Acute subarachnoid haemorrhage: A rare presentation of cerebral dural sinus thrombosis

We report a case of cerebral dural sinus thrombosis presenting as acute subarachnoid haemorrhage and clinically mimicking an aneurysmal bleed. Awareness of this rare initial presentation of cerebral venous thrombosis is important and should be considered in the diagnostic work‐up of acute subarachnoid haemorrhage. The radiologist plays a crucial role in making this often unsuspected but important diagnosis to enable prompt appropriate treatment.     

Cerebral venous sinus thrombosis presenting as subdural haematoma

The authors report a 39-year-old woman who presented with intermittent, excruciating nuchal and occipital headache. Magnetic resonance imaging and magnetic resonance angiography scans showed bilateral subdural haematomas with veno-occlusive disease of the superficial and deep venous systems. There were bridging collaterals with scalp veins, bleeds from which could explain the subdural haematoma. There was acute on chronic veno-occlusive disease with an acute rise in intracranial pressure and a bleed from the vein of Galen.     

Onyx embolisation of cavernous sinus dural arteriovenous fistula via direct percutaneous transorbital puncture

The cavernous sinus dural arteriovenous fistulas of three patients were successfully embolised by using Onyx (Onyx Liquid Embolic System, MTI, Irvine, CA, USA) as the sole embolic agent, through direct percutaneous transorbital punctures of the cavernous sinuses. Our early experience suggests that this direct approach, coupled with the unique physical properties of Onyx, is a safe and effective alternative to treat cavernous sinus dural arteriovenous fistulas when the conventional transvenous routes are inaccessible.     

窦旁脑膜瘤术中静脉窦的处理（附90例报告）

目的:总结窦旁脑膜瘤手术中静脉窦的处理方法和原则。方法:回顾性分析90例窦旁脑膜瘤手术病例,矢状窦前1/3脑膜瘤28例、中1/3脑膜瘤38例、后1/3脑膜瘤8例,横窦脑膜瘤7例,乙状窦旁脑膜瘤9例。术前行MRV或CTA检查判断静脉窦的通畅程度,以决定其处理方法。手术采用仰卧位或侧卧位,根据具体情况选择做窦或跨窦骨瓣。结果:肿瘤全切70例（78%）,次全切20例（22%）。7例进行了上矢状窦的重建;8例进行了矢状窦结扎（包括二次手术的4例）;横窦、乙状窦结扎各2例。本组无死亡病例,无严重并发症。结论:静脉窦是否通畅决定了肿瘤能否全切。如果静脉窦通畅,则应该保留上矢状窦、窦壁或者回流静脉入窦处残留薄层肿瘤;静脉窦完全梗阻,侧支循环完全建立应结扎静脉窦;静脉窦部分梗阻,可完全切除肿瘤后进行上矢状窦的重建修复。次全切除病人肿瘤生长活跃,建议术后辅以放疗。     

Intracranial dural metastases

BACKGROUND:

Intracranial dural metastases (IDM) are found at autopsy in 9% of patients with advanced systemic cancer. However, to the authors' knowledge, IDM have not been studied systematically in the modern neuroimaging era. The objective of the current study was to evaluate the demographics, clinical presentation, imaging, treatment, and prognosis of patients with IDM.

METHODS:

The current study was a retrospective review of 122 patients with IDM diagnosed at Memorial Sloan‐Kettering Cancer Center between 1999 and 2006. Patients with concurrent brain or leptomeningeal metastases were excluded.

RESULTS:

Sixty‐one percent of the patients were women; the median age at diagnosis was 59 years, the median Karnofsky performance scale (KPS) at diagnosis was 80, and the median time to IDM diagnosis from initial cancer diagnosis was 37 months. Breast (34%) and prostate (17%) cancers were the most frequent primary tumors associated with IDM. Fifty‐six percent of patients had a single dural metastasis. On imaging, 70% had metastases of the overlying skull, 44% had dural tail metastases, 53% had vasogenic edema, and 34% had brain invasion. Direct extension from skull metastases was the most common mode of spread. Eighty‐three percent of patients had active systemic disease at the time of IDM diagnosis. A lower KPS and lung cancer were associated with worse overall survival. Surgical resection and chemotherapy improved progression‐free survival, but only resection was found to be associated with improved overall survival.

CONCLUSIONS:

IDM affect a significant proportion of cancer patients. KPS and status of systemic cancer should guide treatment decisions. Cancer 2009. © 2009 American Cancer Society.     

Two cases of cerebral sinus venous thrombosis following chemotherapy for non-seminomatous germ cell tumor

We report on two patients with cerebral sinus venous thrombosis following chemotherapy with cisplatin, bleomycin and etoposide for non-seminomatous germ cell tumor. Headache and neurological deficits were the leading symptoms. Cancer and cisplatin chemotherapy are well-known risk factors for thromboembolic events. The therapeutic strategy is an anticoagulant therapy. Symptoms are usually reversible within weeks under this therapy. Therefore, in patients with testicular cancer and chemotherapy who present with neurological symptoms, cerebral sinus venous thrombosis should be considered in the differential diagnosis.     

Combined diagnostic and therapeutic imaging in the diagnosis of venous sinus thrombosis in postpartum patients

The case of a woman on day four post partum with sensorimotor deficit of the right side and CT evidence of a left temporofrontal hemorrhagic lesion, is presented. Attending physicians requested cerebral angiography. To better evaluate the clinical justification of requested imaging procedure the patient medical history and performed CT examination were carefully revised. According to this analysis and based on a clinicoradiological methodology, the request of a cerebral angiography was considered appropriate. The examination showed several radiological signs but a definitive diagnosis could not be established. Second choice imaging procedures were analyzed and MRI completed with MR-angiography was performed. It allowed to document transverse and sigmoid sinus thrombosis. Therefore, in the diagnosis of venous sinus thrombosis, MRI combined with MR-angiography was shown to be a method of first choice while angiography plays a major role in therapy for intravascular thrombolysis.     

