Update on the natural history of infratentorial cavernous malformations

Infratentorial cavernous malformations are still a source of serious controversies in neurosurgery and their natural history and treatment are intensely debated in literature. Recent studies suggest that symptomatic infratentorial cavernous malformations have a more aggressive clinical outcome than the supratentorial ones (the risk of hemorrhage is approximately 30 times that of the supratentorial cavernomas) The optimal therapeutic approach of infratentorial cavernomas need a good understanding of the natural history and also the characteristics that may influence the associated neurological risk, like the patient status at admission, the localization and the genetics of the malformation. Many studies have been published in the last decades to enlight the clinical aspects and the natural history of these vascular malformations. The purpose of this analysis is to make a literature review of the morbidity risk associated to cavernous malformations and their influence on the treatment plan

Deontological issues - possible misdiagnosis of cerebral metastases

Authors analyses a number of 4588 (52, 24% over 50 years old) patients operated for cerebral tumors in the Clinic Emergency Hospital “Bagdasar-Arseni” from Bucharest, between 2000-2010, with peculiar attention to the concordance between the preoperative and postoperative diagnosis, related to the actual policy to evaluate a neurosurgical patient before surgery. 903 cases were cerebral metastases and 69,5% aged over 50 years old. In 9,7% of cases we recorded a preoperative misdiagnosis of a metastasis due to few main reasons: unavailable information about a present primitive cancer, treacherous MRI image with a single confusing appearance of a cerebral lesion, age less than 50 years old, clinical presentation and biological evaluation inconsistent with malignancy. Authors point that these situations can have serious consequences related to professional competence, deterioration of the patient-doctor relationship, increasing costs for completion of diagnosis and treatment, and inadequate information about patient’s prognosis

Posterior fossa arteriovenous malformations: Case report

The posterior fossa arteriovenous malformation (AVM) is uncommon and different from other intracranial AVM in its natural history, diagnosis, treatment, prognosis, and other features. The authors present the case a 19 years old woman admitted for comatose state, GCS=6 points, left hemiparesis, flexion of right limbs on noxious stimuli, mydriasis with bilaterally preservation of oculomotor reflex and acute respiratory failure. Cerebral CT scan showed an intraparenchymal hematoma, located into the posterior cranial fossa, within the vermin, measuring 2.8/3.2 cm, with important surrounding edema, intraventricular bleeding within the third and fourth ventricle, massive infratentorial subarachnoid hemorrhage and acute hydrocephalus. Cerebral four vessels angiography showed an infratentorial AVM (arteriovenous malformation), located within the right cerebellar hemisphere, with a nidus, measuring around 3 cm maximal diameter, in the craniocaudal direction. The AVM had arterial feeders coming from the right posterior cerebral artery and superior cerebellar artery and venous drainage into the Galen vein, Herophil torculla, and right lateral sinus. We conclude the diagnosis of right ruptured cerebellar hemisphere AVM, grade Martin-Spetzler III, Hunt and Hess 5 and the choice treatment was open surgery. Authors insist on neurosurgical strategy for treatment which in our case conducted to excellent results

Calcified chronic subdural hematoma: Case report

The authors present a case of a female patient, 26 years old, who suffered a craniocerebral trauma 15 years ago, by falling from a different level. She manifested an intracranial hypertension syndrome and seizures at the moment of hospital admission. Brain CT scan reveals a large right fronto-parietal calcified subdural mass with left shift of median line. The lesion was isointense on T1 and hyperintense in T2 weighted magnetic resonance imaging (MRI). Calcified or atypical meningioma, bony tumor and subdural abscess were included in differential diagnosis. She underwent surgery and a calcified chronic subdural hematoma was completely excised, with good postoperative recovery. After two months of follow up, seizures were controlled with a minimal dose of medication, control CT scan showing absence of the hematoma and brain re-expansion. In summary, this uncommon calcified chronic subdural hematoma was successfully excised, resulting in a good recovery. From the literature review and the experience in this patient, authors consider surgical treatment for calcified chronic subdural hematoma as necessary and often results in neurological improvement, especially concerning seizures