthalmic presentations are associated with different malignant intracranial tumors. Clinicians should be aware of the common malignant intracranial tumors and their associated clinical presentations in neuro-ophthalmology.

Surgical management of primary and secondary pilocytic astrocytoma of the cerebellopontine angle (in adults and children) and review of the literature

Glial tumors in the cerebellopontine angle (CPA) are uncommon and comprise less than 1% of CPA tumors. We present four cases of pilocytic astrocytoma of the CPA (PA-CPA) that were treated in our department. Patients who received surgical treatment for PA-CPA from January 2004 to December 2019 were identified by a computer search of their files from the Department of Neurosurgery, Tübingen. Patients were evaluated for initial symptoms, pre- and postoperative facial nerve function and cochlear function, complications, and recurrence rate by reviewing surgical reports, patient documents, neuroradiological data, and follow-up data. We identified four patients with PA-CPA out of about 1500 CPA lesions (~ 0.2%), which were surgically treated in our department in the last 16 years. Of the four patients, three were male, and one was a female patient. Two were adults, and two were children (mean age 35 years). A gross total resection was achieved in three cases, and a subtotal resection was attained in one case. Two patients experienced a moderate facial palsy immediately after surgery (House–Brackmann grade III). In all cases, the facial function was intact or good (House–Brackmann grades I–II) at the long-term follow-up (mean follow-up 4.5 years). No mortality occurred during follow-up. Three of the patients had no recurrence at the latest follow-up (mean latest follow-up 4.5 years), while one patient had a slight recurrence. PA-CPA can be safely removed, and most complications immediately after surgery resolve in the long-term follow-up.

Glioblastoma of the cerebellopontine angle and internal auditory canal mimicking a peripheral nerve sheath tumor: case report

Glioblastoma (GBM) of the internal auditory canal (IAC) is exceedingly rare, with only 3 prior cases reported in the literature. The authors present the fourth case of cerebellopontine angle (CPA) and IAC GBM, and the first in which the lesion mimicked a vestibular schwannoma (VS) early in its natural history. A 55-year-old man presented with tinnitus, hearing loss, and imbalance. MRI identified a left IAC/CPA lesion measuring 8 mm, most consistent with a benign VS. Over the subsequent 4 months he developed facial weakness. The tumor grew remarkably to 24 mm and surgery was recommended; the main preoperative diagnosis was malignant peripheral nerve sheath tumor (MPNST). Resection proceeded via a translabyrinthine approach with resection of cranial nerves VII and VIII, followed by facial-hypoglossal nerve anastomosis. Intraoperative frozen section suggested malignant spindle cell neoplasm, but final histopathological and molecular testing confirmed the lesion to be a GBM. The authors report the first case in which absence of any brainstem interface effectively excluded a primary parenchymal tumor, in particular GBM, from the differential diagnosis. Given the dramatic differences in treatment and prognoses between malignant glioma and MPNST, this case emphasizes the importance of surgical intervention on an aggressively growing lesion, which provides both the best probability of local control and the critical tissue diagnosis.

Ambiguity in the Dural Tail Sign on MRI

Background:

Meningiomas give rise to the dural tail sign (DTS) on contrast-enhanced magnetic resonance imaging (CEMRI). The presence of DTS does not always qualify for a meningioma, as it is seen in only 60-72% of cases. This sign has been described in various other lesions like lymphomas, metastasis, hemangiopericytomas, schwannomas and very rarely glioblastoma multiforme (GBM). The characteristics of dural-based GBMs are discussed here, as only eleven such cases are reported in the literature till date. Here we discuss the unique features of this rare presentation.

Case Description:

A 17-year-old male presented to the emergency department (ED) with, complaints of headache, recurrent vomiting, vision loss in right eye and altered sensorium. On examination patient was drowsy with right hemiparesis, secondary optic atrophy in the right eye and papilledema in the left eye. MRI brain showed, heterogeneous predominantly solid cystic lesion with central hypo-intense core suggestive of necrosis with heterogeneous enhancement and a positive DTS. Patient underwent emergency left parasagittal parieto-occipital craniotomy and gross total tumor excision including the involved dura and the falx. On opening the dura, tumor was surfacing, invading the superior sagittal sinus and the falx, greyish, soft to firm in consistency with central necrosis and highly vascular suggesting a high-grade lesion. Postoperative computed tomography (CT) of the brain showed evidence of gross total tumor (GTR) excision. The postoperative course of the patient was uneventful. Histopathological analysis revealed GBM with PNET like components. The dura as well as the falx were involved by the tumor.

