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Large cystic target lesion: An unusual presentation of cavernoma

Article in Neurology India · September 2010

DOI: 10.4103/0028-3886.72203 · Source: PubMed

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813 Neurology India | Sep-Oct 2010 | Vol 58 | Issue 5

Letters to Editor

In our experience, ONSD measurement correlated well with CT evidence of raised ICP, clinical deterioration and response to therapeutic intervention. Our case series illustrates a very important potential role for a promising new diagnostic technique. Invasive ICP measurement is the gold standard for identifjcation of high ICP as well as monitoring following treatment and can be performed effectively even in resource- constrained environments.[4] We believe that ICUs in developing nations that routinely care for patients with severe brain injury must attempt to perform invasive ICP monitoring as the standard of care for patients suspected to have raised ICP. Realistically, however, this is unlikely to happen in the near future. ONSD measurement is inexpensive, appears to have relatively low inter-observer variability and is a relatively simple technique to teach to junior physicians.[3,5] Optic nerve ultrasonography is a promising tool for the detection

• f intracranial hypertension in resource-constrained

environments. Venkatakrishna Rajajee, Prithiviraj Thyagarajan, Ram E. Rajagopalan

Department of Critical Care Medicine, Sundaram Medical Foundation, Shanthi Colony, 4th Avenue, Annanagar, Chennai 600040, India. E-mail: vrajajee@yahoo.com PMID: *** DOI: 10.4103/0028-3886.72202

References

1. Geeraerts T, Launey Y, Martin L, Pottecher J, Vigué B, Duranteau J, et al. Ultrasonography of the optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury. Intensive Care Med 2007;33:1704-11. 2. Kimberly HH, Shah S, Marill K, Noble V . Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med 2008;15:201-4. 3. Moretti R, Pizzi B, Cassini F , Vivaldi N. Reliability of optic nerve ultrasound for the evaluation of patients with spontaneous intracranial

• hemorrhage. Neurocrit Care. 2009.

4. Joseph M. Intracranial pressure monitoring in a resource constrained environment: a technical note. Neurol India 2003;51:1538-43. 5. Le A, Hoehn ME, Smith ME, Spentzas T, Schlappy D, Pershad J. Bedside sonographic measurement of optic nerve sheath diameter as a predictor of increased intracranial pressure in children. Ann Emerg Med 2009;53:785-91. Accepted on: 27-07-2010

Large cystic target lesion: An unusual presentation of cavernoma

Sir, Imaging characteristics of a large cavernoma are variable; they may be purely cystic or contrast-enhancing mass lesions.[1-3] This report presents a cavernoma with a large cystic target lesion with central core enhancement. A 30-year-old lady presented with recurrent seizure, headache and left hemiparesis. Contrast computerized tomography (CCT) brain showed a well-defjned lesion resembling the target of shooting rifle with central enhancing core and a well-demarcated surrounding hypodense halo along with perilesional edema [Figure 1]. On magnetic resonance imaging (MRI), the central core demonstrated mixed intensity on both T1- and T2-weighted images; the surrounding halo was isointense on T1W and hyperintense on T2W images with blooming on Gradient Echo sequences. Contrast study showed irregular enhancement of central core, while the peripheral rim of halo was perfectly spherical and brilliantly enhancing [Figure 2]. Cerebral angiogram revealed no abnormality. At surgery, xanthochromic fmuid was aspirated from the cystic lesion. Wall of the cyst was easily separable from the surrounding gliotic brain, and total excision

• f the lesion was done. Cut section of the specimen

showed central area of soft, fragile reddish brown mass. Histopathology confjrmed the diagnosis of cavernoma. At the 6-month postoperative follow-up, the patient is asymptomatic.

