Laporan Kasus Butterfly gliobasltoma pada Laki-Laki Usia 24 Tahun

Pendahuluan Butterfly Glioma adalah high grade astrocytoma, biasanya glioblastoma (WHO grade IV), yang melintasi garis tengah melalui corpus callosum. Komissura white matter lainnya kadang juga terlibat. Istilah kupu-kupu mengacu pada ekstensi yang melewati garis tengah seperti sayap. Butterfly Glioma paling sering terjadi di lobus frontal, melintasi garis tengah melalui genu corpus callosum, namun butterfly glioma posterior kadang juga ditemui. Laporan kasus Seorang pasien laki-laki usia 24 tahun dengan keluhan utama 9 bulan, yang lalu. Penglihatan kabur, konsentrasi menurun. Kejang(-). Kemudian 3 bulan yang lalu mata tidak bisa melihat. Dan 1 bulan yang lalu tubuh lemas susah digerakkan Pemeriksaan patologi anatomi menunjukkan Pylocytic Astrocytoma. Pemeriksaan CT scan kepala menunjukkan Massa solid inhomogen intraxial ( ukuran ± AP 7,6 x 8,9 x CC 6,2 cm ) disertai kalsifikasi di dalamnya pada corpus callosum yang tampak cross mid line ( sisi kiri lebih dominan ) membentuk gambaran butterfly sign dengan perifocal edema à curiga gambaran glioblastoma multiformis. Pembahasan Hasil pemeriksaan anamnesis dan pemeriksaan fisik pasien ini menunjukkan kecurigaan adanya SOL. Pemeriksaan CT scan kepala menunjukkan Massa solid inhomogen intraxial disertai kalsifikasi di dalamnya pada corpus callosum yang tampak cross mid line ( sisi kiri lebih dominan ) membentuk gambaran butterfly sign dengan perifocal edema à curiga gambaran glioblastoma multiformis. Dari PA didapatkan hasil Pilocytic astrocytoma. Sedangkan gambaran radiologi Pilocytic astrocytoma berupa lesi kistik dengan nodul mural yang enhanced. Kasus ini secara radiologis lebih mengarah ke Butterfly Glioblastoma dengan adanya lesi yang melewati garis tengah, serta ada komponen nekrotik dan perdarahan.. Modalitas imejing pilihan yang dapat dilakukan pada kasus Butterfly Glioblastoma adalah CT scan dan MRI. Kesimpulan Kasus ini secara radiologis lebih mengarah ke Butterfly Glioblastoma dengan adanya lesi yang melewati garis tengah, serta ada komponen nekrotik dan perdarahan. Dan pemeriksaan radiologis yang dapat digunakan pada Butterfly Glioblastoma adalah CT scan dan MRI.

NIMG-65. RESTING-STATE FUNCTIONAL MRI DEMONSTRATES DAMAGE TO FUNCTIONAL CONNECTIVITY IN MENINGIOMA PATIENTS WITH PERIFOCAL EDEMA

BACKGROUND Meningiomas are common intracranial tumors which usually carry a benign prognosis. Some meningiomas cause perifocal edema which might indicate that this subset could interfere with normal brain function. Resting-state functional MRI (rsfMRI) can be used to assess whole brain functional connectivity (fc) which can be used as a marker for disease severity in patients with intracranial tumors, as was recently shown by our group in a cohort of glioma patients. In this study, we investigated whether the presence of perifocal edema in preoperative patients with meningioma leads to fc. METHODS Patients with suspected meningioma were prospectively included and functional resting state MRI scans were obtained. The resulting data was processed according to our recently published method and abnormality of fc was quantified for each individual patient. Abnormality of fc was then correlated with tumor and edema volume as well as WHO grade. RESULTS 26 patients (23 WHO grade I, 3 WHO grade II) were included. 13 patients had perifocal edema. There was a highly significant correlation between edema volume and higher abnormality of fc both in the lesional and the contra-lesional hemisphere (r=0.51, p=0.008 and r=0.61, p=0.001). Patients with no perifocal edema showed only very low abnormality of fc. Tumor volume was not correlated with abnormal fc in both the lesional and the contralesional hemispheres (r=0.23, p=0.27 and r=0.28, p=0.17). There was also no significant correlation between WHO grade and abnormality of fc. CONCLUSION RsfMRI showed significant abnormal fc in meningioma patients with perifocal edema in contrast to patients without edema, independent of tumor volume. This demonstrates that the presence of edema but not the tumor volume is relevant for disturbances of fc.

