[Downloaded free from http://www.neurologyindia.com on Thursday, September 25, 2014, IP: 202.177.173.189] || Click here to download free Android application fo this journal Letters to Editor
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Figure 1: The pneumocephalus is seen in right frontal lobe arising from fracture of posterior wall of frontal sinus (white arrow in a) and progressing further intracranially (b-d). (e) depicts intra-operative radiograph confirming frontal recess localisation during endoscopic procedure. (f-h) show CT scan done on post-operative day three, showing complete disappearance of pneumocephalus
References 1. Solomiichuk VO, Lebed VO, Drizhdov KI. Posttraumatic delayed subdural tension pneumocephalus. Surg Neurol Int 2013;4:37. 2. Martínez‑Capoccioni G, Serramito‑García R, Cabanas‑Rodríguez E, García‑Allut A, Martín‑Martín C. Tension pneumocephalus as a result of endonasal surgery: An uncommon intracranial complication. Eur Arch Otorhinolaryngol 2013;271:1043‑9. 3. Kendre B, Deopujari C, Karmarkar V, Shah S. Frontal sinus osteoma with pneumocephalus and progressive hemiparesis. Neurol India 2013;61:694‑5. 4. Krischek B, Vescan A, Zweifel C, Zadeh G, Gentili F. Endonasal endoscopic release of a delayed tension pneumocephalus after craniofacial resection of a tumor of the anterior skull base. J Neurol Surg A Cent Eur Neurosurg 2013;74:e271‑4. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.141274
Received: 13-06-2014 Review completed: 18-06-2014 Accepted: 25-08-2014
454
Author Query??? AQ1: Kindly provide copy right form duly signed by
Hemangiopericytoma of pineal region: Case report and review Sir, Intracranial hemangiopericytomas (HPC) are malignant meningothelial tumors, developing from malignant transformation of pericytes. Majority of them are located in the base of the skull, in the middle or posterior fossa. The HPC in the posterior third ventricle region is very uncommon and thus this report. A 24‑year‑old male presented with headache and vomiting of one‑month duration. Neurologic examination was normal except for bilateral papilledema. Magnetic resonance imaging (MRI) brain showed a well‑defined lesion in posterior third ventricular region, iso to hypointense on T1, hyper on T2, enhancing intensely on contrast, causing obstructive hydrocephalus [Figure 1a‑d]. A ventriculoperitoneal shunt was done for hydrocephalus. Cerebrospinal fluid analysis was negative for tumor markers. Subsequently he underwent right‑sided Poppen’s approach and excision of lesion. The tumor was found to be attached Neurology India | Jul-Aug 2014 | Vol 62 | Issue 4
[Downloaded free from http://www.neurologyindia.com on Thursday, September 25, 2014, IP: 202.177.173.189] || Click here to download free Android application fo this journal Letters to Editor
a
b
c
e
d
f
Figure 1: (a-d) MRI brain of a 24 year old man show a well defined lesion in the posterior third ventricular region, isointense on T1, hyper on T2, with uniform contrast enhancement. E, F: Histopathology revealed cellular tumor with characteristic stag horn vessels intersecting the tumor (e). Tumor cells are strongly labeled by CD34 (f). [E:H and ExObj,20, F: CD34Obj.40]
to the tentorium and was highly vascular. Majority of the vascularity was coming from the falx and the tentorium. Following the detachment of the tentorial attachment, the tumor was excised completely. Patient had no deficits in the postoperative period, and was discharged on postoperative day‑4. Histopathology revealed characteristic features of HPC with large dilated staghorn vascular channels and foci of stromal hyalinization and cystic changes intersecting the tumor cells that have elongated vesicular nuclei arranged in sheets [Figure 1e]. Mitotic activity exceeded 5/10 hpf but no necrosis was noted. Tumor cells exhibited strong immunoreactivity for CD34 [Figure 1f] A diagnosis of Grade II HPC was made. In view of high mitosis, and the diagnosis of hemangiopericytoma, he received radiotherapy of 50 Gy in 25 fractions. At 1‑year follow up, he was asymptomatic and had no deficits. The MRI of the brain did not show any evidence of residual or recurrent tumor [Figure 2a‑c]. HPCs represent less than 1% of all intracranial tumors, and approximately 2–4% of all meningeal tumors. Despite sharing a common arachnoid location and near indistinguishable radiological features with benign meningioma, HPC is distinguished by a more aggressive biology that facilitates local recurrence and Neurology India | Jul-Aug 2014 | Vol 62 | Issue 4
