Download Case 1: Brain trauma: epidural hematoma 脑外伤：硬膜外血肿 A 65

Case 1: Brain trauma: epidural hematoma
脑外伤：硬膜外血肿
A 65-year-old right-handed man was transferred to the hospital approximately 16 hours after
suffering head trauma with loss of consciousness in a motor-vehicle accident.
Examination. General examination was remarkable for a left parietal scalp laceration, left
hemotympanum, and right periorbital hematoma. Funduscopic examination was within normal
limits. Neurological examination revealed an alert patient oriented to time and person but no to
place. A mixed aphasia was present with expressive and conductive elements. Sensory
examination was normal. There was left-sided weakness; however, the patient did have a positive
Babinski sign on the left. The remainder of the neurological examination was normal. Skull films
revealed a left parietal linear skull fracture.
Course. The patient was admitted to the hospital for observation, and over the next 24 hours
had modest but definite improvement in his aphasia. A CT scan was obtained approximately 24
hours after injury, and this reveals a left epidural hematoma with a 3-mm shift of midline
structures from left to right, and effacement of the left lateral ventricle. Because the patient had
been improving neurologically, surgery was withheld pending any evidence of neurological
deterioration. By the 2nd day, the patient had complete resolution of his aphasia except for a very
mild dysnomic component. Follow-up CT scan on the 4th hospital day demonstrated no significant
change from the performed 24 hours after admission. The patient continued to improve and was
discharged asymptomatic following complete resolution of his neurological deficits and headaches
on the 6th hospital day. Repeat CT scans were obtained on the 17th and 30th post-injury day. These
showed gradual but complete resolution of the epidural hematoma.
Case 2: Brain trauma: epidural hematoma
脑外伤：硬膜外血肿
A 21-year-old man was transferred to the hospital 3 days after suffering a closed-head injury
with loss of consciousness. On admission, the patient was complaining of severe right-sided
headaches.
Examination. The general examination demonstrated a right parietal laceration. Neurological
examination showed a mild abnormality of recent memory, but was otherwise within normal limits.
Plain films demonstrated a linear right temporo-parietal skull fracture.
Course. The patient underwent CT scan on the day of admission. This revealed a right
temporoparietal epidural hematoma associated with a 4-to 4.5-mm shift from right to left. Because
the patient demonstrated no neurological deficit, he was treated nonoperatively. During the
hospital course, the patient had steady and complete resolution of his headache. Repeat CT scan, 1
week after admission, demonstrated persistent right epidural hematoma, with less shift than noted
previously. The patient was discharged without neurological deficit. A third CT scan, repeated 7
weeks after injury, demonstrated complete resolution of the epidural hematoma.
Case 3: Brain trauma: chronic subdural hematoma
脑外伤：慢性硬膜下血肿
You are asked to see a 27-year-old woman, a successful corporate lawyer, because of
increasing headaches which began approximately 1 month ago. She first noted headache several
days after returning from a ski trip with her husband and two children. The headache are bifrontal,
throbbing, and increasing in severity. During the past week she has awaked from sleep on several
occasions with headache and vomiting. In addition, her husband describes her as more apathetic
and less “sharp” at work than usual. One week ago she saw a local physician who prescribed
Valium. There have been no visual, motor, or sensory complaints. She is not an any medications,
has no other medical illnesses, and has suffered no recent trauma. On examination, she was tearful
and complained of severe steady headache and an inability to sleep for several days. She relied on
her husband for most of the details of her illness. On several occasions, she did not respond to
questions asked directly to her and the questions had to be repeated. There was no aphasia, but
detailed mental status testing was impossible because of her agitated state.
Examination of the optic fundi revealed an absence of venous pulsations and blurring of the
disc margins. The remainder of the cranial nerve examination was normal. There was a mild
pronator drift of the right arm, but power was otherwise normal. There was reflex asymmetry(3/5
on the right, 2/5 on the left)and plantar responses were flexor on the left and equivocal on the right.