Management of Intracranial Pressure Control in Reciprocal Grade 3 Astrocytoma Patient In Dr. Moewardi General Hospital Surakarta: Case Report

<p><strong></strong>Surgery in patients with astrocytoma is performed based on the size of the tumor in the brain and the functional status of the patients. Management of patients with intracranial hypertension can be guided by monitoring intracranial pressure (ICP) perioperatively. A variety of ventricular, intraparenchymal, and subdural equipment can be installed by neurosurgeons to provide ICP measurements.</p><p>We reported a 50-year-old female patient, with a complaint of having a speech disorder since four years ago. Preoperative physical examination showed GCS E4V5M6, patient's body mass index was 29.29 kg/m² (obese). Patient’s physical status was assessed with ASA 3. There was no significant abnormality in laboratory examination. MRI Brain contrast examination showed solid cystic lesion in supratentorial left temporal lobe with size 2.3x3.5x4.7cm accompanied by broad perifocal edema in the left frontal, temporal and parietal lobe. The chest X-ray showed cardiomegaly and pneumonia. Electrocardiography showed normal sinus rhythm.</p><p>Craniotomy in patients with astrocytoma is performed based on the size of the tumor in the brain and the functional status of the patient. Preoperative evaluation for patients undergoing craniotomy should be carried out to determine the presence or absence of intracranial hypertension. In principle, postoperative management in the ICU is to control the respiratory system, optimize the cardiovascular system, and prevent possible complications.</p><p>Management of intracranial pressure control in reciprocal grade 3 astrocytoma patient should be paid attention to various things and consider the condition of the patients. Preoperative preparations, as well as perioperative and postoperative monitoring, should be carefully observed to prevent complications that will adversely affect patients.</p><p> </p>

Case Report: Persisting Lymphopenia During Neuropsychiatric Tumefactive Multiple Sclerosis Rebound Upon Fingolimod Withdrawal

Fingolimod (FTY) is a disease modifying therapy for relapsing remitting multiple sclerosis (RRMS) which can lead to severe lymphopenia requiring therapy discontinuation in order to avoid adverse events. However, this can result in severe disease reactivation occasionally presenting with tumefactive demyelinating lesions (TDLs). TDLs, which are thought to originate from a massive re-entry of activated lymphocytes into the central nervous system, are larger than 2 cm in diameter and may feature mass effect, perifocal edema, and gadolinium enhancement. In these cases, it can be challenging to exclude important differential diagnoses for TDLs such as progressive multifocal leukoencephalopathy (PML) or other opportunistic infections. Here, we present the case of a 26-year-old female patient who suffered a massive rebound with TDLs following FTY discontinuation with primarily neuropsychiatric symptoms despite persisting lymphopenia. Two cycles of seven plasmaphereses each were necessary to achieve remission and ocrelizumab was used for long-term stabilization.

Effect of Lithium Chloride Concentration on Its Neuroprotective Properties in Ischemic Stroke in Rats

Currently, a number of experimental studies have demonstrated compelling evidence of neuro-, cardio-, and nephroprotective properties of medications containing lithium chloride.Aim of the study. To evaluate the effect of various concentrations of lithium chloride on ischemic stroke volume and perifocal edema in rats after cerebral ischemia.Material and methods. Male mongrel rats weighing 315±13.5 g were used in the study. The focal ischemia model according to Longa et al. was employed. The animals (n=35) were divided into 5 groups: sham-operated, control group (ischemic stroke model with NaCl 0.9% administration) and three groups who received lithium chloride in different concentrations (4.2 mg/kg, 21 mg/kg and 63 mg/kg). Lithium chloride was administered immediately after cessation of middle cerebral artery occlusion and then every 24 h until euthanasia. To assess the degree of brain damage, the animals underwent magnetic resonance imaging (MRI) on day 2, and brain sections stained with 2,3,5-triphenyltetrazolium chloride were evaluated after euthanasia on day 7. Intergroup differences were assessed using the Mann-Whitney criterion.Results. According to MRI data, lithium chloride at a dose of 4.2 mg/kg had no significant effect on ischemic stroke volume and perifocal edema versus the control group on day 2 (P=0.9). With lithium chloride at 21 mg/kg, stroke volume and perifocal edema were significantly lower than in the control group (by 25%, P=0.04 and 18%, P=0.03, respectively). Lithium chloride at a dose of 63 mg/kg was more likely to reduce stroke volume (by 45%, P=0.004) and perifocal edema (by 35%, P=0.007). When determining lesion volume on day 7, the data were comparable to those obtained on day 2. With the 21 mg/kg dose, stroke volume was 20% lower than in the control group (P=0.04). Lithium chloride, 63 mg/kg, reduced stroke volume by 40% (P=0.004).Conclusion. Lithium chloride dose affects necrotic focus formation and manifestations of perifocal cerebral edema after middle cerebral artery occlusion. The maximum reduction in the volume of ischemic stroke and perifocal edema was observed when the 63 mg/kg dose was used.