Conclusion:

GBMs can arise in typical locations along with DTS mimicking meningiomas. Excision of the involved dura and the falx becomes important in this scenario, so as to achieve GTR. Hence high index of suspicion preoperatively aided by Magnetic Resonance Imaging (MRS) can help distinguish GBMs from meningioma, thereby impacting upon the prognosis.

Isolated third nerve palsy: A rare presentation of high grade glioma

High grade gliomas account for almost one-third of primary central nervous system neoplasm, mainly in adults with a mean age of 41 years. They usually present with symptoms of raised intracranial pressure such as headache, vomiting, and seizures. We report a case of 55-year-old male presenting with right side complete third nerve palsy. Magnetic resonance imaging revealed an intraaxial tumor of the right medial temporal lobe. The tumor was removed grossly, and the histological diagnosis was anaplastic astrocytoma (WHO grade 3). We discuss clinical presentation of this case along with pertinent literature.

Direct Cranial Nerve Involvement by Gliomas: Case Series and Review of the Literature

Malignant gliomas are characterized by infiltrative growth of tumor cells, including along white matter tracts. This may result in clinical cranial neuropathy due to direct involvement of a cranial nerve rather than by leptomeningeal spread along cranial nerves. Gliomas directly involving cranial nerves III-XII are rare, with only 11 cases reported in the literature before 2014, including 8 with imaging. We present 8 additional cases demonstrating direct infiltration of a cranial nerve by a glioma. Asymmetric cisternal nerve expansion compared with the contralateral nerve was noted with a mean length of involvement of 9.4 mm. Based on our case series, the key imaging feature for recognizing direct cranial nerve involvement by a glioma is the detection of an intra-axial mass in the pons or midbrain that is directly associated with expansion, signal abnormality, and/or enhancement of the adjacent cranial nerves.

Primary glioblastoma of the trigeminal nerve root entry zone: case report

Gliomas of the cranial nerve root entry zone are rare clinical entities. There have been 11 reported cases in the literature, including only 2 glioblastomas. The authors report the case of a 67-year-old man who presented with isolated facial numbness and was found to have a glioblastoma involving the trigeminal nerve root entry zone. After biopsy the patient completed treatment with conformal radiation and concomitant temozolomide, and at 23 weeks after surgery he demonstrated symptom progression despite the treatment described. This is the first reported case of a glioblastoma of the trigeminal nerve root entry zone.

Active endocytosis and microtubule remodeling restore compressed pyramidal neuron morphology in rat cerebral cortex

Previous studies have shown that compression alone reduced the thickness of rat cerebral cortex and apical dendritic lengths of pyramidal neurons without apparent cell death. Besides, decompression restored dendritic lengths at different degrees depending on duration of compression. To understand the mechanisms regulating dendritic shortening and lengthening upon compression and decompression, we applied transmission electron microscopy to examine microtubule and membrane structure of pyramidal neurons in rat sensorimotor cortex subjected to compression and decompression. Microtubule densities within apical dendritic trunks decreased significantly and arranged irregularly following compression for a period from 30 min to 24 h. In addition, apical dendritic trunks showed twisted contour. Two reasons are accounted for the decrease of microtubule density within this period. First, microtubule depolymerized and resulted in lower number of microtubules. Second, the twisted membrane widened the diameters of apical dendritic trunks, which also caused a decrease in microtubule density. Interestingly, these compression-induced changes were quickly reversed to control level following decompression, suggesting that these changes were accomplished passively. Furthermore, microtubule densities were restored to control level and the number of endocytotic vesicles significantly increased along the apical dendritic membrane in neurons subjected to 36 h or longer period of compression. However, decompression did not make significant changes on dendrites compressed for 36 h, for they had already shown straight appearance before decompression. These results suggest that active membrane endocytosis and microtubule remodeling occur in this adaptive stage to make the apical dendritic trunks regain their smooth contour and regular microtubule arrangement, similar to that of the normal control neurons.

