Stereotactic surgery for neurocysticercosis of the 4th ventricle: illustrative cases

BACKGROUND Neurocysticercosis, caused by the larval stage of Taenia solium, affects the cerebral ventricles in 20–30% of cases and may lead to hydrocephalus and other neurological morbidity. Conventional treatment for cysts in the 4th ventricle includes open surgery (suboccipital approach) and neuroendoscopy, with the latter being the option of choice. Stereotactic surgery, minimally invasive, offers a good alternative for this type of deep lesion. OBSERVATIONS The authors report the cases of two women, 30 and 45 years old, who presented with headache, dizziness, and ataxia and were diagnosed with 4th ventricle cysticercosis. Magnetic resonance imaging (MRI) revealed dilated 4th ventricles (approximately 2.5 cm in both cases, with cystic images inside the ventricular cavity). Both patients were treated with stereotactic surgery via a suboccipital transcerebellar approach. Cyst material was extracted, and the diagnosis was confirmed by pathological examination. The surgeries had no complications and resulted in clinical improvement. Control MRI scans showed reduction of the volume of the ventricle without residual cysts. LESSONS Minimally invasive stereotactic surgery provided a safe alternative for 4th ventricle neurocysticercosis cysts, with more benefits than risks in comparison with conventional techniques.

Fluoride and Functionalized β-tricalcium Phosphate (fTCP) Fluoride Toothpaste Affect the Primary Dentin Caries Surface: A Comparison by Estimation Statistics

This study aims to compare the effect of fTCP-contained toothpaste in combination with 950 ppm fluoride on primary dentin caries surface to ordinary 1100 ppm fluoride toothpaste by using estimation statistics. Dental caries with deep lesion and dentin exposure from nine primary teeth were cut into two equal parts and randomly divided into two groups in a before-after study. Each group was brushed with one type of toothpaste two times per day for 28 days and rested in artificial saliva. SEM images of cavity bottom surfaces and energy-dispersive X-ray spectrometry (EDX) were used to determine the percentage of calcium (Ca), phosphorus (P), fluoride (F) and oxygen (O) at six continuous measured areas from the surface of the cavity bottom into 45 µm depth before and after brushing. About 95% confidence interval of the mean difference was calculated by performing bootstrap resampling with 5000 resamples followed by comparison analysis. The percentage of Ca, P, F, O was shifted after treatment. There was no difference between the two groups. The SEM images reflected a similar illustration of EDX data. The combination of fTCP and 950 ppm fluoride in toothpaste showed equivalent effectiveness to the 1100 ppm fluoride toothpaste in primary dentin caries.

Signatures of the Consolidated Response of Astrocytes to Ischemic Factors In Vitro

Whether and under what conditions astrocytes can mount a collective network response has recently become one of the central questions in neurobiology. Here, we address this problem, investigating astrocytic reactions to different biochemical stimuli and ischemic-like conditions in vitro. Identifying an emergent astrocytic network is based on a novel mathematical approach that extracts calcium activity from time-lapse fluorescence imaging and estimates the connectivity of astrocytes. The developed algorithm represents the astrocytic network as an oriented graph in which the nodes correspond to separate astrocytes, and the edges indicate high dynamical correlations between astrocytic events. We demonstrate that ischemic-like conditions decrease network connectivity in primary cultures in vitro, although calcium events persist. Importantly, we found that stimulation under normal conditions with 10 µM ATP increases the number of long-range connections and the degree of corresponding correlations in calcium activity, apart from the frequency of calcium events. This result indicates that astrocytes can form a large functional network in response to certain stimuli. In the post-ischemic interval, the response to ATP stimulation is not manifested, which suggests a deep lesion in functional astrocytic networks. The blockade of Connexin 43 during ischemic modeling preserves the connectivity of astrocytes in the post-hypoxic period.

