Pitfalls in the diagnosis of a tumefactive demyelinating lesion: A case report

<p>Abstract</p> <p>Introduction</p> <p>In rare instances, demyelinating disorders manifest as tumefactive lesions that simulate brain tumors. We report a patient with a space-occupying lesion in the parietal lobe, which presented a serious diagnostic dilemma, between a rare tumefactive demyelinating disease, such as Balo concentric sclerosis and a glioma. This case report highlights important diagnostic clues in the differential diagnosis of Balo concentric sclerosis.</p> <p>Case presentation</p> <p>A 20-year-old Caucasian woman with acute onset of left-sided weakness and numbness was admitted to hospital with neurologic signs of left-sided hemiparesis and hypoesthesia. Brain magnetic resonance imaging showed a mass lesion of abnormal signal intensity with concentric enhancing rings in the right parietal lobe, without perifocal edema. The characteristic concentric pattern detected on the magnetic resonance images was highly suggestive of Balo disease, and corticosteroids were administered. Evoked potentials, cerebrospinal fluid analysis, and magnetic spectroscopy findings were not specific, and glioma was also included in the differential diagnosis. A stereotactic biopsy was not diagnostic.</p> <p>After one month the patient showed moderate clinical improvement, and during 12 months follow-up, no further relapses occurred. In the follow-up magnetic resonance imaging, the concentric pattern had completely disappeared, and only a low-signal, gliotic lesion remained.</p> <p>Conclusion</p> <p>We hope this case presentation will advance our understanding of clinical and radiologic appearance of Balo concentric sclerosis, which is a rare demyelinating disease. Although this is a specific entity, it has a broader clinical impact across medicine, because it must be differentiated from other space-occupying lesions in the central nervous system.</p

Anticancer Gene Transfer for Cancer Gene Therapy

Gene therapy vectors are among the treatments currently used to treat malignant tumors. Gene therapy vectors use a specific therapeutic transgene that causes death in cancer cells. In early attempts at gene therapy, therapeutic transgenes were driven by non-specific vectors which induced toxicity to normal cells in addition to the cancer cells. Recently, novel cancer specific viral vectors have been developed that target cancer cells leaving normal cells unharmed. Here we review such cancer specific gene therapy systems currently used in the treatment of cancer and discuss the major challenges and future directions in this field

Symptomatic syringomyelia secondary to clinically obscure infratentorial tumour

The formation of a cervical spinal cord syrinx as a result of an infratentorial mass, even though uncommon, has been reported in international literature. In such cases, syringomyelia is usually asymptomatic, while the tumour-related symptoms and signs predominate. We report a patient with a posterior fossa tumour and secondary syringomyelia. In this patient, syringomyelia symptoms and signs were present, and a cervical spine Magnetic Resonance Imaging (MRI) showed a large cervical syrinx. A more careful clinical examination though, revealed a sub-clinical posterior fossa syndrome and brain MRI revealed a large infratentorial meningioma. A posterior fossa craniotomy was performed, followed by complete tumour resection and almost complete remission of the syrinx and its related symptoms. The authors discuss the role of posterior fossa tumour induced tonsillar herniation in the development of secondary syringomyelia, the mechanisms leading to syrinx formation and the conditions that must be fulfilled for that to happen

Epidural haematoma after evacuation of contralateral subdural haematoma

Background Sequentially evolving intracranial bilateral haematomas, where the second haematoma develops after the surgical removal of the first one is rarely reported. Aim To report a patient who developed an epidural haematoma after evacuation of a contralateral subdural haematoma. Methods A 49-year-old male was admitted to our department after head injury. A brain computerized tomography (CT) scan revealed an acute subdural haematoma in the right temporal area which was evacuated. During his stay in the intensive care unit, he was submitted to intracranial pressure monitoring, which soon rose. Results A new CT scan showed an acute epidural haematoma in the contralateral parietal area that was also evacuated. Conclusions While rising intracranial pressure after the evacuation of a traumatic haematoma is usually attributed to brain oedema or recurrent haematoma at the craniotomy site, the development of a contralateral epidural haematoma requiring surgical treatment should not be overlooked

Lumbar synovial cyst as a cause of low back pain and acute radiculopathy: A case report

The authors report the case of a 69-year old female with a persistent history of low back pain. Plain lumbar radiographs, performed at symptom initiation, revealed lumbar spondylolisthesis. Low back pain was attributed to this, and the patient received conservative treatment with partial relief of symptoms. Four years later, and as a result of acute onset of radicular symptoms, a lumbar spine magnetic resonance imaging scan was performed, revealing an epidural cystic lesion. The cyst was removed, and histopathology revealed a synovial cyst

Functional outcome of intrathecal baclofen administration for severe spasticity

Purpose: To estimate the functional benefit in patients with severe spasticity treated with intrathecal baclofen infusion through an implantable pump and to stress the need for functional assessment of these patients with a functional scale. Patients and Methods: Between 1999 and 2003, 22 patients with a long history of severe and disabling pharmaceutically intractable spasticity, underwent implantation of a pump for continuous intrathecal baclofen infusion. The patients were subdivided into two categories according to the aetiology of spasticity: 15 had Multiple Sclerosis and seven had suffered a Spinal Cord Injury at different levels (from C4 to T11). Clinical status was assessed with the Ashworth and Penn spasm scales. Functional benefits were evaluated with the Barthel index score and pain relief with a self-reported visual analogue pain scale. Results: Postoperatively, all patients presented improvement in spasticity, reduction of spasm frequency, significant improvement in functional status, enhancement of life comfort and reduction of pain. Conclusion: Reduction of spasticity and spasms achieved with intrathecally delivered baclofen, leads to functional improvement and pain relief. (c) 2004 Elsevier B.V. All rights reserved

Selection of cranial site for shunting debilitated patients

Background-objective. The optimum cranial site for ventricular catheter insertion in CSF shunts is still under debate and there has been no general consensus as far as surgical technicalities are concerned. Furthermore, there have been no reports dealing with appropriate cranial site selection in debilitated patients. The aim of this report is to stress the need to utilize a frontal approach when dealing with patients who are likely to remain bed-bound for long periods and to emphasize the well-known prerequisites such as meticulous surgical technique and perioperative general and local care. Method. A retrospective analysis of all shunt operations and revisions performed in our department during the last 6 years. Findings. This analysis revealed 8 long-term recumbent patients with late valve extrusion (N1 = 5) or primary wound breakdown (N2 = 3), all through the occipital area. Extended periods of bed rest due to neurological disease combined with poor nursing and dietary intake had led to either chronic valve extrusion or wound breakdown. Shunt revision was performed successfully by a frontal approach in 5 whereas 2 tolerated shunt removal and one died of meningitis. Conclusion. In debilitated patients or those who are likely to remain bed-bound for long periods, a frontal approach for proximal catheter insertion may help prevent immediate postoperative wound breakdown or late valve extrusion

Complex neurobehavioural syndrome due to bilateral thalamic glioma

We present a 65-year-old female with bilateral thalamic astrocytoma. The unusual long survival of this patient allowed the manifestation of a complex neurobehavioural syndrome due to gradual involvement of several thalamic nuclei. An attempt is made to approach the complexity of symptoms according to the anatomical areas, nuclei and thalamic connections infiltrated