a
b
c Figure 2 (a-c): MRI Brain with contrast, Axial, Sagittal and coronal sequences revealing complete excision of tumor without any recurrence
distant metastasis.[1] As recurrence is almost invariable, sometimes initial treatment within few months of, radical excision followed by adjuvant therapy, mainly radiotherapy, remains the mainstay of treatment. [2] They almost always present as solitary, supratentorial, dural‑based lesions, often arising from the falx, tentorium, dural sinuses and skull base. However, pineal region location is rare with very few reported cases in literature. 455
[Downloaded free from http://www.neurologyindia.com on Thursday, September 25, 2014, IP: 202.177.173.189] || Click here to download free Android application f this journal Letters to Editor
Only six cases of pineal region hemangiopericytomas have been reported so far in the literature, to the best of our knowledge.[3‑8] The location coupled with tumor vascularity often make gross total resection challenging. The outcomes of previous reports reflect the same.[3,5,6] However, a recent report by Jian et al. suggests that these patients can be managed successfully.[7] In our case, the resection was uneventful, and patient is recurrent‑ free 1‑year post‑treatment. We preferred operating via occipital transtentorial approach because of large supratentorial involvement, and potentially larger surgical corridor through the same. In conclusion, hemangiopericytomas rarely arise in the posterior third ventricular region. Despite, the depth of the tumor and high vascularity, they can be managed successfully with microsurgical techniques.
Tanmoy Kumar Maiti, M. N. Nagarjun, Arivazhagan Arimappamagan, Anita Mahadevan1, Paritosh Pandey Departments of Neurosurgery, and 1Neuropathology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India E‑mail: [email protected]
References 1 2 3 4 5 6 7 8
Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Burger PC, Jouvet A, et al. The 2007 who classification of tumours of the central nervous system. Acta Neuropathol 2007;114:97‑109. Chacko G, Chacko AG, Rajshekhar V, Muliyil JP. Intracranial hemangiopericytomas: Correlation of topoisomerase iialpha expression with biologic behavior. Surg Neurol 2006;65:11‑7. Olson JR, Abell MR. Haemangiopericytoma of the pineal body. J Neurol Neurosurg Psychiatry 1969;32:445‑9. Stone JL, Cybulski GR, Rhee HL, Bailey OT. Excision of a large pineal region hemangiopericytoma (angioblastic meningioma, hemangiopericytoma type). Surg Neurol 1983;19:181‑9. Lesoin F, Bouchez B, Krivosic I, Delandsheer JM, Jomin M. Hemangiopericytic meningioma of the pineal region. Case report. Eur Neurol 1984;23:274‑7. Sell JJ, Hart BL, Rael JR. Hemangiopericytoma: A rare pineal mass. Neuroradiology 1996;38:782‑4. Jian BJ, Han SJ, Yang I, Waldron JS, Tihan T, Parsa AT. Surgical resection and adjuvant radiotherapy for a large pineal hemangiopericytoma. J Clin Neurosci 2010;17:1209‑11. Hasturk AE, Basmaci M, Bozdogan N, Canbay S. Hemangiopericytoma of the pineal region. Neurosciences (Riyadh) 2011;16:159‑61. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.141277
Received: 08-07-2014 Review completed: 25-08-2014 Accepted: 25-08-2014 456
Author Query??? AQ2: Kindly provide copy right form duly signed by the authors