Tone, sensory, and cerebellar examinations were within normal limits, and her gait was normal. A
CT scan was performed. The scan shows a large, left-sided, isodense, chronic subdural hematoma.
On the nonenhanced scan, the subdural hematoma itself was not visible because of its isodense
charactor, but a shift of the lateral ventricles due to mass effect was seen. With contrast
enhancement, the membranous wall of the subdural hematoma can be seen and the size of the
subdural collection is clearly outlined. The treatment for symptomatic, chronic subdural
hematoma is surgical evacuation. In patients with small, stable subdural hematomas, or in those
for whom surgery is contraindicated, medical management with corticosteroids and dehydrating
agents(mannitol)may be successful. In this patient surgical evacuation was performed with
excellent results.
Case 5: Astrocytoma of frontal lobe
额叶星形细胞瘤
The patient was a 48-year-old male who presented with complaints of increasingly severe
headaches. Workup at another hospital revealed a lucent left frontal lesion. The biopsy diagnosis
was grade III astrocytoma. He was referred to our hospital after external radiation therapy was
delivered. Neurological exam revealed mild bradkinesia, but was otherwise unremarkable. He was
admitted and underwent a left frontal lobectomy, with gross total tumor resection. One month later
he underwent stereotactic implantation of brachytherapy catheters. He received 6000 rads to the
margins of the tumor cavity. Subsequent scans revealed progressively worsening enhancement,
edema, and shift around the tumor cavity. Reoperation was undertaken with resection of all
grossly abnormal tissue. Pathologic analysis revealed radiation necrosis and tumor. The patient is
alive 5 years later, with no evidence of disease progression.
Case 7: Glioblastoma multiforme located near motor cortex
运动区附近的多形胶母细胞瘤
History
Patient A.L. is a 23-year-old right handed man from Hebei Who works as a painter and has
had nocturnal seizures for approximately two years. In January the seizures increased in frequency
and began to occur during the day. They are associated with turning of the head and shoulders to
the right prior to generalization. The patient is confused and fatigued afterwards, but does not have
a neurologic deficit. A scan was done in February and this demonstrates an area of
nonenhancement in the posterior portion of the superior frontal convolution, with a small contrast
enhancing area in the center of the lesion. The latter approximately 3 mm, the former measures
approximately 3.5 cm. The scan was repeated recently and it appeared that the lesion had grown
slightly. Stereotactic biopsy was recommended. The patient in fact was scheduled for a biopsy in
Hebei but they decided to seek another opinion. The patient is presently on Dilantin 100 mg three
times per day. Past medical history is noncontributory. Family history and social history are not
significant.
Physical Examination
The patient is a well nourished, well developed, thin, pleasant male who appears
intellectually intact. Recent memory is intact, general information is good. Cranial nerve
examination reveals no abnormalities, sensory examination is intact to all modalities. Motor
examination reveals no drift to distraction, and good strength in upper and lower extremities.
These may be some weakness of the wrist extensors on the right, however. Deep tendon reflexes
are symmetrical, the patient walks with a normal gait with a normal arm swing.
Radiographic Studies
MRI scan shows an approximately 3.5 cm well-demarcated lesion in the posterior aspect of
the left superior frontal convolution.
Impression
Probable low/intermediate grade glioma, possibly ganglio-glioma or ganglio-neurocytoma. If
the lesion is anterior to the motor cortex, resection is recommended. If the lesion is within the
motor cortex, a biopsy is recommended.
Hospital Course
The patient underwent magnetoencephalography(MEG) to map his primary motor cortex and
define its relationship to the tumor. This confirmed the clinical and radiographic impression that
the tumor was anterior to the motor strip.
A stereotactic volumetric resection of the lesion was then performed. The volume of the
tumor, based on the contrast-en-hancing portions on both CT and MRI, as well as from the area pf
abnormality on T2-weighted MRI, was digitized for computer targeting. A view of the cortical
surface after the trephine craniotomy was performed. A strip electrode placed onto the cortical
surface in a direction posterior to the edge of the trephine confirmed the location of sensorimotor
cortex by phase reversal.
