Primary glioblastoma of the medulla spinalis: a report of three cases and review of the literature

Primary spinal glioblastoma multiforme (spinal GBM) is not a very common entity. This paper presents an outline of this rare neoplasm, its clinical presentation, course, management and outcome and reports a 3-case series of spinal GBM. In this 3-case series with spinal GBM, one of the patients was operated for hydrocephalous 10 months later following the tumor surgery and another patient had cerebral metastasis after the surgery. In the postoperative period, two of the cases received radiotherapy and one received combined radiotherapy and chemotherapy with steroid therapy together following the tumor surgery. The review of the pertinent literature has revealed that due to the scarcity of the reported cases of primary spinal GBMs, this issue requires a closer look. GBM behaves more aggressive in medulla spinalis than it behaves when it originates from cerebrum. It may disseminate to the cerebrum during its course and it may cause hydrocephalus due to this dissemination (metastasis).

Intravascular Papillary Endothelial Hyperplasia of the Central Nervous System-Four Case Reports-

Four rare cases of intracranial intravascular papillary endothelial hyperplasia (IPEH) manifesting as cranial nerve disturbances occurred in 16-, 18-, 24-, and 28-year-old females. Magnetic resonance imaging showed all lesions as isointense with strong enhancement on T1-weighted images, and as hyperintense on T2-weighted images. All lesions were removed via craniotomies. Histological examination found vascular structures and papillary spaces lined with endothelial cells showing immunoreactivity for CD31. Complete removal was curative in two cases, whereas incomplete removal resulted in cure in one case and residual deficits in one case. Iatrogenic deficits should be avoided in IPEH treatment by surgery. Differentiation from neoplasm such as angiosarcoma depends on histological characteristics.

Failure to detect Chlamydia pneumoniae DNA in cerebral aneurysmal sac tissue with two different polymerase chain reaction methods

OBJECTIVE

Chlamydia pneumoniae (C pneumoniae) is a common cause of a usually mild, community acquired pneumonia. This organism, however, can spread from the respiratory tract into other parts of the body and has been detected in up to 70% of atheromatous lesions in blood vessels. Although the exact mechanism of the C Pneumoniae contribution to the pathogenesis of atherosclerosis remains unknown, prophylactic antibiotic trials are planned for people at high risk for coronary disease.

METHOD

In this study the authors aimed to investigate C pneumoniae DNA content in the cerebral aneurysmal sac tissue with the aid of polymerase chain reaction (PCR) method. C pneumoniae DNA was searched in 15 surgically clipped and removed aneurysmal sac tissue and in two tumour (an ependymoma of the fourth ventricle and a craniofaringoma) samples by touchdown enzyme time release PCR (TETR PCR) targeting 16S rRNA gene and by nested PCR targeting ompA gene.

RESULTS

Both PCR methods were sensitive to detect in C pneumoniae 4x10(-2) genomes. C pneumoniae DNA was not detected in any of the 17 sample tissues of these patients.

CONCLUSION

The contribution of C pneumoniae in the development of intracranial aneurysms cannot be excluded despite the results of this study. Further studies on the possible role of C pneumoniae or any other micro-organisms in the pathogenesis of aneurysms should be performed.

Secretory meningiomas

Secretory meningiomas are a rare meningioma subtype. Among meningiomas, the frequency of secretory meningiomas is 1.6%. Unlike other meningioma types, most of the patients were female (ratio 3:1). No recurrence was reported during the 24-180 months follow-up period of our secretory meningiomas in which, a low level of 0.3% Ki-67 proliferative index was reported. In this meningioma subtype, the percentage of cases with positive progesterone receptor is 33%. With carcinoembryonic antigen, cytokeratin and epithelial membrane antigen, in all the cases positivity was observed in both, the inclusions and the cells surrounding them. With human milk fat globulin 2, a high ratio (92%) of positivity was observed. Majority of the cases were negative with CA125, only three of the cases had suspicious positivity. Distribution of inclusions was irregular and their positive reactions showed varying staining features. Positivity with alpha-1-antitripsin was seen not only in the inclusions but also in some meningothelial cells as well. Ubiquitin was positive in inclusions of the 83% of cases. Staining features of the inclusions pointed out the possibility of them being in a varying age and/or content. Secretory meningiomas are a different type compared to other meningiomas, not only with their histological features but also with their clinical features as well.