Central nervous system involvement in patients with diffuse large B cell lymphoma: analysis of the risk factors and prognostic from a single-center retrospective cohort study

Purpose The aim of this study was to identify the risk factors for central nervous system (CNS) involvement in systemic diffuse large B-cell lymphoma (DLBCL) patients and to explore prognostic for DLBCL patients with CNS involvement (relapse or progression). Method This was a retrospective cohort study in our hospital. Data were collected from all DLBCL patients diagnosed in our institutes from January, 2013 to June, 2018. Clinical information was collected from medical records. Result The participants included 138 patients with DLBCL. Among them, 38 patients were diagnosed as CNS lymphoma, including 15 patients exhibited CNS involvement while DLBCL were pathologically confirmed, and 23 patients developed CNS lymphoma during or after initial chemotherapy. The median disease-free interval to CNS involvement was 13 months. Multivariate analysis identified elevated serum lactate dehydrogenase(LDH) level [hazard ratio(HR)=4.035; 95% confidence interval(95%CI):1.147~14.195] was independent predictor of CNS involvement. The median progression-free survival (PFS) and overall survival (OS) time of DLBCL patients with CNS involved were 12.5 months and 22 months, respectively. Multivariate prognostic analysis showed that eastern cooperative oncology group (ECOG) score>2(P=0.018; HR=7.333; 95%CI:1.424~42.002), elevated serum LDH level (P=0.046; HR=6.510; 95%CI:1.035~40.949), deep lesion (P=0.005; HR=10.957; 95%CI:2.050~58.569), and CNS with systemic involvement (P=0.023; HR=2.730; 95%CI:1.151~6.479) were independent poor prognostic factors for the patients. The cases with lymphocyte absolute count >0.75×109/L (HR=0.047; 95%CI:0.003~0.732) had better prognosis. The OS of DLBCL patients with secondary CNS lymphoma was inferior to DLBCL patients without CNS involvement. There was no significant difference between the patients with CNS and extra-CNS involvement. There was no significant difference between the patients with CNS involvement and stage III-IV DLBCL cases without CNS lymphoma. Conclusion In conclusion, elevated serum LDH was independent high-risk factor for secondary CNS lymphoma. For patients DLBCL with CNS involvement, ECOG score>2, elevated serum LDH level, deep lesion, lymphocyte absolute count ≤0.75×109/L and CNS with systemic involvement retained a significant association with outcome.

Central nervous system involvement in patients with diffuse large B cell lymphoma: analysis of the risk factors and prognostic from a single-center retrospective cohort study

Purpose The aim of this study was to identify the risk factors for central nervous system (CNS) involvement in systemic diffuse large B-cell lymphoma (DLBCL) patients and to explore prognostic for DLBCL patients with CNS involvement (relapse or progression). Method This was a retrospective cohort study in our hospital. Data were collected from all DLBCL patients diagnosed in our institutes from January, 2013 to June, 2018. Clinical information was collected from medical records. Result The participants included 138 patients with DLBCL. Among them, 38 patients were diagnosed as CNS lymphoma, including 15 patients exhibited CNS involvement while DLBCL were pathologically confirmed, and 23 patients developed CNS lymphoma during or after initial chemotherapy. The median disease-free interval to CNS involvement was 13 months. Multivariate analysis identified elevated serum lactate dehydrogenase(LDH) level [hazard ratio(HR)=4.035; 95% confidence interval(95%CI):1.147~14.195] was independent predictor of CNS involvement. The median progression-free survival (PFS) and overall survival (OS) time of DLBCL patients with CNS involved were 12.5 months and 22 months, respectively. Multivariate prognostic analysis showed that eastern cooperative oncology group (ECOG) score>2(P=0.018; HR=7.333; 95%CI:1.424~42.002), elevated serum LDH level (P=0.046; HR=6.510; 95%CI:1.035~40.949), deep lesion (P=0.005; HR=10.957; 95%CI:2.050~58.569), and CNS with systemic involvement (P=0.023; HR=2.730; 95%CI:1.151~6.479) were independent poor prognostic factors for the patients. The cases with lymphocyte absolute count >0.75×109/L (HR=0.047; 95%CI:0.003~0.732) had better prognosis. The OS of DLBCL patients with secondary CNS lymphoma was inferior to DLBCL patients without CNS involvement. There was no significant difference between the patients with CNS and extra-CNS involvement. There was no significant difference between the patients with CNS involvement and stage III-IV DLBCL cases without CNS lymphoma. Conclusion In conclusion, elevated serum LDH was independent high-risk factor for secondary CNS lymphoma. For patients DLBCL with CNS involvement, ECOG score>2, elevated serum LDH level, deep lesion, lymphocyte absolute count ≤0.75×109/L and CNS with systemic involvement retained a significant association with outcome.

