Solitary cysticercus granuloma of the brainstem. Report of four cases

Isolated brainstem involvement in patients who have neurocysticercosis is rare. The authors describe the clinical and radiological features of four patients with a solitary cysticercus granuloma of the brainstem and discuss their case management. In three of the patients the onset of symptoms was fairly rapid, occurring over a few days. The granuloma appeared as an enhancing lesion measuring 20 mm or less, with a ring- or disklike appearance on computerized tomography and magnetic resonance imaging. A stereotactic biopsy provided the definitive diagnosis in one patient. In two patients the granuloma resolved spontaneously with complete regression of symptoms and signs and in one patient the granuloma resolved following albendazole therapy. In all patients, outcome was excellent or good (follow-up evaluation 6 months-3 years) with only one patient having persistent paresthesias on one side of his body. Because spontaneous resolution is the rule, a conservative approach to case management, including observation, is recommended. The importance of recognizing this entity and avoiding unnecessary surgical intervention or empirical antituberculous chemotherapy is emphasized.     

Treatment of posterior skull base tumors

Treatment of ureteral stenosis has been attempted in many patients with transplanted kidneys. Treatment with the Acucise catheter system is a new approach for such patients. Published results of the approach in eight patients promise safety, effectiveness, and low perioperative morbidity. We report two cases of transplant ureteral stenosis treated with Acucise. One patient with stenosis of the pyeloureteral junction was treated successfully and has been free of recurrence for 9 months. The other patient had long-distance stenosis of the lower portion of the transplant ureter. Acucise incision was successful, but the patient had to undergo uretero-neocystostomy because of a ureteroperitoneal fistula. We use these cases to illustrate the disadvantages of endourological ureteral surgery as a standard therapeutic approach after renal transplantation. We suggest that Acucise is reliable when used in patients with uncomplicated short-distance ureteral stenosis; however, patients with long-distance stenosis or stenosis caused by heavily scarred periureteral tissue will not profit from it because of a higher complication rate.     

Surgery of the anterior skull base

Inflammatory disease of the frontal, ethmoid, and sphenoid paranasal sinuses may extend to the adjacent anterior skull base and then intracranially. The potential for this serious complication of sinus disease must be recognized by the primary otolaryngologist-head and neck surgeon, and alternative management strategies must be taken once it is diagnosed. Topics discussed in this article include cranial anatomy, surgical techniques and variations, complications, and special considerations.     

Solitary plasmacytoma of the skull: a case report

Solitary plasmacytoma of the skull is very rare and only 35 cases have been reported in the English literature. It remains controversial whether solitary plasmacytoma of the skull is essentially identical with solitary plasmacytoma of bone or not. Solitary plasmacytoma of bone including solitary plasmacytoma of the skull is characterized by a radiologically solitary bone lesion, neoplastic plasma cells in the biopsy specimen, fewer than 5% plasma cells in bone marrow, less than 2.0 g/dl monoclonal protein in the serum when present and negative urine test for Bence Jones protein (monoclonal light chain). Solitary plasmacytoma of bone tends to disseminate or progress to multiple myeloma even as long as 7-23 years after presentation. We report the first case of solitary plasmacytoma of the skull in which both beta2-microglobulin for detection of early renal disturbance and neoplastic plasma cell labeling index for detection of DNA synthesis were examined in order to predict the clinical course of solitary plasmacytoma of the skull.     

Chondrosarcomas of the skull base: review of the literature and report of two cases

The use of intravital microscopy as a tool for studying the microcirculation has increased greatly over the last several decades. Early microscopes provided the first pictures of the microcirculation, but were cumbersome to use and subjected the tissue to a high light intensity, a problem which has recently become the subject of much discussion. The goal of this project was therefore to build a more ergodynamic microscope which minimizes the light exposure to the tissue. The automation of the microscope controls provides a platform on which other options can be built into the microscope, such as an autofocus feature. Furthermore, the use of the Optimas software also opens the possibility for on-line data processing.     