Manajemen Anestesi pada Pasien dengan Tumor Regio Pineal yang Menjalani Kraniotomi Pengangkatan Tumor dengan Posisi Duduk

Incidence of pineal regio tumor is 0.4-1% of intracranial tumors. Its location which is buried between two cerebral hemispheres, close to brainstem and hypothalamus become a difficult challenge for the neurosurgeon. Surgery with supracerebellar approach in sitting position is the best method to access the lesion. Sitting position also facilitates the optimal visual field with minimal retractions. However, for anesthesiologist, sitting position is challenging since it has its own complexities during positioning the patient and the risk of complications. Venous air embolism is one of the main concern and if not detected early and treated appropriately would leads to cardiovascular collapse instantly. This is a case of a 38-year-old male with chief complaint of severe headache and blurred vision started 4 months before admission. The Magnetic Resonance Imaging showed a pineal region tumor with perifocal edema, without midline deviation. The patient underwent craniotomy tumor removal with sitting position. The procedure lasted for 10 hours and uneventful. The principle of ABCDE neuroanesthesia, sitting position and its implications, and difficult tumor location are some anesthesia considerations for this patient. A thorough preoperative evaluation, good communication and coordination between surgery and anesthesia team are needed for a smooth uneventful procedure performed in sitting position.

P14.92 Combination of Tumor Treating Fields and CCNU chemotherapy as valuable option for the treatment of unresectable progressive glioblastoma: A case presentation

BACKGROUND Tumor Treating Fields (TTFields) are low intensity (1–3 V/cm) alternating electric fields with an intermediate frequency of 100–300 kHz. TTFields in addition to temozolomide (TMZ) after radiochemotherapy according to Stupp significantly increased progression-free survival (PFS), overall survival (OS) and long-term survival rates in patients with newly diagnosed glioblastoma (GBM) in the multicenter phase 3, EF-14 trial. Post-hoc analysis of the trial revealed that TTFields in combination with second-line therapy after first recurrence significantly prolonged OS compared to second-line therapy alone. We here report on a GBM patient with partial resection showing regressive volume of unresected, previously progressive tumor under combination therapy of TTFields and second-line CCNU chemotherapy. MATERIAL AND METHODS In November 2018, MRI of a 59-year-old female patient revealed a large heterogeneous space-occupying lesion in the left occipital region with clearly contrast-enhanced margin, perifocal edema and two smaller contrast-enhancing lesions in the splenium corporis callosi and right of the trigonum suboccipitale. While the tumor in the left occipital region was completely resected, lesions in the right hemisphere remained unresected. Histopathology identified MGMT-promoter methylated GBM. The patient received concomitant radiochemotherapy followed by adjuvant TMZ. However, after three cycles, the unresected tumor progressed, TMZ was exchanged by procarbazine/CCNU and TTFields therapy was initiated. After two cycles, chemotherapy was changed to only CCNU due to further progression while TTFields therapy was continued. RESULTS One year after diagnosis, MRI showed no contrast-enhancing tissue in the resection cavity and regressive perifocal edema while lesions in the right hemisphere remained stable. Under tolerable hematotoxicity CCNU was continued together with TTFields, to which the patient showed high adherence far beyond the suggested threshold of 75%. Control examination in February 2020 reported regressive tumor volume in the right hemisphere under CCNU/TTFields therapy. Until January 2021, the tumor regressed even further without the detection of new lesions. The patient is currently continuing CCNU together with TTFields, achieving an average usage of 84% over the last twelve months. CONCLUSION In the presented case, the combination of TTFields and CCNU was feasible and safe in progressive GBM. The patient showed radiological response and local tumor regression under the combination therapy, whereas the tumor had previously progressed under chemotherapy alone. In conclusion, the addition of TTFields to chemotherapy is a valuable treatment option to improve clinical and radiological outcome of patients with progressive GBM. This example of TTFields use in clinical practice encourages its use beyond tumor progression.

The role of high-resolution ultrasonic examination in the analysis of the structure and causes of complications after cosmetological thread implantation into the face and neck soft tissues