The tumor volume can be superimposed onto the field of view of the operating microscope,
to assist the surgeon in defining the margins of the tumor. The lesion was dissected away from the
surrounding brain tissue at its interface and was removed as a single specimen.
The patient’s neurologic function postoperatively was unchanged from his preoperative
status.
Pathologic Report
The tumor was signed out as glioblastoma multiforme arising as a small focus within a
lowgrade astrocytoma. The malignant portion apparently was the contrast-enhancing portion on
the preoperative scans. The patient is scheduled to began external beam radiotherapy followed by
chemotherapy.
Case 25: Cerebellopontine angle meningioma
(located anterior to the IAM)
小脑桥脑角脑膜瘤（内听道前）
A 55-year-old man presented to us with left-sided deafness of 1-year duration. Neurological
examination, other than for the left ear deafness was unremarkable. CT scan showed a
homogeneously enhancing tumor of the left posterior pyramid with enlargement of the internal
auditory meatus. A tumor located anterior to the internal auditory meatus was removed via the
usual lateral suboccipital approach. The tumor was also growing inside the internal auditory
meatus and was completely surrounding the anterior inferior cerebellar artery while pushing the
lower cranial nerves caudally. Both structures were carefully preserved. The VII-VIII nerve
complex was clearly seen to be infiltrated by the tumor, staring 3 mm lateral to the brainstem all
the way to the fundus of the internal auditory canal, whose posterior wall had to be totally drilled
off. The tumor, together with its attachment on anterior dural of the internal auditory meatus was
completely removed, with sacrifice of the involved VII-VIII nerve complex. Due to the
impossibility of finding an uninvolved distal portion of the facial nerve in the internal auditory
canal, after harvesting a 20-cm dural cable graft, we exposed the facial nerve in the neck, in
proximity to the stylomastoid foramen. The proximal end of the graft was then secured to the
intracranial facial nerve stump 4 mm lateral to the brainstem with a drop of fibrin glue while the
distal end of the graft, after exiting through the dura incision and after having been tunneled
beneath the neck muscles, was connected to the distal stump of the facial nerve in the neck using
100 sutures and fibrin glue. The defect in the posterior pyramid and internal anditory canal was
closed with a free myofacial graft held in place with fibrin glue. The dura was closed as usual. The
patient’s postoperative course was uneventful, and he left the hospital 2 weeks after the operation.
Postoperative CT scan showed no evidence of tumor. At follow-up 1 year after the operation, the
patient showed electromyographic and clinical evidence of early facial nerve reinnervation.
Case 30: Meningioma(C2~3)
脊膜瘤（颈 2~3）
A 39-year-old male originally had a standard C2-C3 laminectomy for removal of
meninginma. The patient was neurologically stable for 6 years when he represented with weakness
of the right arm and leg. A MR study of the C2-C3 region showed a recurrent meninginma that
had engulfed the vertebral artery, compressed the spinal cord, and eroded the bone. A
CT/myelography study confirmed the compression and accurately assessed the extent of the bony
involvement. The recurrent tumor clearly required removal.
At surgery the patient was placed in a modified park bench position, his head flexed and
rotated downward. An inverted hockey stick incision started at the mastoid prominence, extended
under the superior nuchal line, incorporated the previous midline incision, and terminated at the
C6 spinous process. A 1-cm edge of nuchal fascia and muscle was left attached to the occiput for
closure. The paraspinous muscle was split until the spinous processes of C1 and C4 were
identified. The muscle flap was retracted inferiorly and laterally with fish hooks attached to a
Leyla bar.