Figure 1: Contrast CT scan showing a target-shaped lesion having a central enhancing core with a well-demarcated surrounding hypodense halo and marked edema

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814 Neurology India | Sep-Oct 2010 | Vol 58 | Issue 5

Letters to Editor Figure 2: On MRI, the central core of target lesion is irregularly enhancing, while the peripheral rim of halo is spherical and brilliantly enhancing

An unusual cause of entrapment of temporal horn: Neurocysticercosis

Sir, Entrapment of temporal horn is a rare entity caused by

• bstruction at the trigone of the lateral ventricle, which

seals off the temporal horn from the rest of the ventricular system.[1] Intraventricular cysticercosis accounts for 7% to 30% of NCC[2] and it causing an entrapped temporal horn has not been reported till date. We are reporting two interesting cases of entrapped temporal horn syndrome caused by giant intraventricular cysticercosis. Case 1: A 35-year-old woman presented with a 4-day history of headache and vomiting. Computerized tomography (CT) scan showed a large right temporal cystic lesion with a few intra-cystic and parenchymal micro calcifications. Contrast magnetic resonance imaging (MRI) showed multiple large cysts in the right temporal horn. Patient was taken up for surgery and the temporal horn was approached endoscopically. Multiple cysts were removed and a stoma was made to connect with the ipsilateral atrium; but later, shunt surgery was required. There were no further complications during 1-year of follow-up. Case 2: A 35-year-old woman presented with two months history of headache and left-sided focal

• seizures. On examination, the Glasgow coma scale

score was E3V3M5. Contrast CT scan brain showed a non-enhancing right temporal cystic mass. Contrast MRI showed a huge 6-cm T1 hypointense and T2 hyperintense lesion. The patient was taken up for emergency surgery. The cyst was aspirated, yielding a lightly viscous straw-colored fmuid. The lesion was approached through a trans-sulcal route until a well- defjned whitish translucent cyst wall was encountered. The fluid earlier aspirated was actually from the entrapped horn as the cyst itself contained only clear

• fmuid. The cyst was removed in toto without rupture

and was found to contain multiple similar small cysts inside it measuring about 5 cm in diameter. Microscopically the typical cysticercus cyst wall was seen in both the cases. The lesion showed areas of degeneration, including the scolex. The large cysts also contained multiple daughter cysts [Figure 1]. On follow-up CT scans, the size of the temporal horn had signifjcantly reduced in both patients [Figure 2] Entrapment of the temporal horn is the term first used by Maurice-Williams et al. to describe a form of focal hydrocephalus. Temporal horn contains choroid In brain lesions, central calcific nidus or central enhancement with surrounding enhancing ring has been considered as target sign. This sign was fjrst described in intracerebral tuberculoma and was considered to be pathognomic of this lesion.[4] Target sign has also been reported in a case of metastatic adenocarcinoma.[5] Chhitij Srivastava, Sunil K. Singh, Bal Krishna Ojha, Anil Chandra, Swati Srivastava1

Department of Neurosurgery, CSM Medical University, Formerly King George’s Medical College, Lucknow - 226 003,

1Department of Pathology, Vivekanand Polyclinic Institute of

Medical Science, Lucknow - 226 007, U.P., India E-mail: drchhitij@yahoo.co.in PMID: *** DOI: 10.4103/0028-3886.72203

References

1. Curling OD, Kelly DL, Elster AD, Craven TE. An analysis of the natural history of cavernous angiomas. J Neurosurg 1991;75:702-8. 2. Chicani CF , Miller NR, Tamargo RJ. Giant cavernous malformation of the occipital lobe. J Neuroophthalmol 2003;23:151-3. 3. Thiex R, Kruger R, Friese S, Gronewaller E, Kuker W. Giant cavernoma

• f the brain stem: Value of delayed MR imaging after contrast injection.

Eur Radiol 2003;13: L219-25. 4. Van Dyk A. CT of intracranial tuberculomas with specific reference to the “target sign”. Neuroradiology 1988;30:329-36. 5. Kong A, Koukourou A, Boyd M, Crowe G. Metastatic adenocarcinoma mimicking ‘target sign’ of cerebral tuberculosis. J Clin Neurosci 2006;13:955-8. Accepted on: 06-08-2010 [Downloaded free from http://www.neurologyindia.com on Tuesday, May 28, 2013, IP: 122.163.246.255] || Click here to download free Android application for this journal

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