Case Report: Concurrent primary CNS lymphoma and meningothelial meningioma - nuances of diagnosis and management

Background: The incidence of two distinct primary intracranial pathologies is an exceedingly rare phenomenon. Although meningiomas are well known to coexist with other primary intracranial malignancies there are only nine reported cases of a meningioma occurring simultaneously with primary CNS lymphoma in the literature. We report a case of a woman who sustained multiple injuries due to two distinct intracranial pathologies, however, lateralizing signs were unrecognized for two weeks prior to her final diagnosis. Case Description: A 64-year-old female with history of diabetes mellitus type 2 initially presented to the Emergency Department, two weeks prior, following a mechanical fall at home resulting in a left bimalleolar fracture. CT imaging revealed a right occipital mass with significant vasogenic edema causing 12mm of midline shift. MRI revealed two distinct homogeneously contrast-enhancing lesions: a right occipital mass with dural-based attachment, as well as a homogenously contrast-enhancing lesion adjacent to the right posterolateral ventricle. FLAIR signal changes were also appreciated and were noted to extend across the corpus callosum, raising concerns for a high-grade glial process. She underwent a right occipital craniotomy with gross total resection of the right occipital mass as well as subtotal resection and biopsy of the second lesion. Final pathology of the extra-axial lesion was found to be meningothelial meningioma and the deep lesion was found to be diffuse large B-cell lymphoma. Discussion: We describe a rare instance of simultaneous meningioma and primary CNS lymphoma that was found to be the underlying cause of a traumatic injury several weeks after the incident. We review the current diagnosis and management nuances in the setting of multiple intracranial oncologic processes.

Contemporary radiosurgery of cerebral cavernous malformations: Part 2. Treatment outcome for hemispheric lesions

OBJECTIVEThe role of radiosurgery (RS) in treating superficial cavernous malformations (CMs) is insufficiently studied in part because of the disappointing results of early experimental attempts as compared to the mostly safe and effective microsurgery. Nonetheless, because of lesion- or treatment-specific factors, a therapeutic alternative may be required. In this study, the authors aimed to assess the safety of RS in treating superficial CMs and to analyze its long-term effect on hemorrhage rates and epilepsy control.METHODSThe authors conducted a retrospective analysis of 96 patients with 109 CMs located in the cerebral or cerebellar hemispheres and treated with RS between 1995 and 2014. A median of 15 Gy (range 10–25 Gy) was given to the 50% prescription isodose level, lesion volume was 604 mm3 (4–8300 mm3), and the prescription isodose volume was 638.5 mm3 (4–9500 mm3). Outcomes were compared to those of 206 deep-seated lesions reported on in another study. Ninety-five patients had available follow-up, which was a median of 7 years (1–21 years). Median patient age was 42 years (0.5–77) at presentation and 45 (3–80) at treatment. Seventy-one CMs presented with symptomatic hemorrhage, and 52 caused seizures.RESULTSIn the nonhemorrhagic group (37 lesions), one bleed occurred during the follow-up period, for an annual bleed rate of 0.4% per lesion. The lifetime annual bleed rate of CMs having a single hemorrhage prior to treatment was 2.5%. The rebleed rate in the single-bleed group decreased from 1.8% within the first 2 years after RS to 0.7% thereafter. The pretreatment rebleed rate for lesions having multiple bleeds prior to RS was 14.15%, which fell to 3.85% for the first 2 years after RS and declined to 1.3% thereafter. Multivariate analysis showed younger age, deep lesion location, and multiple pretreatment hemorrhages as significant predictors of posttreatment hemorrhage.Pretreatment hemorrhages led to permanent deficits in 41.4% of the cases with a single bleed and in 46.1% of cases with multiple bleeds. Only mild (modified Rankin Scale score 1) and a low rate of permanent neurological deficits were caused either by posttreatment hemorrhages (4.3%) or by radiation (2%).The rate of improvement in epilepsy was 84.9% after RS in patients with at least one seizure prior to treatment, not depending on the presence of hemorrhage or the time interval between presentation and treatment. Favorable outcome occurred in 81% of patients whose seizures were not controlled with antiepileptic medication prior to RS.CONCLUSIONSRadiosurgery for superficial CMs is safe and appears to be effective, offering a real treatment alternative to surgery for selected patients. Given their relatively benign natural history, superficial CMs require further study to verify the long-term benefit of RS over the lesions’ natural history.