The dissection was continued 1 cm until the dura was identified. Once the anatomy was
visible in this normal area, the dissection was continued inwardly to expose the rest of the dura
and tumor. As expected, the epidural adhesions were dense and required careful dissection with a
NO. 15 scalpel blade and bipolar coagulation. The vertebral artery, located between C1 and the
occiput, was dissected under the microscope about 4 cm from its entrance into the foramen
magnum to the lateral edge of C3. The meninggioma, which surrounded the artery, was partially
removed with an ultrasonic aspirator. Once the vertebral artery was freed from the tumor, it was
displaced laterally. To remove the remaining tumor, the C1 arch was removed via a laminotomy
with a high speed air drill with the craniotome attachment. The contralateral lamina was cut across
the midline, and the ipsilateral lamina was cut at the sulcus for the vertebral artery. Although
unnecessary in this case, the superior lateral mass and facet of C1 can be removed to access the
most anterior portion of the dura for decompression of vertebral body tumor or resection of the
intradural tumor. The lamina was difficult to identify and required careful dissection to release the
adhesions that had formed between the tumor and spinal cord. A microdissector and NO. 11
scalpel blade were used. Once the posterior aspect of the tumor was identified, the center was
resected with an ultrasonic aspirator. The anteromedial aspect was adherent to the dura, which was
ellipsed to obtain complete removal of the tumor and associated adhesions. The dura was closed
with a cadaver patch graft and 4-0 suture. Histological analysis identified an angioblastic
meningioma. Postoperatively, the patient had no sign of recurrent tumor. However, he did develop
a pseudocyst that required reclosure of the dura and fascial planes. A lumbar drain was also placed
for 3 days postoperatively, to prevent further CSF leak.
Case 32: Pituitary macroadenoma in acromegaly
垂体大腺瘤伴肢端肥大症
This patient is a 40-year-old woman presenting with a 1-year history of acromegaly. Before
therapy, basal growth hormone levels were elevated(25 ng/ml)and could not be suppressed by an
oral glucose load. MRI shouwed an intrasellar, parasellar, and slightly suprasellar pituitary
adenoma. She was initially started on subcutaneous injections of octreotide(Sandostatin)for 6
weeks and had received increasing daily doses ranging up to 300 ug. Neither basal serum growth
hormone nor somatomedin C levels were significantly decreased and there was no change in
tumor size and extension as documented by repeat MRI scanning. The film shows a section
through the midsellar portion of the tumor just prior to surgery. Since the patient had previously
undergone surgery for a nasal septum deviation resulting in a septum perforation, a direct pernasal
transsphenoidal route was chosen. The nasal speculum was inserted into the right nostril up to the
floor of the sphenoid sinus. The medial nasal mucosa was then incised and the vomer exposed and
opened widely. The sellar floor was found to protrude into the sphenoid sinus right dorsolaterally.
There was a circumscribed invasion of the sellar floor in a region 4 mm in diameter approximately
in the midline. The intrasellar tumor portion could easily bu removed by curettage. The medial
aspect of the right cavernous sinus was then visualized and was found to be invaded by the
adenoma. This could be removed by curettes and microforceps, resulting in an exposure of the
right carotid artery over a distance of about 10 mm. The trabecular structure of the medial
cavernous sinus was clearly visible by higher magnification. Normal pituitary tissue was identified
and preserved in the left lateral and dorsal parts of the sella. The exposed region was covered with
fibrin glue-coated fascia lata and a nasal tampon was inserted bilaterally without any suturing of
the nasal mucosa. The postoperative course was uneventful. Postoperatively, basal growth
hormone levels decreased to 6.1 ng/ml and could bu suppressed to 3.9 ng/ml after an oral glucose
load.