Upper limbs spread of orthostatic tremor following hip replacement surgery Sir, Orthostatic tremor (OT) is characterized by a high frequency (13-18 Hz), which causes a great deal of unsteadiness while standing and is most obvious in the legs. It can occasionally be seen in the trunk and upper limbs when these regions are used to support body weight or when they contract isometrically.[1] Total hip replacement (THR) is the treatment option for severe hip osteoarthritis often with generally good prognosis. However, postoperative posturography shows evidence of some residual gait and balance deficit.[2‑4] While OT of the upper extremities is an unusual phenomenon, its appearance post‑THR is rather uncommon. A 57‑year‑old female was diagnosed as a case of OT since five years with good response to 2 mg daily of clonazepam. She had a right THR in April, 2013. Following the surgery, she admitted that her lower limb OT worsened. She could use a brace walker minimally but noted tremor of the upper extremities on doing so. In January 2014, polymyographic recordings were performed with the Ag–AgCl pair of cutaneous recording electrodes placed on rectus femoris, anterior tibialis, gastrocnemius, biceps brachii, forearm flexorand extensor muscles as well as paraspinal muscles during sitting, standing and walking. During sitting, polymyographic recordings showed a 10 Hz postural tremor of the upper extremities with no tremor in the lower extremities [Figure 1a]. Upon standing, a rapidly developed 16 Hz tremor was noted over the rectus femoris, anterior tibialis, gastrocnemius and paraspinal muscles [Figure 1b and c]. Simultaneously, we noted the same high frequency tremor in the forearm extensor muscles [Figure 1b]. Immediately on initiation of the swing phase of gait, the lower extremities tremor disappeared [Figure 1d]. Altered weight‑bearing seems to explain this observation even though the upper extremities could be involved in about 15% of patients with OT. [5] Theoretically, post‑THR patients are prone to balance and gait abnormalities due to factors such as damage to proprioceptive fibers resulting from excision of the capsules, weakened abductor muscles, unequal length, shortened abductors lever arm and restricted range of motions in addition to altered weight bearing.[3] Consequent upon these, trunk compensatory mechanism ensues to help compensate for weakened abductor muscles and to maintain body balance in Neurology India | Jul-Aug 2014 | Vol 62 | Issue 4
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
a
c
b
e
f
d
g
h
Figure 1: The pneumocephalus is seen in right frontal lobe arising from fracture of posterior wall of frontal sinus (white arrow in a) and progressing further intracranially (b-d). (e) depicts intra-operative radiograph confirming frontal recess localisation during endoscopic procedure. (f-h) show CT scan done on post-operative day three, showing complete disappearance of pneumocephalus
References 1. Solomiichuk VO, Lebed VO, Drizhdov KI. Posttraumatic delayed subdural tension pneumocephalus. Surg Neurol Int 2013;4:37. 2. Martínez‑Capoccioni G, Serramito‑García R, Cabanas‑Rodríguez E, García‑Allut A, Martín‑Martín C. Tension pneumocephalus as a result of endonasal surgery: An uncommon intracranial complication. Eur Arch Otorhinolaryngol 2013;271:1043‑9. 3. Kendre B, Deopujari C, Karmarkar V, Shah S. Frontal sinus osteoma with pneumocephalus and progressive hemiparesis. Neurol India 2013;61:694‑5. 4. Krischek B, Vescan A, Zweifel C, Zadeh G, Gentili F. Endonasal endoscopic release of a delayed tension pneumocephalus after craniofacial resection of a tumor of the anterior skull base. J Neurol Surg A Cent Eur Neurosurg 2013;74:e271‑4. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.141274
Received: 13-06-2014 Review completed: 18-06-2014 Accepted: 25-08-2014
454
Author Query??? AQ1: Kindly provide copy right form duly signed by
