Case reports / Journal of Clinical Neuroscience 13 (2006) 487–489
In conclusion, neurobrucellosis should be considered in the diﬀerential diagnosis of patients with brain abscess in areas where brucellosis is endemic. References 1. Osborn AG, Blaser S, Salzman KL. Diagnostic Imaging: Brain. 1st ed. Altona: Amirsys; 2004. 2. Galassi E, Piazza G. Arachnoid cysts of the middle cranial fossa: A clinical and radiological study of 25 cases treated surgically. Surg Neurol 1980;14:211–9.
3. Rengachary SS, Kennedy JD. Intracranial arachnoid and ependymal cysts. In: Wilkins RH, Rengachary SS, editors. Neurosurgery, 2nd edition. Vol. 3. New York: McGraw-Hill; 1996. p. 3709–26. 4. Martin AJ, Jarosz JM, Thomas NW. The strange association of pneumosinus dilatans and arachnoid cyst: case report and review of the literature. Acta Neurochir (Wien) 2001;143:197–201. 5. Kalelioglu M, Ceylan S, Koksal I, Kuzeyli K, Akturk F. Brain abscess caused by Brucella abortus and Staphylococcus aureus in a child. Infection 1990;18:386–7. 6. Stranjalis G, Singounas E, Boutsikakis I, Saroglou G. Chronic intracerebral Brucella abscess. Case illustration. J Neurosurg 2000;92:189.
Intracranial metastasis of lung adenocarcinoma mimicking colloid cyst of the third ventricle Ozerk Okutan a, Ihsan Solaroglu a b
, Erkan Kaptanoglu a, Etem Beskonakli
Department of Neurosurgery, Ankara Numune Research and Education Hospital, Ankara, Turkey Department of Neurosurgery, Ankara Ataturk Research and Education Hospital, Ankara, Turkey Received 4 April 2005; accepted 23 June 2005
Abstract A patient with intracranial lung adenocarcinoma metastasis mimicking a colloid cyst of the third ventricle is reported. These tumours may be associated with excessive bleeding and may inﬁltrate into surrounding structures. Open microsurgery rather than endoscopic surgery should be considered for these cases, particularly a transcortical-transventricular or transcallosal approach, in order to avoid serious complications. 2006 Elsevier Ltd. All rights reserved. Keywords: Adenocarcinoma; Colloid cyst; Endoscopy; Metastasis; Third ventricle
1. Introduction Primary lung carcinoma is the leading cause of death from cancer in both women and men, and is the most common source of brain metastasis. It has been reported that between 20% and 24% of patients with non-small-cell lung cancer are diagnosed with brain metastases at some time during the course of their disease.1,2 The overall frequency of brain metastasis in patients with lung carcinoma is approximately 32%.3 A predominance of single and supratentorial parenchymal brain metastases have been reported in non-small-cell lung cancer.4,5 Although wide variability exists in the location of brain metastases, metastases in * Corresponding author. Present address: Yeni Ziraat Mahallesi, 13 Sokak Fulya Apt. 8/15, 06550 Altındag, Ankara, Turkey. Tel.: +90 505 565 72 38; fax: +90 312 311 11 21. E-mail address: [email protected]
the third ventricle are rare. Colloid cysts are the most common tumours encountered within the third ventricle. Other lesions, including meningioma, cavernoma, germ-cell tumours, lymphomas, metastasis, and epidermoid cysts are rare.6 In this report, a case of intracranial adenocarcinoma metastasis mimicking a colloid cyst of the third ventricle is presented. 2. Case report A 56-year-old man presented with a 3-day history of nausea, vomiting, headache, and gait disturbance. Two weeks prior to developing these symptoms, he had been treated for pneumonia. Neurological examination revealed mild ataxia. Chest X-ray revealed reticulonodular shadowing in the right lung and an inﬁltrate in the right lung base. Cranial magnetic resonance imaging (MRI) revealed a solitary mass in the third ventricle, with enlargement of the
Case reports / Journal of Clinical Neuroscience 13 (2006) 487–489
lateral ventricles (Figs. 1, 2). Gross total removal of the tumour was accomplished using a transcortical-transventricular approach. Histopathological examination revealed adenocarcinoma metastasis (Fig. 3). The patient was discharged without any major neurological deﬁcit on postoperative day 7, and was referred to a thoracic surgery clinic.