Case 40: Craniopharyngioma with invasion of the third ventricle
and obstructive hydrocephalus
颅咽管瘤侵入第三脑室伴梗阻性脑积水
A 9-year-old girl with headache and diminished visual acuity was referred for
ophthalmologic and diminished visual acuity was referred for ophthalmologic evaluation, which
disclosed a central scotoma of the left eye. Acuity in the right eye was considerably decreased,
only light perception was possible. Examination of the fundus disclosed bilateral optic atrophy. CT
scans showed a large, suprasellar, cystic mass with a smaller solid component, which, considering
the patient’s age, was consistent with a craniopharyngioma. The tumor completely filled the third
ventricle and had produced hydrocephalus by obstruction of the foramen of Monro. A
ventriculoatrial shunt was inserted to relieve the hydrocephalus, and the patient’s level of
consciousness improved. Two weeks later operative removal was performed through a bifrontal
osteoplastic craniotomy. The anterior pole of the tumor was exposed, tapped, and cystic fluid was
aspirated. Then the tumor capsule was progressively separated from both optic nerves and the
internal carotid arteries. The bulk of the capsule and tumor could be removed below the optic
chiasm. Pathological tissue still remained behind the chiasm and third ventricle, so the last vestige
of tumor was removed. At the end of the procedure we had a clear view of the pons and
interpeduncular fossa and of the basilar artery and its branches. Transient symptoms of diabetes
mellitus and diabetes insipidus developed in the early postoperative period, and the patient
remained somnolent for three days. By five weeks her general condition was very good and she
was discharged home, although her visual acuity did not improve. Postoperative CT scans
confirmed total removal.
Case 58: Intrinsic brainstem tumor(glioma)
脑干肿瘤（胶质瘤）
A 4-year-old girl was evaluated in the emergency department for a 1-week history of
dysphagia, drooling, and irritability. Additional history elicited from the parents revealed the
gradual onset of hoarseness and right hemiparesis during at least a 3-week period before
evaluation. Her physical examination was remarkable for a diminished gag reflex, partial right
facial palsy, and paresis with spasticity in the right upper and lower extremities. A computed
tomographic scan demonstrated dilated 3rd and lateral ventricles, compression of the 4th ven tricle,
and a low attenuation area within the pons. MRI revealed a ring enhancing mass lesion centered in
the pons and rostral medulla.
Operative technique
After placement of a ventriculoperitoneal shunt, a suboccipital craniectomy was performed
with the patient in the sitting position. The ependymal lining on the floor of the 4th ventricle was
exposed, and an eccentric protuberance in this area suggested subjacent tumor. The tumor
boundaries were precisely localized with a miniature intraoperative ultrasonic probe.
Electrophysiological mapping of the surrounding brain-stem structures was then performed to
further plan the ependymal incision required for approach to the tumor.
Using a monopolar, constant current electromyogram(EMG)stimulator in a non-paralyzed
patient, the margins of the underlying mass were mapped along the floor of the 4th ventricle. Using
a constant current of 0.1 mA for approximately 1.0s, both facial colliculi were localized by direct
stimulation with the appropriate ipsilateral facial movement noted. Next, the area of the
hypoglossal trigone was stimulated, with resultant unilateral movement of the tongue. In both of
these areas, conduction was confirmed by EMG responses from electrodes placed in the face and
the tongue. Additional stimulation to define the abducens nucleus, however, did not result in
abduction of either eye(no EMG electode was placed in the lateral rectus). Care was taken to
avoid the region of the vagal trigone, as acute cardiovascular changes might be expected with
stimulation in this region. An area just caudal to the right facial colliculus did not produce right
facial movement nor an EMG response. This was within the region delineated by ultrasonography
and, therefore, was chosen as the site for ependymal incision. Tumor was evidence just below the
surface of the incision. The tumor was encapsulated with a soft center, and there was no evidence
of hemorrhage or cystic components. With continued use of electrical stimulation in the tumor bed,
a maximal debulking was achieved. During the procedure, somatosensory evoked potentials were
monitored with no change from the preoperative baseline.
Postoperatively, the patient exhibited no new neurological deficits. In particular, there was no
evidence of VI, VII, or XII cranial nerve dysfunction. A pathological examination revealed that the
tumor was an intermediate grade glioma. The patient has subsequently been treated with radiation
and chemotherapy.