Remote Paraparesis due to a Traumatic Extradural Arachnoid Cyst Developing 2 Years after Brachial Plexus Root Avulsion Injury: Case Report and Review of the Literature

Traumatic extradural arachnoid cyst is a rare entity. However, late appearance of paraparesis due to formation of an extradural arachnoid cyst as a sequel of brachial plexus injury is extremely rare and the literature regarding this issue is scarce revealing only 11 cases. Herein, we report a patient with delayed progressive spastic paraparesis appearing after a multilevel brachial plexus root avulsion injury where imaging revealed formation of a large traumatic extradural arachnoid cyst at the cervicothoracic region. Furthermore, to propose that a high-energy trauma might simultaneously result in delayed formation of an extradural arachnoid cyst. However, preganglionic root avulsion injury with pseudomeningocele formation in association with extradural arachnoid cyst is not reported previously. A case of a 36-year-old man with spastic paraparesis developing 2 years after a multilevel brachial plexus root avulsion injury is presented. Root avulsion had immediately resulted in complete paralysis of the left upper limb that had not ameliorated. Imaging studies of the cervicothoracic region disclosed left-sided multilevel pseudomeningoceles and a large extradural arachnoid cyst extending from C5 to T2. After appropriate en bloc laminotomy, the cyst was excised and the causative dural tear was closed. Subsequently, three large defects of pseudomeningoceles were obliterated with artificial dural patch for the prevention of cord herniation. This was followed with laminoplasty of the corresponding levels after dural closure. The postoperative course was uneventful and paraparesis recovered steadily within 2 months. Paraparesis even years after brachial plexus injury should be regarded as a serious event that deserves extensive imaging survey for the possibility of the formation of an extradural arachnoid cyst. Careful review of the literature disclosed that the current case is the 12th case that an extradural arachnoid cyst has developed after brachial plexus injury and the first example that the pathogenic factor that might be implicated in occurrence of this rare association could be clarified with review of the MRI features. Actually, the presence of posttraumatic pseudomeningoceles in association with an arachnoid cyst in the current case is in favor of the belief that only preganglionic root injuries that are in close proximity to the spinal canal had been the cause dural tear with remote formation of extradural arachnoid cyst.     

Age-dependent cognitive defects caused by local brain lesions of various geneses

The results of neuropsychological analysis of 808 children and adolescents 7–18 years of age were studied. Among the test subjects, 689 children were patients with local brain lesions (tumors, arachnoid cysts, vascular pathology, and congenital hydrocephaly) and 119 children were healthy. Both patients and healthy subjects were divided into four age groups: junior school age (7–9 years), prepubertal age (10–12 years), pubertal age (13–15 years), and senior school age (16–18 years). Cognitive defects were found and demonstrated to depend on the test subject’s age and the type of brain pathology.     

Cytokeratin provides a specific marker for human arachnoid cells grown in vitro

Cells from cranial and spinal arachnoid membranes of humans were grown in culture. Their growth characteristics, morphology and details of their cytoskeletal composition are described. Arachnoid membranes, obtained at autopsy, were finely minced and incubated in tissue culture medium. Monolayers of cells of homogeneous morphology grew from these tissue fragments. The cells were flat and polygonal. They divided slowly to form non-overlapping monolayers of low cell density. Electron microscopic examination of cultured arachnoid cells revealed numerous desmosome-like tight junctions and abundant intermediate filaments (tonofilaments). Both morphological features are characteristic of arachnoid cells in situ, but not of cells in the fibroblast-rich dura mater. Immunofluorescence microscopy with monoclonal antibodies demonstrated cytokeratin in the cytoplasm of primary cultures of arachnoid cells. Thus we demonstrated that these cultured cells retained certain of the specific differentiated properties of arachnoid cells in situ and that they are not fibroblasts (which lack tight junctions and cytokeratins). To our knowledge, there have been no previous reports of in vitro growth of arachnoid cells. This in vitro model should be useful in studying the response of arachnoid cells to a variety of substances thought to be involved in the chronic inflammatory condition of the meninges known as arachnoiditis.     