Primary glioblastoma of the cerebellopontine angle in adults

Gliomas are rare entities in the cerebellopontine angle (CPA) in adults. The authors present clinical, neuroradiological, serological, and neuropathological findings in a 60-year-old man with an extraaxial CPA glioblastoma arising from the proximal portion of cranial nerve VIII. The patient presented with progressive left-sided deafness and left-sided facial palsy lasting less than 2 months and progressive dysarthria and dysphagia lasting 2 weeks. Preoperative neuroimaging suggested the diagnosis of CPA meningioma with "dural-tail" sign and involvement of the internal auditory canal. Serological examination showed an increase in the malignant markers of ferritin and neuron-specific enolase, which suggested underlying malignancy. The tumor was subtotally removed, and it was confirmed to be completely separated from the brainstem and cerebellum. Cranial nerves VII and VIII were destroyed and sacrificed. Transient severe bradycardia occurred during surgery due to entrapment of the caudal cranial nerve complex by the tumor in such an infiltrative way. The neuropathological examination revealed a glioblastoma. The patient underwent no further treatment and died of cachexia 2 months postoperatively. To the authors' knowledge, this represents the first case of a primary glioblastoma in the CPA in an adult. A high index of suspicion along with reliance on clinical assessment, radiological findings, and serum detection of specific malignant markers is essential to diagnose such uncommon CPA lesions.

Isolated Oculomotor Nerve Paresis in Anaplastic Astrocytoma With Exophytic Invasion

A 30-year-old man presented with a supratentorial malignant glioma manifesting as isolated progressive left oculomotor nerve paresis. Computed tomography and magnetic resonance imaging showed an intra-axial tumor in the left temporal lobe, extending to the basal and prepontine cisterns, and compressing the brainstem. The tumor was removed subtotally. The histological diagnosis was anaplastic astrocytoma. Malignant glioma with exophytic growth in the temporal lobe should be considered in the differential diagnosis of isolated oculomotor nerve paresis.

Paralysies oculomotrices douloureuses : une approche diagnostique

We review the question of diagnosis of painful and relatively isolated ophthalmoplegia due to diseases affecting the ocular motor nerves. For each clinical setting, we provide an overview of the main causes and a practical way to approach the diagnosis. As vascular malformations should always be kept in mind in patients with painful ophthalmoplegia, emergency neuroradiological investigations may be needed. However, the etiological scope is wide and the rationale for choosing the more appropriate examination and its optimal timing depends exclusively on the clinical evaluation. Despite advances in investigation techniques, diagnosis may remain difficult or even unresolved in a certain number of patients. We discuss successively paralysis of the third, sixth and fourth nerve, paralysis of several ocular motor nerves, recurrent ophthalmoplegia and ischaemic ocular motor palsies, which are the most frequent cause.

The effects of decompression and exogenous NGF on compressed cerebral cortex

Using a rat epidural bead implantation model, we found that compression alone could reduce the overall and individual layer thicknesses of cerebral cortex with no apparent cell death. The dendritic lengths and spine densities of layer II/III and V pyramidal neurons started to decrease within 3 days of compression. Decompression for 14 days resulted in near complete to partial recovery of the cortical thickness and of the dendritic lengths of layer II/III and V pyramidal neurons, depending on the duration of the preceding compression. The recoverability was better following short (3-day) than long (1- or 3-month) periods of compression. The loss of dendritic spines nevertheless persisted. An intraventricular infusion of NGF was performed after decompressing the lesions following 3 days of cortical compression, and this increased the recovery of the spines but not the dendritic length of the cortical pyramidal neurons, nor did it alter the recovery of the cortical thickness. NGF also promoted the increase of the dendritic spines, but not the dendritic length of the cortical pyramidal neurons of normal animals. In short, the data show that a few days of compression alone can cause permanent cortical damage. Exogenous NGF, if applied topically, may restore the dendritic spine density of cortical neurons subjected to compression.

The effect of epidural compression on cerebral cortex: a rat model

We developed a rat model of epidural plastic bead implantation to study the effect of physical compression on the cerebral cortex. Epidural implantation of a bead of appropriate size compressed the underlying sensorimotor cortex without apparent ischemia, since the capillary density of the cortex was increased. Although the thickness of all layers of the compressed cortex was significantly decreased, no apparent changes in the number of NADPH-diaphorase reactive neurons, reactive astrocytes, or microglial cells were observed, nor were apoptotic neurons observed. In fact, the densities of the neurons in most cortical layers apparently increased. To determine how epidural compression affects neuronal morphology, the dendritic arbors of layer III and V pyramidal neurons were evaluated using a fixed tissue intracellular dye injection technique. Neurons in both layers remained pyramidal in shape and their somatic sizes remained unaltered for at least a month after compression. On the other hand, their total dendritic length was significantly reduced beginning at 3 days post implantation. These analyses showed that apical dendrites were affected sooner than basal ones. The reduction of dendritic length was associated with a drop in the number of dendritic branches rather than dendritic trunks, suggesting the trimming of the peripheral part of the dendritic arbor. Detailed analysis showed that dendritic spines on all dendrites were reduced as early as 3 days following implantation. These results suggest that cortical neurons remodel their structures substantially within 3 days after being subjected to epidural compression.