Dural venous sinus thrombosis in anaplastic astrocytoma following concurrent temozolomide and focal brain radiotherapy plus bevacizumab

Malignant gliomas have long been a therapeutic dilemma in neuro-oncology, with a poor overall prognosis. Standard treatment, consisting of primary resection, followed by radiation therapy and temozolomide, has improved prognosis. Recently, studies have looked at the addition of bevacizumab (Avastin), a humanized murine IgG1 monoclonal antibody against vascular endothelial growth factor-A, to conventional regiments. Bevacizumab gained US FDA approval for single agent use in recurrent glioblastoma in 2009. Known side effects of bevacizumab include increased risk of arterial and venous thromboembolism, as well as hemorrhage. With emerging data for the use of bevacizumab in malignant gliomas, the extent of risks such as bleeding and thrombosis in patients with primary brain tumors treated with bevacizumab remains unknown. Here, we present only the second reported case of dural venous sinus thrombosis during treatment with bevacizumab and the first reported case for a primary glioma treated with temozolomide, radiation, and bevacizumab.     

Solitary dural plasmacytoma with conspicuous cytoplasmic inclusions

A solitary intracranial plasmacytoma originated from the left parietal meninges of a 67-year-old woman; the patient had a four-month history of generalized seizures. Immunoelectrophoresis, performed nine months after surgery, revealed a monoclonal IgG band in the cerebrospinal fluid (CSF) but not in the blood. A peculiar feature of the tumor cells was the presence of abundant hyaline, eosinophilic cytoplasmic inclusions. Ultrastructurally, these inclusions consisted of electron-dense floccular material within distended cisterns of endoplasmic reticulum (ER). These ultrastructural features resemble "thesaurocytes" originally described by Paraskevas et al. in IgA myeloma. Tumors composed mainly of such inclusion-bearing cells are extremely rare. Only a fraction of the tumor cells stained positively for IgG with the immunoperoxidase technique; most inclusion-bearing cells did not stain. It is therefore unlikely that the electron-dense material is stored immunoglobulins.     

Homologus dural graft as neo tympanic membrane

50 cases of chronic suppurative otitis media wth dry ear were taken up for myringoplasty operation by underlay technique through permeatal route in most of the cases. The dura mater was taken at autopsy from dead bodies within 6–8 hours of death, which was then stored in 70% Alcohol. The graft was washed with normal saline half an hour before the use. Homologus duramater graft was fully taken up in 68 percent cases and partially taken up in 12% cases, failure rate of the graft was 20% in a follow up of 6–12 months.     

Sylvian meningioma without dural attachment in an adult

Summary A 69 year-old man developed sudden-onset multidirectional, constant, involuntary ocular movements associated with vertigo, truncal ataxia and involuntary movements of the lower limbs. These features were typical of opsoclonus-myoclonus-ataxia syndrome (OMS). MRI of the brain was normal. CSF studies showed a single oligoclonal IgG band. A chest x-ray showed a 2-centimeter lesion in the periphery of the left lung. Fine needle aspiration biopsy of this lesion revealed large B-cell lymphoma. OMS can be either idiopathic or a paraneoplastic manifestation of underlying malignancy. 20 of OMS cases are paraneoplastic in origin; breast and lung cancer are responsible for 70 of these. Association of this syndrome with non-Hodgkins lymphoma is rare, with only one case previously reported.     

MRI in multiple myeloma with orbital and dural invasion

The case of a 42-year-old woman with aleukemic Bence Jones-type multiple myeloma who developed ocular abnormalities is described. Extramedullary plasmocytomas, either as solitary lesions or as manifestations of multiple myeloma, rarely involve the orbit and dural structures. Early detection of such lesions indicates an aggressive clinical course. In this paper we describe the magnetic resonance imaging findings of ocular and dural myelomatous involvement.     

Lateral sinus thrombosis

Twelve cases of lateral sinus thrombosis, which occurred as a complication of attico antral type of chronic otitis media, are reported. Management includes broad spectrum intravenous antibiotics and surgery. Radical mastoidectomy with incision of the lateral sinus and removal of its content was done for all cases. There were no deaths. The prognosis of lateral sinus thrombosis is good if treatment is instituted early with broad-spectrum antibiotics and surgery.     

Paranasal sinus tuberculosis

Tuberculosis of the paranasal sinuses is a rare condition. During a five year period at the Sea View Hospital, Myerson had reported only one case. The Nair Hospital records show 5 cases of sinus tuberculosis involving the maxillary aud ethmoidal sinuses without involvement of any other organ including the lung. This in the 6th case.     

Carotico-cavernous sinus fistula

We present a rare case of carotico-cavernous sinus fistula who presented with proptosis with gradual diminision of vision following a roadside accident. Contrast enhanced CT scan and angiography confiruned the diagnosis and it was managed by transfemoral embolisation of right ICCF.     

Thoracic ventral dural defect: Idiopathic spinal cord herniation

Thoracic ventral dural defect, and resultant idiopathic spinal cord herniation, is a rare but increasingly recognized cause of a chronic progressive thoracic myelopathy, particularly in middle‐aged women. A neurosurgically confirmed case is presented, together with a review of the pathogenesis, clinical presentation, imaging features, treatment options and progress of this entity post‐treatment.     

Congenital cervical sinus

A Congenital midline cervical sinus, running downwards from an external opening, is very rare. The case of a young girl having a congenital midline sinus in the neck, other than a Branchial or a Thyroglossal one, is reported.