Case Report: Concurrent primary CNS lymphoma and meningothelial meningioma - nuances of diagnosis and management

Background: The incidence of two distinct primary intracranial pathologies is an exceedingly rare phenomenon. Although meningiomas are well known to coexist with other primary intracranial malignancies there are only nine reported cases of a meningioma occurring simultaneously with primary CNS lymphoma in the literature. We report a case of a woman who sustained multiple injuries due to two distinct intracranial pathologies, however, lateralizing signs were unrecognized for two weeks prior to her final diagnosis. Case Description: A 64-year-old female with history of diabetes mellitus type 2 initially presented to the Emergency Department, two weeks prior, following a mechanical fall at home resulting in a left bimalleolar fracture. CT imaging revealed a right occipital mass with significant vasogenic edema causing 12mm of midline shift. MRI revealed two distinct homogeneously contrast-enhancing lesions: a right occipital mass with dural-based attachment, as well as a homogenously contrast-enhancing lesion adjacent to the right posterolateral ventricle. FLAIR signal changes were also appreciated and were noted to extend across the corpus callosum, raising concerns for a high-grade glial process. She underwent a right occipital craniotomy with gross total resection of the right occipital mass as well as subtotal resection and biopsy of the second lesion. Final pathology of the extra-axial lesion was found to be meningothelial meningioma and the deep lesion was found to be diffuse large B-cell lymphoma. Discussion: We describe a rare instance of simultaneous meningioma and primary CNS lymphoma that was found to be the underlying cause of a traumatic injury several weeks after the incident. We review the current diagnosis and management nuances in the setting of multiple intracranial oncologic processes.

Chronic lymphocytic leukemia revealed by a rare complication: Noma. First description from Togo

Introduction: Noma is defined as a gangrenous ulcerative stomatitis whose starting point is endobuccal. Its exact etiology remains unknown, but many risk factors have been described (malnutrition, poor hygiene, etc.). Chronic lymphoid leukemia (LLC) is a lymphoproliferative syndrome characterized by medullary proliferation of a B lymphocyte clone. It is not considered as a risk factor for noma disease. Observation: A 43-year-old patient is admitted in the odontostomatology unit of the Dapaong Regional Hospital Centre (Togo) for a deep lesion of the left cheek. The clinical examination allows to conclude the presence of a noma. Biological examinations also show a LLC at Binet stage C. In our patient, the LLC is associated with an immunosuppression and the development of infections due to the late diagnosis of the LLC. Comment: The immunosuppression and the development of infections are described in the literature as risk factors for noma disease. An association between LLC and noma could therefore exist. However, such association has been reported to date only once in the literature in 1976. Conclusion: Our observation suggests that the LLC could be a risk factor for noma disease. However, further studies based on large samples are necessary to conclude a causal association between LLC and noma.