Transalar transsphenoidal meningoencephalocele presenting in the form of recurrent meningitis: Report of two cases and discussion of the diagnosis and treatment

INTRODUCTION

Skull base meningoencephaloceles are rare congenital malformations. The two cases of transalar transsphenoidal malformation reported here differ from the classical transsphenoidal meningoencephalocele.

CASE REPORTS

Case 1 was a three-and-a-half-year-old boy and case 2 was a 36-year-old man. Both cases presented with clinical features of recurrent meningitis. Surgical management of case 1 was performed via an intradural infratemporal fossa craniotomy with reoperation 2years later. In the second case, surgery was initially performed via an endonasal approach and then via pterional craniotomy. Reoperation via Sekhar's transpetrosal approach was also a failure. Only closure of the trigeminal-pontine angle via a suboccipital retrosigmoid approach allowed repair of the defect.

DISCUSSION

Surgical access to the pterygopalatine fossa is complex due to its anatomical position and its anatomical relations with nerves and vessels. An endoscopic approach appears to be a valuable alternative to classical craniotomy.

CONCLUSION

In the two cases reported here, neurosurgery allowed lasting closure of the defect.

Influence of PET/CT on radiologists and contrast-enhanced CT on nuclear medicine physicians in patients with lymphoma

AIM

We assessed in this study the influence of contrast-enhanced CT (ceCT) on PET/CT interpretation and PET/CT on ceCT interpretation in patients with lymphoma, before and after chemotherapy.

METHODS

Fifty patients with Hodgkin disease (N.=17) or non-Hodgkin lymphomas (N.=33) were assessed before and after chemotherapy. PET/CT were performed 60 minutes after injection of FDG. Iopamidol was then injected and followed, 50 seconds later, by another CT. PET images were successively reconstructed using non-enhanced CT (PET-) and ceCT (PET+). Four nuclear physicians rated PET- and PET+ in random order. Three radiologists initially rated ceCT alone and then ceCT along with PET+.

RESULTS

Before chemotherapy, global agreement (GA) was 99% (k=0.96) when PET- was compared to PET+. Nine (5%) lesions were discordant, 5 according to PET- and 4 to PET+. After chemotherapy, GA was 99% (k=0.91). Eight (15%) lesions were discordant, 3 according to PET- and 5 to PET+. Before chemotherapy, GA was 97% (k=0.91) when ceCT was compared to ceCT with PET+. Twenty-one (12%) lesions were discordant, 16 when ceCT were analyzed alone and 5 when ceCT was analyzed with PET+. After chemotherapy, GA was 95% (k=0.76). All 30 (35%) discordant lesions were positive according to ceCT alone. A significant difference between the 2 procedures was found in the pelvis and in the groin (P<0.05).

CONCLUSION

PET+ did not differ from PET-, before and after chemotherapy. Fewer abnormalities were observed, when ceCT was analyzed with PET+, particularly after chemotherapy, due to residual masses that are better analyzed with functional imaging.

[Laryngeal schwannomas]

Laryngeal schwannoma is a rare benign tumour of the larynx. Schwannomas derive from the Schwann cells. The majority occurs in supraglottic area and may arise at any age. Magnetic resonance imaging (MRI) is the best imaging tool for suggesting the diagnosis in the appropriate clinical context. Conservative surgery is the treatment of choice. These tumors have to be distinguished from neurofibromas. We report 2 cases of laryngeal schwannoma. The first one concerned an 8-month-old baby with a laryngeal stridor history which seemed to be related to laryngomalacia. The second case was a 22-year-old man with a 5-year history of dysphonia. On nasofibroscopic examination, a sub mucosal mass enlarged the posterior part of the right false vocal cord in both cases. Both CT scan and MRI sequences showed a well margined lesion in the same place. Histological biopsies identified a schwannoma. External surgeries were subsequently and successfully performed. Diagnosis (imaging), specific treatment (endoscopic or external surgery), and possible association of laryngeal schwannomas are discussed.

Metastatic spread of gynaecological neoplasms to the adrenal gland: case reports with a review of the literature

Metastatic involvement of the adrenal glands due to gynaecological neoplasms is a relatively rare condition. The aim of our study was to present four cases of metastases to the adrenal gland due to endometrial adenocarcinoma, ovarian and cervical cancer. These cases are correlated with a review of the literature. CT scan and MRI have been previously used in an attempt to define the nature of the adrenal mass but this approach is of limited value in diagnosis. Image-guided pathological confirmation of an adrenal lesion may significantly change the staging or management of the primary neoplasm. The authors suggest that isolated adrenal metastasis should be routinely considered for surgical management.

[Imaging of a foreign body in the submandibular space]

Foreign bodies in the oral cavity are infrequent in children. In spite of a negative clinical exploration, US and CT showed the suction cup of a rubber-tipped dart in the left submandibular space of a 3 year-old child. Surgery could be guided by these investigations.

Giant cervical epidural veins after lumbar puncture in a case of intracranial hypotension

A 29-year-old woman presented with dilated epidural veins and incapacitating headache after undergoing a lumbar puncture. Two months later, the results of follow-up MR imaging were normal. These findings suggest that temporary dilation of the epidural vein may occur in association with post-lumbar puncture intracranial hypotension syndrome. In these cases, it seems useful to confirm whether the patient has recently undergone a lumbar puncture.