Intradural Aneurysm Caused by Arterial Injury during Surgery: Treatment with Coil Embolization

SUMMARY

We described a patient with subarachnoid hemorrhage due to a ruptured intradural aneurysm caused by arterial injury during surgery and severe symptomatic vasospasm. The iatrogenic posttraumatic aneurysm was occluded by using GDC with preservation of parent artery followed by intraarterial infusion of papaverine to treat vasospasm as an one-stage procedure. This resulted in significant angiographic resolution of the vasospasm and the patient's clinical outcome was excellent. Endovascular approach to posttraumatic intracranial aneurysms and endosaccular GDC embolization of aneurysm with concomitant intraarterial papaverine infusion to treat vasospasm are discussed.

Local interstitial chemotherapy with sustained release bucladesine in de novo glioblastoma multiforme: a preliminary study

This clinical study was designed to evaluate the safety and efficacy of the sustained release form of dibutryl adenosine-3',5'-cyclic monophosphate (dB-cAMP, bucladesine) placed in the tumor resection cavity at the time of recurrence of the de novo glioblastoma multiforme (GBM) patients. In a randomized prospective manner, 40 patients who were diagnosed as GBM in their first operations were included in this study. Four different therapy protocols were used: First group of 10 patients had tumor resection only. Second group assessed had only systemic chemotherapy as six i.v. infusions of fotémustine after tumor resection. Third group had implantation of bucladesine-loaded biodegradable polymeric sustained release (bcl-SR) pellets while the last group received six i.v. infusions of systemic fotémustine as in the second group in addition to local implantation of bcl-SR pellets. A biodegradable polymer, poly-DL-lactide-co-glycolide with molecular weight of 80000, was used as carrier matrix for the drug with an approximately 4-5 months of release time. Maximal doses of 20 mg of bucladesine with a mean dose of 15.5 mg were implanted. No bone marrow suppression occurred and there were no wound infections as far as the local bucladesine-loaded polymer therapy is concerned. In this randomized prospective trial of local interstitial chemotherapy with long acting bcl-SR did show a statistically significant delay of recurrence on the treatment of GBM patients. Best treatment results obtained from the local bcl-SR + systemic fotémustine treated group in which survival rate estimated by the Kaplan-Meier method was 70% in de novo GBM at 12 months.

Efficacy of controlled-release papaverine pellets in preventing symptomatic cerebral vasospasm

OBJECT

Vasospasm as a complication of subarachnoid hemorrhage is a major concern in clinical practice. The systemic drugs in current use are of limited value. Topical, intrathecal, or intraarterial papaverine administered during surgical or angiographic procedures is a potent vasodilating drug; however, hypotension limits its systemic application. Local application of papaverine in a biodegradable controlled- or sustained-release matrix is proposed for vasospasm prophylaxis to be used in patients scheduled for aneurysm surgery.

METHODS

Controlled-release papaverine (PapaCR) drug pellets were prepared using the biodegradable aliphatic polyester poly(DL-lactide-co-glycolide) as the carrier matrix. In vitro tests were performed to determine drug kinetics. One hundred seventeen patients, 73 assigned to the control group and 44 assigned to the PapaCR-treated group, participated in this study. Patients who were deemed to be at high risk for the development of vasospasm were selected to participate in the study. During aneurysm surgery, drug pellets were placed in cisterns over arterial segments. In two patients, cerebrospinal fluid was sampled every 6 hours for the first 5 days through a lumbar catheter that had been inserted at the beginning of aneurysm surgery. The incidence of clinical vasospasm and Glasgow Outcome Scale scores in the patients were evaluated statistically. The results of in vitro studies showed that effective local concentrations of papaverine could be maintained for more than 10 days. The first-degree drug-release profile was demonstrated using this design. In clinical studies no adverse effects due to the drug were seen. The PapaCR effectively prevented development of clinical vasospasm. and outcome scores were significantly better in patients in the treated group.

CONCLUSIONS

Local application of controlled- or sustained-release papaverine can be safely used in preventing vasospasm.

