Diffuse Meningiomatosis without Neurofibromatosis: A Rare Diagnosis with Atypical Presentation

Meningiomas are amongst the most common neoplasms of the central nervous system; however, “multiple meningiomas” or “meningiomatosis” account for < 10% of cases. The association with neurofibromatosis 2 is seen in ∼50% of cases. We report a case of 35-year-old female patient who presented with left eye proptosis, left forehead swelling, and multiple cranial nerve palsies predominantly on the left side. Imaging evaluation revealed innumerable en plaque meningiomas forming a sheet-like nodular thickening along the dura, causing marked hyperostosis and extending into the orbits, cavernous sinuses, sellar–suprasellar regions, various skull foramina, basal cisterns and into the cervical spinal canal causing mass effect on vital structures of the brain and cervical spinal cord. Similar lesions were found scattered in rest of the spine. We intend to highlight the role of imaging in accurately establishing the diagnosis and evaluating the extent and burden of disease in such rare cases.

Development of a Prognostic Model to Predict Mortality after Traumatic Brain Injury in Intensive Care Setting in a Developing Country

Objectives We aimed to develop a prognostic model for the prediction of in-hospital mortality in patients with traumatic brain injury (TBI) admitted to the neurosurgery intensive care unit (ICU) of our institute. Materials and Methods The clinical and computed tomography scan data of consecutive patients admitted after a diagnosis TBI in ICU were reviewed. Construction of the model was done by using all the variables of Corticosteroid Randomization after Significant Head Injury and International Mission on Prognosis and Analysis of Clinical Trials in TBI models. The endpoint was in-hospital mortality. Results A total of 243 patients with TBI were admitted to ICU during the study period. The in-hospital mortality was 15.3%. On multivariate analysis, the Glasgow coma scale (GCS) at admission, hypoxia, hypotension, and obliteration of the third ventricle/basal cisterns were significantly associated with mortality. Patients with hypoxia had eight times, with hypotensions 22 times, and with obliteration of the third ventricle/basal cisterns three times more chance of death. The TBI score was developed as a sum of individual points assigned as follows: GCS score 3 to 4 (+2 points), 5 to 12 (+1), hypoxia (+1), hypotension (+1), and obliteration third ventricle/basal cistern (+1). The mortality was 0% for a score of “0” and 85% for a score of “4.” Conclusion The outcome of patients treated in ICU was based on common admission variables. A simple clinical grading score allows risk stratification of patients with TBI admitted in ICU.

RARE-47. DIFFUSE LEPTOMENINGEAL DISSEMINATED GLIONEURONAL TUMOR: CASE-SERIES

Diffuse leptomeningeal disseminated glioneuronal tumor (DL-GNT) is a rare brain tumor that presents as a plaque-like subarachnoid tumor, commonly involving the basal cisterns and interhemispheric fissure of children but lacking intraparenchymal tumor. Here we report two cases focusing on clinicopathologic features. In all patients, radiography revealed characteristic leptomeningeal thickening and enhancement with minor superficial parenchymal lesions. The broadcast of the knowledge about this type of disease is important to increase awareness on this subject.

NEWTON-2 Cisternal (Nimodipine Microparticles to Enhance Recovery While Reducing Toxicity After Subarachnoid Hemorrhage): A Phase 2, Multicenter, Randomized, Open-Label Safety Study of Intracisternal EG-1962 in Aneurysmal Subarachnoid Hemorrhage

ABSTRACT BACKGROUND A sustained release microparticle formulation of nimodipine (EG-1962) was developed for treatment of patients with aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE To assess safety, tolerability, and pharmacokinetics of intracisternal EG-1962 in an open-label, randomized, phase 2 study of up to 12 subjects. METHODS Subjects were World Federation of Neurological Surgeons grades 1 to 2, modified Fisher grades 2 to 4, and underwent aneurysm clipping within 48 h of aSAH. EG-1962, containing 600 mg nimodipine, was administered into the basal cisterns. Outcome on the extended Glasgow Outcome Scale (eGOS), pharmacokinetics, delayed cerebral ischemia and infarction, rescue therapy, and safety were evaluated. RESULTS The study was halted when a phase 3 study of intraventricular EG-1962 stopped because that study was unlikely to meet its primary endpoint. Six subjects were randomized (5 EG-1962 and 1 oral nimodipine). After 90-d follow-up, favorable outcome on the eGOS occurred in 1 of 5 EG-1962 and in the single oral nimodipine patient. Four EG-1962 and the oral nimodipine subject had angiographic vasospasm. One EG-1962 subject had delayed cerebral ischemia, and all subjects with angiographic vasospasm received rescue therapy except 1 EG-1962 patient. One subject treated with EG-1962 developed right internal carotid and middle cerebral artery narrowing 5 mo after placement of EG-1962, leading to occlusion and cerebral infarction. Pharmacokinetics showed similar plasma concentrations of nimodipine in both groups. CONCLUSION Angiographic vasospasm and unfavorable clinical outcome still occurred after placement of EG-1962. Internal carotid artery narrowing and occlusion after placement of EG-1962 in the basal cisterns has not been reported.