Fig. 3. Histopathological examination of the surgical specimen showed that the tumour was an adenocarcinoma metastasis (hematoxylin and eosin, original magniﬁcation · 100).
Fig. 1. Axial contrast-enhanced T1-weighted MRI shows an oval hyperintense lesion in the anterior third ventricle with lateral ventricular enlargement.
Fig. 2. Coronal contrast-enhanced T1-weighted MRI shows an oval hyperintense lesion in the third ventricle. The fornices are elevated and the third ventricle is expanded.
The overall frequency of brain metastasis in patients with lung carcinoma is approximately 32%, and adenocarcinoma accounts for somewhere between 49% and 69% of these patients.3–5 One-third of intracranial metastases are located in the subdural or extradural space and do not invade the surrounding tissue. Although wide variability exists in the location of brain metastases, there are few reported cases of metastases in the third ventricle.6,7 MRI signal characteristics of colloid cysts of the third ventricle are variable.8 Approximately 50% of colloid cysts are hyperintense on T1-weighted images, and the remainder are either isointense or hypointense with respect to brain tissue.9 Despite their variable signal characteristics, their location and shape allow for correct preoperative diagnosis in most patients. In our case, the signal intensity and location of the lesion in the anterior third ventricle mimicked the features of a colloid cyst with respect to its hyperintense signal on T1-weighted images. The appropriate treatment approach generally depends on the location and size of the metastatic tumour, and the relationship of the tumour to the surrounding structures. There are numerous surgical approaches for the treatment of tumours of the third ventricle, with none being clearly accepted as standard. Endoscopic techniques are being used increasingly for the treatment of third ventricle tumours, particularly for colloid cysts,10–15 but this requires experience with endoscopic techniques. Although the combination of endoscopic surgery with neuronavigation, and the development of sophisticated endoscopic instruments have decreased complication rates, there is no doubt that there is a deﬁnite learning curve associated with this surgical technique. Damage to the fornices due to manipulation of the endoscopic sheath, thermal injuries due to excessive electrocoagulation, aseptic ventriculitis, and intraoperative haemorrhage are potential complications associated with endoscopic surgery.11,12,15 Excessive bleeding is diﬃcult to control during endoscopic surgery.
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Furthermore, as compared with microsurgical techniques, endoscopy less often results in complete excision of tumours such as colloid cysts of the third ventricle, and thus also carries a potential risk of recurrence.11 In our patient, the tumour was totally removed using a transcortical-transventricular approach under general anaesthesia. The transcortical-transventricular route was chosen for two reasons: (1) ventricular enlargement was observed in our patient on MRI scans; (2) we had experience with this operative approach.16 During the operation we noticed that the tumour consisted of haemorrhagic, solid components, and was associated with excessive tumour bleeding. We were unable to totally remove the capsule of the tumour as the inferior part was ﬁrmly adherent to the adjacent vascular structures and inﬁltrated neural structures near the foramen of Monro. The residual part of the capsule was carefully coagulated by using a bipolar coagulator. In summary, intracranial metastasis of lung adenocarcinoma may mimic a colloid cyst of the third ventricle and should be considered in the diﬀerential diagnosis. Such metastases may be associated with excessive tumour bleeding and tumours located near the foramen of Monro may be inﬁltrative or adherent. Microsurgery rather than endoscopic surgery should be considered for such patients to avoid serious complications. References 1. Martini N, Burt ME, Bains MS, McCormack PM, Rusch VW, Ginsberg RJ. Survival after resection of stage II non-small cell lung cancer. Ann Thorac Surg 1992;54:460–5. 2. Sorensen JB, Hansen HH, Hansen M, Dombernowsky P. Brain metastases in adenocarcinoma of the lung: frequency, risk groups, and prognosis. J Clin Oncol 1988;6:1474–80.