Alterations in superoxide dismutase, glutathione peroxidase and catalase activities in experimental cerebral ischemia-reperfusion

Free radicals are thought to be the most important cause of the reperfusion injury subsequent to ischemia. The antioxidant status of the tissue affected by ischemia-reperfusion is of great importance for the primary endogenous defense against the free radical induced injury. This investigation was performed to evaluate the antioxidant enzyme capacity of the brain tissue in the ischemia-reperfusion period using an experimental global moderate (penumbral) ischemia model on rat brains. Experiments were performed on 45 male Sprague Dawley rats. Ischemia was induced by bilateral vertebral arteries cauterization and temporary bilateral carotid arteries occlusion and sustained for 10 minutes. At the end of ischemia (0 min reperfusion) and various reperfusion periods (20 min, 60 min, 240 min), rats were decapitated and brains were frozen in liquid nitrogen. Changes in the intracellular antioxidant enzyme (superoxide dismutase, glutathione peroxidase and catalase) activities were assessed in the rat brain tissues, by spectrophotometric methods. In all moderate ischemia-reperfusion groups, superoxide dismutase activities were found to have decreased significantly compared to the sham operated controls (P < 0.05). During ischemia superoxide dismutase activity was lowered to 31% of that of the control group. The decreases were more significant in reperfusion groups, particularly in 60 min reperfusion (40%). Relatively smaller but still significant diminution was observed in glutathione peroxidase activities (P < 0.05). The ratio of diminution was striking in 20 min and 60 min reperfusion groups with 26% of the sham operated rats. Conversely, moderate ischemia-reperfusion caused significant increase in catalase activities (P < 0.05). The increment was 63% of the preischemic level with 10 min of moderate ischemia. In conclusion, activities of the major antioxidant enzymes were changed significantly in moderate brain ischemia-reperfusion. These results suggest that the disturbance in oxidant-antioxidant balance might play a part in rendering the tissue more vulnerable to free radical induced injuries.

Evaluation of lipid peroxidation, cathepsin L and acid phosphatase activities in experimental brain ischemia-reperfusion

This investigation was conducted in rat brain tissues to elucidate the free radical induced cellular and subcellular membrane injuries in two different depth of global ischemia. Global moderate (penumbral) ischemia was performed on rat brains by bilateral vertebral arteries cauterization and temporary occlusion of the bilateral carotid arteries. Global severe ischemia was produced by a neck tourniquet in addition to four vessel occlusion. Somatosensory evoked potentials (SSEPs) were used as a feed back parameter to monitor electrophysiologically the ischemia. At the end of ischemic insult (0 min reperfusion) or various reperfusion periods (20, 60 and 240 min), all rats were decapitated and brains were frozen in liquid nitrogen. The brain tissues were prepared for the determination of cathepsin L (CL) and acid phosphatase (AP) activities in the supernatant (cytosolic) fraction (SF) and the fraction enriched with lysosomes (FEL). Further the level of thiobarbituric acid reactive substances (TBARS) of lipid peroxidation was assessed by the spectrophotometric methods. Severe ischemia-reperfusion was accompanied by a significant increase in TBARS levels and the SF/FEL ratio for CL and AP activities compared to the sham operated group and the concurrent reperfusion groups of moderate ischemia (p<0.05). There were no significant differences between the sham operated and moderate ischemia-reperfusion groups for the same parameters. Our data clearly demonstrate that; in rat brain although severe ischemia-reperfusion causes lipid peroxidation in cellular membranes and redistribution of lysosomal enzymes from lysosomes to cytoplasm due to lysosomal membrane injury, there are no changes in lysosomal membrane stability in moderate ischemia-reperfusion.

Meningioma of the cavernous sinus in a child

Intracranial meningiomas in children are rare, representing 1-4.2% of central nervous system tumors and 1.5-1.8% of all intracranial meningiomas. Meningiomas arising from the lateral wall of the cavernous sinus account for less than 1% of all intracranial meningiomas. To our knowledge, only one case of a meningioma arising from the cavernous sinus has been reported in childhood. A 6-year-old boy presented with left ophthalmoplegia. A slight drooping of the left eyelid was noted at the age of 1 year. Magnetic resonance imaging (MRI) with contrast administration revealed an enhancing mass lesion located in the left cavernous sinus. The tumor, arising from the lateral wall of the cavernous sinus, was totally removed and the oculomotor nerve was reconstructed with a sural nerve graft. MRI displayed total tumor removal 1 month after the surgery. The pathological diagnosis was of a psammomatous meningioma.