Hemangiopericytoma of pineal region: Case report and review Sir, Intracranial hemangiopericytomas (HPC) are malignant meningothelial tumors, developing from malignant transformation of pericytes. Majority of them are located in the base of the skull, in the middle or posterior fossa. The HPC in the posterior third ventricle region is very uncommon and thus this report. A 24‑year‑old male presented with headache and vomiting of one‑month duration. Neurologic examination was normal except for bilateral papilledema. Magnetic resonance imaging (MRI) brain showed a well‑defined lesion in posterior third ventricular region, iso to hypointense on T1, hyper on T2, enhancing intensely on contrast, causing obstructive hydrocephalus [Figure 1a‑d]. A ventriculoperitoneal shunt was done for hydrocephalus. Cerebrospinal fluid analysis was negative for tumor markers. Subsequently he underwent right‑sided Poppen’s approach and excision of lesion. The tumor was found to be attached Neurology India | Jul-Aug 2014 | Vol 62 | Issue 4
[Downloaded free from http://www.neurologyindia.com on Thursday, September 25, 2014, IP: 202.177.173.189] || Click here to download free Android application fo this journal Letters to Editor
a
b
c
e
d
f
Figure 1: (a-d) MRI brain of a 24 year old man show a well defined lesion in the posterior third ventricular region, isointense on T1, hyper on T2, with uniform contrast enhancement. E, F: Histopathology revealed cellular tumor with characteristic stag horn vessels intersecting the tumor (e). Tumor cells are strongly labeled by CD34 (f). [E:H and ExObj,20, F: CD34Obj.40]
to the tentorium and was highly vascular. Majority of the vascularity was coming from the falx and the tentorium. Following the detachment of the tentorial attachment, the tumor was excised completely. Patient had no deficits in the postoperative period, and was discharged on postoperative day‑4. Histopathology revealed characteristic features of HPC with large dilated staghorn vascular channels and foci of stromal hyalinization and cystic changes intersecting the tumor cells that have elongated vesicular nuclei arranged in sheets [Figure 1e]. Mitotic activity exceeded 5/10 hpf but no necrosis was noted. Tumor cells exhibited strong immunoreactivity for CD34 [Figure 1f] A diagnosis of Grade II HPC was made. In view of high mitosis, and the diagnosis of hemangiopericytoma, he received radiotherapy of 50 Gy in 25 fractions. At 1‑year follow up, he was asymptomatic and had no deficits. The MRI of the brain did not show any evidence of residual or recurrent tumor [Figure 2a‑c]. HPCs represent less than 1% of all intracranial tumors, and approximately 2–4% of all meningeal tumors. Despite sharing a common arachnoid location and near indistinguishable radiological features with benign meningioma, HPC is distinguished by a more aggressive biology that facilitates local recurrence and Neurology India | Jul-Aug 2014 | Vol 62 | Issue 4
a
b
c Figure 2 (a-c): MRI Brain with contrast, Axial, Sagittal and coronal sequences revealing complete excision of tumor without any recurrence
distant metastasis.[1] As recurrence is almost invariable, sometimes initial treatment within few months of, radical excision followed by adjuvant therapy, mainly radiotherapy, remains the mainstay of treatment. [2] They almost always present as solitary, supratentorial, dural‑based lesions, often arising from the falx, tentorium, dural sinuses and skull base. However, pineal region location is rare with very few reported cases in literature. 455
[Downloaded free from http://www.neurologyindia.com on Thursday, September 25, 2014, IP: 202.177.173.189] || Click here to download free Android application f this journal Letters to Editor
Only six cases of pineal region hemangiopericytomas have been reported so far in the literature, to the best of our knowledge.[3‑8] The location coupled with tumor vascularity often make gross total resection challenging. The outcomes of previous reports reflect the same.[3,5,6] However, a recent report by Jian et al. suggests that these patients can be managed successfully.[7] In our case, the resection was uneventful, and patient is recurrent‑ free 1‑year post‑treatment. We preferred operating via occipital transtentorial approach because of large supratentorial involvement, and potentially larger surgical corridor through the same. In conclusion, hemangiopericytomas rarely arise in the posterior third ventricular region. Despite, the depth of the tumor and high vascularity, they can be managed successfully with microsurgical techniques.