Bitemporal hemianopsia after skull base fracture

We report a case of bitemporal hemianopsia after skullbase fracture. An 18-year-old male presented with frontal head hit due to a traffic accident. Consciousness level on admission was JCS 10. Initial CT scan revealed traumatic SAH and pneumocephalus. We treated him conservatively. Ten hours after the accident, consciousness level went down, and CT imaging disclosed bilateral frontal hemorrhage. The three dimensional CT (3D-CT) imaging showed two fracture lines from the roof of the ethmoid sinus to the planum sphenoidale. Although his consciousness improved gradually, he complained of rhinorrhea, anosmia and double vision. On preoperative visual field examination, bitemporal hemianopsia was noticed. Repair operation for CSF rhinorrhea was performed. Operative findings revealed two fracture lines corresponding to the 3D-CT scan. The optic chiasm was compressed by the tuberculum sellae. We could not find obvious tearings or stretchings of the chiasm. Reports on operative findings of traumatic chiasmal syndrome are rare, and most of the reports presume that bitemporal hemianopsia results from tearing or stretching of the chiasm. We could confirm that, in some cases, bitemporal hemianopsia could result from direct pressure of the tuberculum sellae.     

Congenital malformations causing skull base changes

Recent advances in imaging have enabled both the clinician and radiologist to better understand the therapeutic implications of congenital anomalies involving the skull base. Critical to this understanding is a full knowledge of normal embryologic development, anatomic detail, and clinical manifestations in the wide variety of congenital malformations involving the skull base. This review focuses on individual malformations in terms of their pathophysiology and their imaging findings of critical importance.     

Surgery of the base of the skull

To treat pathological processes, primarily tumors, in the base of the skull is one of the most intricate neurosurgical problems. In the past decade, interest in this problem has greatly increased due to the advent of new methods of diagnosis, up-to-date neurosurgical equipment and to a greater cooperation of physicians of related disciplines: ophthalmologists, otosurgeons, plastic surgeons. The authors present and summarize the experience accumulated by the researchers of the N. N. Burdenko Institute of Neurosurgery in the past 10 years in treating basal tumors. Based on a great deal of clinical findings, approaches are proposed in treating some groups of basal tumors, such and pituitary adenomas, craniopharyngiomas, meningiomas at various sites, trigeminal and acoustic neurinomas, and malignant neoplasms of the base of the skull. The conditions required for successful surgical treatment of the processes in the base of the skull are described in detail. One of them is a correct determination of a surgical approach.     

Congenital encephalocele of the medial skull base

Intensive case management for severely psychiatrically ill patients is a relatively new phenomenon in the private sector. The authors describe a comprehensive case management program designed at Blue Cross Blue Shield of Massachusetts to meet the needs of the most severely ill psychiatric patients in a private managed care environment. The case management program emphasizes involvement of patients in creating comprehensive treatment plans; development of a relationship between case managers, patients and their families, and providers; and clinical coordination between the public and private sectors to create individualized treatment plans. The program's case managers are able to flex the benefit limitations of a managed care or indemnity plan to integrate public and private services and can enlist providers outside a managed care network. The paper describes service utilization by the first 33 patients who participated in the program for one year.     

Injuries of the central base of the skull

In different types of lesions, especially in frontobasal and laterobasal ones, the central base of the skull is injured, too (in about 20% of severe frontabasal lesions). Surgical treatment is necessary. Examination of intra- and infrabasal structures and localized intracranial operations may be performed by transthemoidal-transphenoidal or transpyramidal approaches. Main problems are the treatment of dura lesions, the control of hemorrhages, the examination of the optic nerve, and the compensation of disturbances of central regulation. The above experiences we gathered from patients in the ORL Clinic of Jena University.     