3. Boring CC, Squires TS, Tong T. Cancer statistics, 1991. CA Cancer J Clin 1991;41:19–36. 4. Sheehan JP, Sun MH, Kondziolka D, Flickinger J, Lunsford LD. Radiosurgery for non-small cell lung carcinoma metastatic to the brain: long-term outcomes and prognostic factors inﬂuencing patient survival time and local tumor control. J Neurosurg 2002;97:1276–81. 5. Wronski M, Arbit E, Burt M, Galicich JH. Survival after surgical treatment of brain metastases from lung cancer: a follow-up study of 231 patients treated between 1976 and 1991. J Neurosurg 1995;83:605–16. 6. Le Gars D, Lejeune J, Desenclos C. Tumors of the third ventricle: review of the literature. Neurochirurgie 2000;46:296–319. (in French). 7. Villani R, Papagno C, Tomei G, Grimoldi N, Spagnoli D, Bello L. Transcallosal approach to tumors of the third ventricle. Surgical results and neuropsychological evaluation. J Neurosurg Sci 1997;41:41–50. 8. Maeder PP, Holtas SL, Basibuyuk LN, Salford LG, Tapper UA, Brun A. Colloid cysts of the third ventricle: correlation of MR and CT ﬁndings with histology and chemical analysis. Am J Neuroradiol 1990;11:575–81. 9. Armao D, Castillo M, Chen H, Kwock L. Colloid cyst of the third ventricle: Imaging-pathologic correlation. Am J Neuroradiol 2000;21:1470–7. 10. Abdou MS, Cohen AR. Endoscopic treatment of colloid cysts of the third ventricle. Technical note and review of the literature. J Neurosurg 1998;89:1062–8. 11. Decq P, Le Guerinel C, Brugieres P, et al. Endoscopic management of colloid cysts. Neurosurgery 1998;42:1288–94. 12. Hellwig D, Bauer BL, Schulte M, Gatscher S, Riegel T, Bertalanﬀy H. Neuroendoscopic treatment for colloid cysts of the third ventricle: the experience of a decade. Neurosurgery 2003;52:525–33. 13. Longatti P, Martinuzzi A, Moro M, Fiorindi A, Carteri A. Endoscopic treatment of colloid cysts of the third ventricle: 9 consecutive cases. Minim Invasive Neurosurg 2000;43:118–23. 14. Rodziewicz GS, Smith MV, Hodge Jr CJ. Endoscopic colloid cyst surgery. Neurosurgery 2000;46:655–60. 15. Schroeder HW, Gaab MR. Endoscopic resection of colloid cysts. Neurosurgery 2002;51:1441–4. 16. Solaroglu I, Beskonakli E, Kaptanoglu E, Okutan O, Ak F, Taskin Y. Transcortical-transventricular approach in colloid cysts of the third ventricle: surgical experience with 26 cases. Neurosurg Rev 2004;27:89–92.
Heparin-induced transient prolongation of the QT interval during endovascular embolisation of intracranial aneurysm M. Radhakrishnan a, Sanjay Agarwal a, Parmod K. Bithal a
, Vipul Gupta
Department of Neuroanaesthesiology, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, Room 709-A, New Delhi 110029, India b Department of Neuroradiology, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India Received 17 March 2005; accepted 28 May 2005
Abstract Prolonged QT interval and increased QTC dispersion have been described immediately following rupture of intracranial aneurysm, due to increased sympathetic activity. Here, we report a patient with transient prolongation of the QT interval, probably due to heparin-induced *
Corresponding author. Tel.: +91 11 26588700; fax: +91 11 26588663. E-mail address: [email protected]