山东古代人群头骨上蛛网膜颗粒压迹的观察与探讨

蛛网膜颗粒是由蛛网膜绒毛成组聚集在一起而形成的,有时会在颅骨内板上形成局限性压迹,当颗粒较大时会造成颅内局部骨质吸收,形成溶蚀状小坑。在以往的病理观察中,蛛网膜颗粒压迹多不作为观察统计对象,然其溶蚀状的形态却容易被误认为是某些病理性改变。本文通过对济南大辛庄、刘家庄、曲阜奥体中心等六个遗址出土的114例人骨标本的观察发现:1)蛛网膜颗粒压迹从古至今均表现出较高的发生率且两性间不存在明显差异。2)蛛网膜颗粒压迹的最大径平均值大致在1-6mm之间,个体间存在较大差异,但总体上呈现出随年龄增长而增大的现象。3)蛛网膜颗粒压迹的出现位置最常见于顶骨和额骨,枕骨部位相对少见,但不同年龄组间的出现位置可能存在一定差异。此外,蛛网膜颗粒在颅内形成的溶蚀状小坑易与一些以骨质侵蚀为特征的疾病相混淆,如颅内感染、颅骨板障表皮样囊肿、嗜酸性肉芽肿、脑膜瘤等,需注意对其特征加以辨别。     

Posterior Fossa Decompression Combined with Resection of the Cerebellomedullary Fissure Membrane and Expansile Duraplasty: A Radical and Rational Surgical Treatment for Arnold–Chiari Type I Malformation

This study aims to introduce a new surgical procedure for the treatment of Arnold–Chiari type I malformation (ACM-1) and to compare its effectiveness with the techniques described in previous studies. We performed the following procedures: foramen magnum decompression combined with the removal of both the atlanto-occipital membrane, extended resection of the cerebellomedullary fissure arachnoid membrane, and artificial duraplasty to enlarge the membranic posterior fossa without resecting the cerebellar tonsils and syringosubarachnoid shunting. There were 21 ACM-1 patients: 12 cases had osteo-compression on the cerebellar hemisphere, 18 cases had thickened adhered fabric ring that stretched from arachnoid membrane to cerebellar hemisphere, and 15 cases with syringomyelia. The patients were followed up for 6 months to 3 years after the surgery. All patients showed a remarkable recovery of syringomyelia. There were no morbidity or death related to the surgery. Most of ACM-1 patients, the osteo- and membrane compression on cerebellar hemisphere and tonsil were observed during the operation. Therefore, decompression of foramen magnum and posterior craniocervical combined with the removal of cerebellomedullary fissure arachnoid membrane and placement of an artificial dural graft should be considered as a comprehensive option of minimally invasive surgery and rational and radical treatment of ACM-1. Our experience showed that, by using our procedure, shunting becomes no longer necessary in the treatment of ACM-1-associated syringomyelia.     

The application of ultrasound in neuroendoscopic procedures: first results with the new tool "NECUP-2"

In this paper, our experience with originally constructed Neurosurgical Endoscopic Contact Ultrasound Probe "NECUP-2" in neuroendoscopy is reported. Between June 1997 and June 2007, 132 neuroendoscopic procedures have been performed: 102 endoscopic thrid ventriculostomies (ETV), 15 arachnoid cysts and 5 intraventricular tumours operations. The "NECUP-2" was applied effectively in all cases in which blunt perforation was not possible: 38/102 ETY, 10/10 septostomies, 15/15 arachnoid cysts. In five cases of intraventricular tumours, neuroendoscopic procedure was combined with open microsurgery for tumour removal with preservation of vascular structures. There were no "NECUP-2" related complications. Of postoperative complications, we had liquorrhea (9 patients), and symptoms of meningitis (6 patients). In the follow-up period (6 months to 6 years), we had a patency rate of 80% (50/63 patients). All patients improved in clinical status. According to the first results, it seems that ultrasonic contact probe NECUP-2 presents a new device in neurosurgical armamentarium that can be used in various fields of neurosurgery. With minimal and controlled lesion that is produced at the tip of the probe, it can be used in highly demanding operations such as third ventriculostomy and tumour resection.     