Tanmoy Kumar Maiti, M. N. Nagarjun, Arivazhagan Arimappamagan, Anita Mahadevan1, Paritosh Pandey Departments of Neurosurgery, and 1Neuropathology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India E‑mail: [email protected]
References 1 2 3 4 5 6 7 8
Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Burger PC, Jouvet A, et al. The 2007 who classification of tumours of the central nervous system. Acta Neuropathol 2007;114:97‑109. Chacko G, Chacko AG, Rajshekhar V, Muliyil JP. Intracranial hemangiopericytomas: Correlation of topoisomerase iialpha expression with biologic behavior. Surg Neurol 2006;65:11‑7. Olson JR, Abell MR. Haemangiopericytoma of the pineal body. J Neurol Neurosurg Psychiatry 1969;32:445‑9. Stone JL, Cybulski GR, Rhee HL, Bailey OT. Excision of a large pineal region hemangiopericytoma (angioblastic meningioma, hemangiopericytoma type). Surg Neurol 1983;19:181‑9. Lesoin F, Bouchez B, Krivosic I, Delandsheer JM, Jomin M. Hemangiopericytic meningioma of the pineal region. Case report. Eur Neurol 1984;23:274‑7. Sell JJ, Hart BL, Rael JR. Hemangiopericytoma: A rare pineal mass. Neuroradiology 1996;38:782‑4. Jian BJ, Han SJ, Yang I, Waldron JS, Tihan T, Parsa AT. Surgical resection and adjuvant radiotherapy for a large pineal hemangiopericytoma. J Clin Neurosci 2010;17:1209‑11. Hasturk AE, Basmaci M, Bozdogan N, Canbay S. Hemangiopericytoma of the pineal region. Neurosciences (Riyadh) 2011;16:159‑61. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.141277
Received: 08-07-2014 Review completed: 25-08-2014 Accepted: 25-08-2014 456
Author Query??? AQ2: Kindly provide copy right form duly signed by the authors
Upper limbs spread of orthostatic tremor following hip replacement surgery Sir, Orthostatic tremor (OT) is characterized by a high frequency (13-18 Hz), which causes a great deal of unsteadiness while standing and is most obvious in the legs. It can occasionally be seen in the trunk and upper limbs when these regions are used to support body weight or when they contract isometrically.[1] Total hip replacement (THR) is the treatment option for severe hip osteoarthritis often with generally good prognosis. However, postoperative posturography shows evidence of some residual gait and balance deficit.[2‑4] While OT of the upper extremities is an unusual phenomenon, its appearance post‑THR is rather uncommon. A 57‑year‑old female was diagnosed as a case of OT since five years with good response to 2 mg daily of clonazepam. She had a right THR in April, 2013. Following the surgery, she admitted that her lower limb OT worsened. She could use a brace walker minimally but noted tremor of the upper extremities on doing so. In January 2014, polymyographic recordings were performed with the Ag–AgCl pair of cutaneous recording electrodes placed on rectus femoris, anterior tibialis, gastrocnemius, biceps brachii, forearm flexorand extensor muscles as well as paraspinal muscles during sitting, standing and walking. During sitting, polymyographic recordings showed a 10 Hz postural tremor of the upper extremities with no tremor in the lower extremities [Figure 1a]. Upon standing, a rapidly developed 16 Hz tremor was noted over the rectus femoris, anterior tibialis, gastrocnemius and paraspinal muscles [Figure 1b and c]. Simultaneously, we noted the same high frequency tremor in the forearm extensor muscles [Figure 1b]. Immediately on initiation of the swing phase of gait, the lower extremities tremor disappeared [Figure 1d]. Altered weight‑bearing seems to explain this observation even though the upper extremities could be involved in about 15% of patients with OT. [5] Theoretically, post‑THR patients are prone to balance and gait abnormalities due to factors such as damage to proprioceptive fibers resulting from excision of the capsules, weakened abductor muscles, unequal length, shortened abductors lever arm and restricted range of motions in addition to altered weight bearing.[3] Consequent upon these, trunk compensatory mechanism ensues to help compensate for weakened abductor muscles and to maintain body balance in Neurology India | Jul-Aug 2014 | Vol 62 | Issue 4
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