Fomepizole (4-methylpyrazole) in fatal methanol poisoning with early CT scan cerebral lesions

BACKGROUND

Methanol poisoning, potentially fatal, is generally treated with the combination of ethanol as antidote, and hemodialysis. Fomepizole, a competitive inhibitor of alcohol dehydrogenase, has more recently been used, and is capable of blocking the toxic metabolism of methanol. To our knowledge, its use has never been reported as an antidote in severe methanol poisoning requiring hemodialysis.

CASE REPORT

We report a case of fatal methanol poisoning (1.9 g/L on admission) suspected due to the combined presence of coma and severe metabolic acidosis with normokalaemia.

CONCLUSION

The fomepizole treatment protocol (10 mg/kg by i.v. infusion over 1 hour before dialysis, repeated 12 hours later in combination with 1.5 mg/kg/h during dialysis) was simple to use and appeared effective in eliminating methanol in combination with hemodialysis. The case is also unusual in terms of severity and the early onset of cerebral lesions demonstrated by computed tomography (CT) scan.

Haemorrhage in the labyrinth caused by anticoagulant therapy: case report

We report a patient who experienced a severe vertiginous episode with bilateral tinnitus and progressive right-sided hearing loss. She had Marfan's disease and was on anticoagulant treatment. The fluid in the labyrinth gave higher signal than cerebrospinal fluid on T1-weighted images, suggesting haemorrhage. The radiological follow-up is discussed.

[Brachial diplegia caused by cervical spinal cord ischemia. A case]

We report one case of acute cervical spinal cord infarction characterized by motor impairment of the upper limbs with respect of the lower limbs. It occurs infrequently. The purpose of this paper is to discuss the clinical, neurophysiological and magnetic resonance imaging findings, and to review the presumed mechanisms of spinal cord infarction.

[Spontaneous intracranial hypotension syndrome. A case]

We report a 49-year-old woman with spontaneous intra-cranial hypotension. this characteristic syndrome associates postural headache and a low cerebro-spinal fluid pressure. It was confirmed by lumbar puncture and magnetic resonance imagery. We describe the clinical and the cerebro-spinal fluid features, the radiological appearances, and the clinical and radiological course. The interests of this diagnosis are, first, its spontaneous benign course and, second, to avoid unnecessary invasive investigations.

[Orbital metastases of melanoma of the choroid. Value of imaging]

Choroidal melanoma is characterized by an unpredictable clinical course, during which metastatic disease may occur after a prolonged disease-free interval. However, metastases to orbit are quite rare; there have been only 6 reported cases in the literature. We report well documented examples of metastases to the orbit from a melanoma of the choroïd first diagnosed 8 years earlier. MR imaging is accurate in determining the exact location of lesions and their nature owing to the paramagnetic properties of melanin.

[Spontaneous thrombosis of cerebral arteriovenous malformation]

Complete disappearance of a cerebral arteriovenous malformation (AVM), 9 years after its discovery, is reported in a 45-year-old man. This unusual evolution was revealed by the onset of 3 seizures. CT scan and MR imaging eliminated any hemorrhage and carotid angiography showed the spontaneous thrombosis of the whole malformation. The evolution of the MRI signals demonstrates that seizures and the disappearance of the AVM were concomitant. It is suggested that the spontaneous thrombosis of the venous drainage caused the AVM disappearance with cerebral oedema responsible of seizures.

[Lumbar interapophyseal septic arthritis. Apropos of 3 cases]

Septic arthritis of spinal apophyseal joint, seldom described, mainly concern the lumbar spine. We report three cases. Inflammatory lesions of the paravertebral soft tissues were associated in each case; an epidural abscess was present twice. Our three cases were due to Staphylococcus aureus. The initial clinical features were consistent with a spondylodiscitis. Imaging led to the correct diagnosis in all cases. According to our observations and several others of the literature: facet joint lesions are visible too late on plain films. Bone scintigraphy is sensitive, but not specific. CT scan and MRI are the most contributive investigations. A pathologic aspect of the paravertebral soft tissues is visible less than one week after the beginning of the symptoms on CT scan and MRI. Lesions of the facet joint are detectable as soon as the first week on MRI, and after 15 days of clinical course on CT scan. Epidural abscess, when present, is best shown by MRI as early as the first week. CT scan can guide percutaneous needle biopsies of the paravertebral abscesses or of the concerned facet joint.

[Mammographic aspects of Aschoff's proliferative centres]

The pseudotumoral feature of radial scar cause considerable diagnostic problems mammographically and at the extemporaneous examination. From a series of 28 cases, the authors confront their experience with classical mammographic data and emphasize: the difficulty in analysing the central area of the radiating structure, the possibility of glandular retraction, the relationship between spicules and radiolucent linear structures. These radiological criterias do not allow us to affirm the diagnosis. Extraction with histological examination of the operatory fragment is the only attitude.

[Granular cell tumors (Abrikossoff's tumors) of the breast. Apropos of 4 cases]

Granular cell tumors are rarely localized in the breast gland because of diagnosis is difficult compared to breast skin lesions. Clinically and radiologically, pseudo-neoplastic aspect can be encountered. Differential diagnosis with an invasive carcinoma can be difficult on frozen section. But final histological analysis easily confirms the diagnosis. The treatment consists in local excision of the tumor. Today we can admit that granular cell tumors are derived from schwann cells.