Chordomas of the skull base: dynamic MRI

OBJECTIVE: To investigate the role of dynamic MRI in the diagnosis of chordomas at the skull base. MATERIALS AND METHODS: Six patients with surgically proven chordomas of the skull base were examined with spin-echo technique (repetition time/echo time 200 ms/15 ms). Serial imaging was performed every 30 s for 240 s after a rapid injection of gadopenetate dimeglumine (0.1 mmol/kg). The contrast material enhancement ratio (CER) was analyzed. The CER was obtained for each region of interest as follows (Sn - So) x 100/Smax - So, where Sn indicates signal intensity at each dynamic phase; So, signal intensity on the image obtained before administration of contrast material; and Smax, maximum signal intensity of all dynamic imaging. RESULTS: All chordomas showed very slow but steady increase of contrast enhancement with no peak within 240 s. The CERs of six cases at 30 s are 13 to 40 (mean value +/- standard deviation: 22.8 +/- 10.2). CONCLUSION: Dynamic MRI may be helpful in differentiating between chordomas and other tumors of the skull base.     

Atypical central nervous system lymphoma at the cranial base: report of four cases

OBJECTIVE AND IMPORTANCE: Primary central nervous system lymphoma is a disease with increasing incidence. Atypical presentations are becoming more frequent. CLINICAL PRESENTATION: Three patients bearing cavernous sinus lesions presented initially with periorbital pain and diplopia. Tolosa-Hunt syndrome was the initial presumptive diagnosis for two patients, and meningioma was the diagnosis for the third patient. A fourth patient presented with left ear pain, and a mass in the left internal auditory canal was thought to represent an acoustic neuroma. INTERVENTION: For all four patients, an operative pathological diagnosis was obtained and was compatible with central nervous system lymphoma. All patients were treated with osmotic blood-brain barrier disruption with intra-arterial chemotherapy using a methotrexate-based regimen. CONCLUSION: All four cases included atypical presentations of lymphoma. These cases again illustrate that a correct diagnosis cannot be obtained based only on imaging and clinical findings.     

Microsurgical treatment of midfacial tumours involving the skull base

PROBLEM: In rats, immunization with male accessory gland (MAG) extract promotes experimental autoimmune vesicle prostatitis. A specific mononuclear cell-mediated immune response and prostate androgen metabolism impairment in MAG-immunized rats were observed. The possibility that lymphocytic soluble factors (SoFs) can regulate the local steroid metabolism in these rats directly was studied. We investigated whether the SoFs released by MAG-sensitized lymphocytes are capable of modifying the prostatic androgen metabolism and whether they induce histologic lesions "in vivo" when they are inoculated, carried by liposomes, into untreated rats. METHOD OF STUDY: "In vitro" enzymatic [3H]-5 alpha-dihydrotestosterone bioconversion and histologic studies were performed with prostates from SoF-treated rats (LK rats). The obtained 3 alpha/beta-hydroxysteroid-oxidoreductase activities showed that LK rat values were significantly lower than in controls: 79.0 +/- 2.5 vs 158.7 +/- 10.2 pmol/min/mg protein, respectively (P < 0.01). RESULTS: In the histologic studies, LK rat prostates showed focalized mononuclear infiltrates of various degrees, whereas control rats showed non-atypic modification of the gland. CONCLUSION: These results indicate that SoFs (probably total lymphokines) contribute significantly to the pathogenesis of experimental autoimmune prostatitis, involving a biochemical relationship between immune reaction and the androgenic enzymatic inhibition in the prostate.     

Benign fibroosseous lesions involving the skull base, paranasal sinuses, and nasal cavity. Report of two cases

We report a case of a basilar artery migraine in a 17-year-old boy with transient CT and MR abnormalities after each of two migraine episodes. A repeat MR study 6 months after the last event showed complete resolution of the lesion. Transient abnormalities on brain images similar to those shown in our case have been reported in patients with migraine and other neurologic conditions and are most likely related to cerebral vasogenic edema.     

Hemifacial dismasking flap for anterior skull base tumor--technical note

A new approach to malignant tumor in the anterior skull base using a hemifacial dismasking flap is described. A bicoronal incision is extended unilaterally down to the neck, degloving the craniofacial tissue to widely expose the skeleton underneath, allowing easy resection of an extensive tumor without postoperative scarring of the face. This method has been used successfully on five patients.     