Objective The goal is to optimize the diagnosis of complications after thread implantation using high-resolution ultrasound (US).Material and Methods The study design included the formation of twelve sample comparison groups. Inclusion criteria for the group: women without evident somatic pathology after cosmetic implantation in various periods after the procedure. The difference between the groups was in the chemical composition of the material (L-lactic acid, polydiaxanone, copolymer of L-actide with ԑ-caprolactone, polypropylene, polyester fiber in a silicone sheath, metal), complaints (the presence of amyctic, the presence of overcorrection, the absence of complaints), the period of time after implantation (up to 6 months, from 6 to 12 months, more than a year). Then ultrasound was performed, 33 qualitative and 7 quantitative indicators were analyzed. The study involved 93 women aged 29 to 65 years after the thread implantation. The circulation period varied from 3 days to 20 years.Results An analysis of the relationship between quantitative and qualitative features revealed statistically significant connections between the presence of an acoustic shadow and threads of polylactic acid and polypropylene, the presence of reverberation, and the metal – gold (p < 0.0001). Relationships were established between polyester fibers in a silicone sheath with complaints of inflammation, the presence of edema during examination, perifocal edema around the thread during ultrasound (p < 0.0001). The difference was also found between the diameter of the thread in the group of patients examined up to 6 months and the group in the period 6–12 months after implantation (p < 0.0001), as well as the group up to 6 months and more than a year (p = 0.0033).Conclusion The presence of an acoustic shadow, a thread diameter of more than 1 mm are ultrasound signs of fibrotic changes around the thread. The characteristic echographic signs of inflammation around the thread will be a zone of reduced echoicity, corresponding to perifocal edema. Hypercorrection is a consequence of fibrotic changes development around the thread.

An unexpected intracerebral lesion – case report of a superinfected aspergillosis mimicking a brain metastasis

Background Invasive aspergillosis of the central nervous system is a rare but increasingly prevalent disease. We present the unusual case of an immunosuppressed patient suffering from unexpected superinfected invasive aspergillosis with cerebral, pulmonal, and adrenal manifestations, mimicking a metastasized bronchial carcinoma. This report reveals the importance of including aspergillosis in the differential diagnosis of a cerebral mass lesion in the light of unspecific clinical findings. Case presentation A 58-year-old immunocompromised female presented to our emergency department with a single tonic-clonic seizure. Imaging showed a ring enhancing cerebral mass with perifocal edema and evidence of two smaller additional hemorrhagic cerebral lesions. In the setting of a mass lesion in the lung, and additional nodular lesions in the left adrenal gland the diagnosis of a metastasized bronchus carcinoma was suspected and the cerebral mass resected. However, histology did not reveal any evidence for a neoplastic lesion but septate hyphae consistent with aspergillus instead and microbiological cultures confirmed concomitant staphylococcal infection. Conclusions A high index of suspicion for aspergillus infection should be maintained in the setting of immunosuppression. Clinical and radiological findings are often unspecific and even misleading. Definite confirmation usually relies on tissue diagnosis with histochemical stains. Surgical resection is crucial for establishing the diagnosis and guiding therapy with targeted antifungal medications.

Staging of Plantar Fasciitis According to Ultrasonography

Objective. Analysis of sonographic examination of plantar aponeurosis in norm and in plantar fasciitis, determination of the staging of plantar fasciitis depending on the duration of the pain syndrome and sonographic changes in plantar aponeurosis. Materials and Methods. 193 patients (272 cases) with plantar fasciitis (131 females and 62 males). The average age of patients was 47.69±0.97 years (18-81 years). Unilateral pathology was noted in 114 patients (114 cases) and bilateral – in 79 patients (158 cases). The average body mass index was 26.68±0.24. The average duration of pain syndrome was 101.12±5.83 days (7-390 days). The pain syndrome lasted up to 1 month in 26 patients (37 cases), from 1 to 6 months – in 126 patients (181 cases), and more than 6 months – in 41 patients (54 cases). The control group included 20 healthy volunteers (40 feet). Clinical radiological, sonographic, and statistical methods were used. Results. The average thickness of plantar aponeurosis in the study group was 6.14±1.49 mm (2.3-7.7 mm) and in control group – 3.5±0.1 mm (2.5-4.4 mm). There were three stages of the plantar fasciitis. Stage I was characterized by the absence of thickening of the plantar aponeurosis and structural changes, and by signs of local perifocal edema in the subcutaneous fat of the area adjacent to the aponeurosis, which are manifested by a zone of heterogeneous echogenicity. Stage II was characterized by a spindle-shaped form of aponeurosis, a thickening of enthesis more than 4 mm, significant reduction in echogenicity, erased or missing fibrous pattern, fuzzy contour of the aponeurosis, and modified contour of the calcaneus. At stage III, inequality of the cortical calcaneal contour and small focal hyperechogenicity points in enthesis were detected. Distal free part of the aponeurosis also changed. Loci of vascularization were detected using power Doppler sonography. Conclusions. A quantitative sonographic sign of plantar fasciitis is the thickening of the enthesis of the plantar aponeurosis of more than 4 mm. Qualitative signs were changes in echogenicity and structure, changes in the contours of the cortical layer of enthesis and plantar aponeurosis, and distribution of echographic changes distally to the free part of the aponeurosis. The described signs, when compared with the duration of the pain syndrome, determine the stage of plantar fasciitis.