Effect of primary decompressive craniectomy on outcomes in severe traumatic brain injury with mass lesions and the independent predictors for operation decision

Background: Although operative indications for traumatic brain injury (TBI) have been evaluated, neurosurgeons often face a dilemma of whether or not to remove the bone flap after mass lesion evacuation, and a useful predictive scoring model for which patients should be decompressive craniectomy (DC) has yet to be developed. The aim of this study was firstly to compare the outcomes of craniotomy and DC, and secondly to determine independent predictors and develop a multivariate logistic regression equation to determine whom should perform primary DC in TBI patients with mass lesions.Methods: A total of nine different variables were evaluated. All 245 patients with severe TBI in this study were retrospectively evaluated between June 2015 and May 2019 and all underwent decompressive craniectomy (DC) or craniotomy for mass lesion removal. The 6-month mortality and Extended Glasgow Outcome Scale (GOSE) were compared between DC and craniotomy. By using univariate, multiple logistic regression and prognostic regression scoring equations it was possible to draw Receiver Operating Characteristic curves (ROC) to predict the decision for DC.Results: The overall 6-month mortality in the entire cohort was 11.43% (28/245). DC patients had a lower mean preoperative Glasgow Coma Scale (GCS) (p = 0.01); more patients with GCS of 6 (p=0.007);more unresponsive pupillary light reflex (p< 0.001); more closed basal cisterns (p< 0.001); and more patients with diffuse injury (p=0.025) than craniotomy patients. Given the greater severity, patients undergoing primary DC had higher 6-month mortality than the remainder of the cohort. However, in the surviving patients, the favorable GOSE rate was similar in two groups. We found that pupillary light reflex and basal cisterns were independent predictors for DC decision. Using ROC curve to predict the probability of DC, the sensitivity was 81.6% and the specificity was 84.9%.Conclusion: Our preliminary findings showed that the primary DC may benefit subgroups of sTBI with mass lesions, and unresponsive pre-op pupil reaction, and closed basal cistern to predict the DC decision were useful. These sensitive variables can be used as a referential guideline in our daily practice to decide to perform or avoid primary DC.

A Child with Primary Leptomeningeal Melanoma

Primary malignant melanoma of the meninges is an exceedingly rare neoplasm. Usually its symptoms include raised intracraneal pressure resulting from hydrocephalus seconday to tumoral obliteration of cisternal basal cisterns, but the passage of time from initial symptomalogy to diagnosis is frequently delayed. A 12-year-old male with primary letomeningeal melanoma is reported. At the beginning, he presented with vomiting, headache, complex seizures, fever four months before the admission in the hospital where progressive loss of consciouness after admission. Lumbar puncture reveled high protein level, normal glucose level and 50 leucocytes/mm3 with 86% polymorphic cells. Magnetic ressonance imaging of the brain was referred and in T1-weighted images revealed a diffuse enhancement of the leptomeninges on right frontal cortical. An open brain biopsy trough was performed, after exclusion of the infectious nervous system disease. Histological examination revealed massive infiltration of meninges with brown tumor cells. These cells stained positive for HMB-45, S-100 protein and vimentin. The patient received post operative radiation therapy, but died after three months of the diagnosis with septic shock and epileptical status

Role of repeat CT in mild to moderate head injury: an institutional study

OBJECTIVEPatients with traumatic brain injury (TBI) often undergo repeat head CT scans to identify the possible progression of injury. The objective of this study is to evaluate the need for routine repeat head CT scans in patients with mild to moderate head injury and an initial positive abnormal CT scan.METHODSThis is a retrospective study of patients presenting to the emergency department from January 2016 to December 2017 with Glasgow Coma Scale (GCS) scores > 8 and an initial abnormal CT scan, who underwent repeat CT during their in-hospital medical management. Patients who underwent surgery after the first CT scan, had a GCS score < 9, or had a normal initial CT scan were excluded. Demographic, medical history, and physical examination details were collected, and CT scans were reviewed. Radiological deterioration, neurological deterioration, and/or the need for neurosurgical intervention were the primary outcome variables.RESULTSA total of 1033 patients were included in this study. These patients underwent at least two CT scans on an inpatient basis. Of these 1033 patients, 54.1% had mild head injury and 45.9% had moderate head injury based on GCS score at admission. The most common diagnosis was contusion (43.8%), followed by extradural hematoma (28.8%) and subdural hematoma (26.6%). A total of 2636 CT scans were performed for 1033 patients, with a mean of 2.55 per patient. Of these, 25 (2.4%) had neurological deterioration, 90 (8.7%) had a progression of an existing lesion or appearance of a new lesion on repeat CT, and 101 (9.8%) required neurosurgical intervention. Seventy-five patients underwent surgery due to worsening of repeat CT without neurological deterioration, so the average number of repeat CT scans required to identify one such patient was 21.3. On multiple logistic regression, GCS score at admission (p = 0.024), abnormal international normalized ratio (INR; p < 0.001), midline shift (p = 0.005), effaced basal cisterns (p < 0.001), and multiple hemorrhagic lesions (p = 0.010) were associated with worsening of repeat CT, neurological deterioration, and/or need for neurosurgical intervention.CONCLUSIONSThe role of routine repeat head CT in medically managed patients with head injury is controversial. The authors have tried to study the various factors that are associated with neurological deterioration, radiological deterioration, and/or need for neurosurgical intervention. In this study the authors found lower GCS score at admission, abnormal INR, presence of midline shift, effaced basal cisterns, and multiple lesions on initial CT to be significantly associated with the above outcomes.