Spinal hydatid disease

Vertebral hydatid cysts are rare and found in less than 1% of all the cases of hydatidosis. Neural compression is common in vertebral hydatidosis. The prognosis is generally regarded as very poor. This paper examines the natural history and complications which may arise during the treatment of vertebral hydatid cyst, and discusses their treatment. Thirteen cases of hydatid disease affecting the vertebrae are presented. The patients were admitted with symptoms of spinal cord compression. Twelve were treated by laminectomy and one by costotransversectomy. Low back pain radiating to the legs and lower extremity weakness were the predominant symptoms. Different degrees of pareses were present in 12 patients. Nine patients had impaired sensation in lower extremities. In 13 patients, 27 operations were performed. The major complication of surgery was the death of one patient due to the formaline irrigation. The surgical goal should be an extensive removal of the cysts and affected bone. The surgical area needs to be irrigated with hypertonic saline. Mebendazole or albendazole therapy seems to retard the recurrences and control the disease.

Surgery of intramedullary spinal cord tumors

The diagnosis and management of intramedullary spinal cord tumors have been significantly influenced by new diagnostic and surgical tools such as MRI, ultrasonic aspiration, intraoperative ultrasound, and evoked potential monitoring. In this study we compared the surgical results of our earlier cases using conventional methods with more recent cases using these new methods. We report our experience based on 44 adult cases. Histologic diagnosis revealed ependymoma (20 cases), astrocytoma (15 cases), glioblastoma multiforme (1 case), and other histologic diagnoses (8 cases). We performed 20 gross total resections, 19 partial resections, and 5 biopsies. The mean follow-up period was 25.8 months (3 months-10 years). Surgical results were improvement in 11 patients (25%), stabilization in 24 (54%), and deterioration in 9 (20%). The first 28 cases (group A) were diagnosed using conventional myelography and CT myelography. The more recent 16 cases (group B) were diagnosed with MRI and operated on using techniques such as ultrasonic aspiration, intraoperative monitoring and ultrasound imaging. Radical surgery (total excision) was performed in 36% (n = 10) of group A, while it was possible in 62% (n = 10) of group B. Deterioration after operation was noted in 28% (n = 8) of group A, but only 6.2% (n = 1) of group B. These results stress the importance of a preoperative MRI scan and the positive effects of intraoperative ultrasound imaging, ultrasonic aspiration, and evoked potential monitoring on surgical results. With the help of these tools, most intramedullary spinal cord tumors may be diagnosed and treated surgically with significantly decreased risk. Radical surgery was possible in as many as 62% of our more recent patients. Partial resection with radiotherapy should be confined to patients with high-grade astrocytomas.

A case of Rathke's cleft cyst presenting with diabetes insipidus

Rathke's cleft cysts (RCCs) are considered to arise from the remnants of Rathke's pouch, an invagination of the stomodeum. They are classically described as benign epithelium lined intrasellar cysts containing mucoid material, and also found in 2-33% of routine autopsy series. The most common presenting symptoms are visual impairment, hypothalamic dysfunction, hypopituitarism and headache. Diabetes insipidus has been described in patients with RCC. Very few cases presented with only diabetes insipidus in adults. To our knowledge, our patient is the first case of RCC presenting with only diabetes insipidus in childhood. A 9-year-old girl presented with diabetes insipidus. The physical, neurological and endocrinological examinations were normal, except for diabetes insipidus. Magnetic resonance imaging scan revealed a hyperintense lesion with supra sellar extension in the posterior pituitary both on T1 and T2 weighted images. Subtotal excision of RCC was performed via transsphenoidal surgery. However, diabetes insipidus persisted after the surgery.

Petrous apex mucocele: high resolution CT

Mucocele of the petrous apex is very rare, only three cases having been reported. Since this area is inaccessible to direct examination, imaging, preferably high resolution computed tomography (HR CT) is essential. We report a case showing an eroding, non enhancing mass with sharp, lobulated contours, within the petrous apex. The presence of a large air cell on the opposite side suggested a mucocele.

Pressure distribution on the wall of experimental aneurysms

Since it is known that turbulent flow exists in aneurysms, we have investigated whether pressure might be distributed unevenly on the aneurysmal wall, and whether it varies with the shape and size of the aneurysm and its orifice diameter as well as with the direction of blood flow in the parent vessel. It was found that in some instances, such as with aneurysms having narrow necks and situated at 90 degrees to the parent vessel blood flow, aneurysmal pressure is relatively low.