Leptomeningeal glioblastoma presenting with multiple cranial neuropathies and confusion

Glioblastoma multiforme (GBM) is the commonest primary malignant neoplasm of the CNS. Usually, patients present with seizures and headache but in the elderly, confusion and generalised cognitive decline are more frequently the initial features. Multiple cranial nerve lesions as a manifestation of leptomeningeal meningitis is a rare presentation of GBM. The diagnosis is not often suggestive on either brain computed tomography (CT) or magnetic resonance imaging (MRI) and is usually confirmed by cerebrospinal fluid (CSF) cytology or histology. We describe the case of an 80-year-old man, who presented with multiple cranial nerve palsies and confusion secondary to leptomeningeal gliomatosis, in whom GBM was detected along the intra-ventricular lining of the left lateral ventricle at ventriculoscopy, in the absence of a distinct parenchymal lesion.

Cranial nerve root entry zone primary cerebellopontine angle gliomas: a rare and poorly recognized subset of extraparenchymal tumors

With the exception of patients with neurofibromatosis type II, pediatric extraparenchymal cerebellopontine angle (CPA) tumors of any sort are extremely rare. Most gliomas encountered in the CPA in either children or adults involve the CPA as exophytic extensions of primary brain stem and/or cerebellar tumors. We encountered an unusual case of a giant CPA pilocytic astrocytoma arising from the proximal trigeminal nerve, completely separate from the brain stem. A nine-year-old girl with no evidence for any neurocutaneous syndrome, presented with headaches, mild obstructive hydrocephalus, trigeminal hypesthesia and a subtle peripheral facial paresis. Pre-operative neuroimaging suggested a petroclival meningioma. The tumor was completely resected via a right pre-sigmoid, retro-labyrinthine, subtemporal, transtentorial ('petrosal') approach, using intraoperative neurophysiological monitoring, with minimal morbidity. This appears to be the first reported case of a pediatric primary CPA glioma and the seventh reported case of primary CPA glioma, overall. It represents the second reported case of a primary CPA pilocytic astrocytoma. Given the findings in this case and the six other cases of primary CPA gliomas reported in the literature, as well as the results of histological studies of normal cranial nerves, we hypothesize that the point of origin of these rare and unusual tumors is the root entry zone of the involved cranial nerves. The differential diagnosis of primary CPA tumors should be expanded to include cranial nerve root entry zone primary CPA gliomas.

Neurocytoma of the cauda equina. Case report

A case of a neurocytoma involving a nerve root of the cauda equina in a 46-year-old woman is reported. The patient presented with a 2-month history of progressive left lower-extremity weakness and pain and decreased ability to walk, as well as complaints of incomplete voiding. A magnetic resonance image revealed a 7-mm oval mass that was located intrathecally and extended from T-12 to L-1 and was adjacent to a nerve root. No lesions were identified at higher vertebral levels. The mass was excised. On histological examination it was found to have classical features of a neurocytoma. To the best of the authors' knowledge, this is the first report of a neurocytoma occurring in that region. A detailed histological description of this case and review of the pertinent literature are provided.

Isolated oculomotor nerve palsy: an unusual presentation of glioblastoma multiforme. Case report and review of the literature

The authors present a case of a very unusual clinical presentation of an intra-axial supratentorial glioblastoma multiforme (GBM) in a 63 year old diabetic female patient presenting with a three week history of left progressive complete oculomotor nerve palsy. CT scan and magnetic resonance imaging of the head revealed a left intra-axial mesial temporal glioblastoma multiforme. Operative resection and microscopic examination of a tissue specimen confirmed the diagnosis. The nature of the tumor, the pattern of spread and the postulated mechanisms of such a presentation are discussed. The authors suggest including the diagnosis of GBM in the differential diagnosis of patients with isolated complete oculomotor nerve palsy at the appropriate age group.

Oculomotor motion disorders: current imaging of cranial nerves 3, 4, and 6

The eye movements are controlled by the cranial nerves 3, 4, and 6 working in close cooperation under the supervision of the voluntary cortex. Clinically, the most common presentation of abnormal ocular motor motion is double vision. A thorough clinical examination can usually separate a local orbital cause which can produce a restriction of the muscles moving the eye from a neurogenic cause due to an abnormality of one of the three nerves or their association pathways. Recent articles in the scientific literature have described major advances in our understanding of the anatomy and vascular relationships of the three ocular motor nerves (cranial nerves 3, 4, and 6) and of the diagnosis and treatment of a variety of pathological processes that damage these nerves, including ischemia, inflammation, and compression.