Traumatic Posterior Fossa Hematoma, A Rare Entity: Study of 21 Cases

Background Traumatic posterior fossa hematoma is a rare entity. Traumatic posterior fossa hematomas are associated with considerable morbidity and mortality and their surgical management remained controversial. Methods From August 2011 to August 2017, approximately 5,100 patients with head injury were managed. Authors reviewed clinical and radiological findings, management criteria, and outcome of posterior fossa hematoma in 21 patients. Results Out of 21 cases, 13 survived with our management. The Glasgow Coma Scale (GCS) on admission was higher in favorable group than in poor outcome group. Factors associated with Glasgow Outcome Scale in two groups were status of fourth ventricle, basal cisterns, subarachnoid hemorrhage (SAH), hematoma volume, and their location (hemispheric or midline). Similarly, associated supratentorial lesions, age, gender, lesions in other parts of body, and timing from injury to reporting to hospital were taken into consideration. Conclusion The factors correlated with patient outcome were age, sex, mode of injury, GCS at admission, associated intracranial hematomas, associated SAH, hematoma volume, hematoma location, basal cisterns, status of fourth ventricle, and associated multiple injuries on other body parts. It is hereby concluded that timely surgical intervention should be employed whenever indicated without delay. Posterior fossa hematomas were rarely observed in the pediatric age group.

Spinal cerebrospinal fluid dynamics

Cerebrospinal fluid (CSF) within the spinal canal is far from a stagnant column of liquid, simply bathing the spinal cord, but is constantly being subjected to waves of energy, produced by both the cardiac and the respiratory cycles. Moreover, the spinal subarachnoid channels are normally in free communication with the intracranial basal cisterns and volume exchanges take place between these two compartments, during normal daily activities. A variety of pathological processes can alter CSF hydrodynamics, leading to the development of several conditions. These include Chiari malformations and syringomyelia, as well as extra-axial collections of CSF. They are best regarded as disorders of CSF circulation, rather than as isolated spinal pathologies.

Radiological Parameters Predicting Clinical Outcome After Decompressive Hemicraniectomy in Malignant Ischemic Stroke

INTRODUCTION Decompressive Hemicraniectomy (DH) is advocated as a lifesaving procedure in the management of patients with raised intracranial pressure due to malignant hemispheric infarction. The purpose of this study was to identify radiological parameters predicting the clinical outcome in patients with DH in large-territory ischemic stroke. METHODS Patients undergoing DH for malignant ischemic stroke were identified from electronic data base search (2011-2018). Logistic regression analysis evaluated the association of radiological variables with clinical outcome according to modified Rankin Scale (mRS) and Glasgow Outcome Scale Extended (GOSE) at 180 d. RESULTS Among 98 patients, 59 (60.2%) underwent CT scan post DH within 24 h. The median age of the included patients was 54 yr (29-80 yr), with males being predominant (89.8%). The mean NIHSS score for the included patients was 18.64 ± 6.8 (3-33), and majority of the patients (88.1%) had Middle Cerebral Artery Infarction (MCA). The mean mRS and GOSE at 180 d were 3.88 ± 1.39 and 4.12 ± 1.8, respectively. Univariate analysis identified a greater likelihood of good functional outcome in patients with ischemic stroke post DH on CT scan if there was absence of effacement of cortical sulci [OR 1.31: 95% CI: 1.28-1.39; P = .05], absence of effacement of basal cisterns [OR 3.4: 95% CI:1.36-8.5; P = .03], absence of hemorrhagic transformation in the infarct core [OR 2.3: 95% CI: 2.00-2.65; P = .03], or absence of compression of lateral ventricle [OR 1.25: 95% CI: 1.20-1.27; P = .05]. Furthermore, multivariate analysis found significant association in predicting good functional outcome with absence of effacement of cortical sulci [OR 2.01: 95% CI: 1.22-20.71; P = .02], absence of hemorrhagic transformation [OR 2.09: 95% CI: 1.01-27.30; P = .02], and absence of compression of lateral ventricles [OR 1.35: 95% CI: 1.28-18.4; P = .05], but absence of effacement of basal cisterns was not statistically significant (P = .36). CONCLUSION The radiographic features post DH in ischemic stroke predict the clinical outcome, thus stratify our management plan.