Non-Hodgkin lymphoma of the central skull base: MR manifestations

OBJECTIVE: The aim of this study was to demonstrate the MR characteristics of non-Hodgkin lymphoma of the skull base to help in the differential diagnosis of this neoplasm from other conditions. MATERIALS AND METHODS: MR of five patients, 7-64 years old, with pathologically proved lymphomas of the skull base were reviewed. Three cases had primary skull base lesions involving the sphenoid bone and the cavernous sinus. One case with a nasal cavity lesion involving the skull base and one with a relapsing skull base lesion of previously treated tonsillar lymphoma were included. RESULTS: The lesions had signal intensities that were similar to that of gray matter of brain on both T1- and T2-weighted imaging. Bilateral cavernous sinuses were involved with encasement of internal carotid arteries in every case. Postcontrast MR showed homogeneous enhancement of the tumor with dural infiltration along the planum sphenoidale, clivus, or tentorium. The clivus was destroyed or replaced by tumors in adult cases but in two children the clivus was preserved with intact sphenooccipital synchondrosis. In one case the tumor extended to the extracranial portion through the jugular foramen. CONCLUSION: The MR findings of a permeative lesion of the skull base, invasion of the cavernous sinus without arterial narrowing, infiltration along the dural surface, and an iso- or hypointensity with brain on T2-weighted imaging should suggest lymphoma.     

Chordomas of the skull base. Radiologic and clinical evaluation

Chordomas are uncommon skull base tumors, which are locally agressive and are usually not amenable to complete surgical resection. Proton beam irradiation, following surgery, is the preferred treatment modality. For diagnosis and determination of tumor site and extension, CT and MR imaging are the imaging modalities of choice. CT delineates bone destruction and the presence of calcifications and destroyed bone optimally. MR imaging is the modality of choice for better definition of the tumor margin from brain and other soft tissue structures (pharynx) and visualization of blood vessels. The signal intensities and enhancement pattern fail to differentiate chordoma from chondroid chordoma or chondrosarcoma. Chordomas arise from the clivus and therefore are located more centrally, whereas the majority of chondrosarcomas originate in the petroclival fissure and occur more laterally, although occasional overlap occurs in about one third of cases. Immunohistochemical methods allow differentiation of pure chordoma from chondroid chordoma and chondrosarcoma. Chordomas have a lower local control rate than chondrosarcomas.     

Craniofacial resection. An alternative incision and skull base repair

Neoplasia of the superior group of paranasal sinuses (frontal, ethmoidal and sphenoidal) has an extremely poor prognosis. Resection, preceded or followed by radiotherapy offers a 5 year survival of less than 30% (1). Satisfactory surgical excision has been undermined by difficulties of access to the cribriform plate area, a common site for residual disease. Furthermore the practice of piecemeal removal invariably resulted in inadequate clearance. The craniofacial approach allows not only excellent access to the anterior skull base but also in bloc excision. The results of treating 7 patients with craniofacial resection for tumours in this area are presented. Particular reference is made to a horizontal forehead skin crease incision for intracranial access. A new technique using a combination of surgical, pericranium, partial thickness skin and fibrin glue to repair the skull base defect is described.     

Involvement of the skull base and vault in chronic idiopathic hyperphosphatasia

OBJECTIVE: To evaluate whether mutation in the exon 10 of the fibroblast growth factor receptor 3(FGFR3) gene in common in Chinese patients with achondroplasia. METHODS: Genomic DNA from seven sporadic cases of achondroplasia was studied by using PCR-SSCP and restriction enzymes. RESULTS: All patients carried the same glycine-to-arginine mutation at codon 380(G380R) of the transmembrane domain of FGFR3. CONCLUSION: The results suggest that the G380R mutation of FGFR3 is also a frequent mutation causing achondroplasia in Chinese. Detecting FGFR 3 gene mutation with PCR-SSCP and restriction enzymes analysis is a convenient, rapid and reliable molecular diagnostic assay for prenatal and early diagnosis of achondroplasia.