Gonadotrophin-independent puberty in a boy with a beta-HCG-secreting brain tumour

We report on a short-statured boy in whom therapy with recombinant human growth hormone was initiated at the age of 9.7 years for assumed idiopathic growth hormone deficiency. On recombinant human growth hormone, height improved from -1.9 (standard deviation score) to -0.9 within 1 year, and the patient entered puberty spontaneously at 10.7 years. At 11.6 years he showed low morning cortisol and thyroxine levels, but was otherwise well. He showed an inconspicuous growth, and puberty progressed adequately until the age of 13.4 years, when he developed signs of an increased intracranial pressure, and a suprasellar choriocarcinoma was diagnosed. This case confirms the fact that beta chorionic gonadotrophin secreting tumours will not be diagnosed by the characteristic clinical manifestation of gonadotrophin-independent puberty if they occur at a time when normal puberty is expected. Particularly, it raises the question of how often the CNS should be re-evaluated by magnetic resonance imaging in children with growth hormone deficiency and normal initial neuroradiological imaging, when they develop additional hormonal deficiencies but no other clinical symptoms of an intracranial process.     

Gradual progress of ACTH deficiency in a child with panhypopituitarism associated with pituitary stalk transection.

We present here a 13-year-old male with hypopituitarism which accompanied an insidious and gradual progress of ACTH deficiency. ACTH deficiency finally led to an overt crisis of adrenal insufficiency at the age of 12 years and 7 months. This patient is unique because the insidious and gradual progress has been proved by not only the laboratory results but also the clinical course for over 13 years. The cause of panhypopituitarism including ACTH deficiency is thought to have existed before or at the delivery because of the stalk transection seen on the magnetic resonance image (MRI). At the crisis, his laboratory results suggested that he had secondary adrenal insufficiency, whereas he showed normal adrenal function proved by the insulin tolerance test (ITT) at the age of 4 years. Abrupt crisis of secondary adrenal insufficiency developed at the age of 12 years, although he had been well until the crisis.     

Calibration of LAI-2000 canopy analyser with leaf area index in a young eucalypt stand

Plant area index (PAI) measured with a LI-COR LAI-2000 plant canopy analyser (PCA) was calibrated with leaf area index (LAI) in a young stand of Eucalyptus grandis in the KwaZulu-Natal Midlands, South Africa. Destructive sampling and allometric equations were used to estimate LAI at 2 and 3 years after planting. Significant correlations (P<0.001) were found between LAI and PAI for each age with different equations being generated for the two ages (LAI=1.0594(PAI)−0.892 at 2 years of age, and LAI=1.0393(PAI) at 3 years of age). The equations differed from those reported in other eucalypt studies, as the PCA in this study over-predicted LAI at 2 years, and slightly under-predicted at 3 years, of age. It is argued that the stage of growth influenced this calibration, as the canopy and foliar structure may have been different in the young stands, affecting the basic assumptions for the PCA. A broad conversion from PCA derived PAI to LAI may not necessarily be valid for young, short rotation eucalypt plantations.     

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy presenting with severe keratopathy in an Egyptian patient with a homozygous R139X mutation

OBJECTIVE: To report a patient with an unusual presentation of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) and severe keratopathy. CASE HISTORY: An Egyptian male sustained an injury to the left eye at 13 years of age and was found to have corneal damage which was attributed to the injury. Subsequently, however, he continued to have sore eyes with photophobia. A year later he became weak with pigmentation and episodes of collapse, and investigation showed that he had Addison's disease together with mucocutaneous candidiasis. At 15 years of age he developed carpo-pedal spasm and was found to have hypoparathyroidism with intracranial calcification. At 20 years of age the ophthalmic diagnosis was revised to keratopathy by which time the patient had corneal opacity and problems with visual acuity, especially in the right eye. Investigation at 22 years of age showed that he was homozygous for an R139X mutation in the gene encoding the AIRE protein, a mutation which to date has only been found in Sardinian patients. CONCLUSIONS: Keratopathy can be an early and severe manifestation of APECED, requiring expert ophthalmic care. Its presence should prompt a search for other components of APECED, some of which are life-threatening.     

3 beta-hydroxysteroid dehydrogenase deficiency. Follow-up study in a girl with pubertal bone age.

Follow-up data on a girl with 3 beta-hydroxysteroid dehydrogenase deficiency at a pubertal bone age are presented. On examination at age 14.7 years (bone age 12 years), there was no spontaneous breast development. On treatment with hydrocortisone and fludrocortisone, most steroids with the exception of increased 17OH-pregnenolone in plasma and delta 5-pregnenetriol and pregnanetriol in urine, were normal. After 1 week off hydrocortisone, plasma 17OH-pregnenolone, DHA and delta5-androstenediol and urinary delta 5-pregnenetriol and pregnanetriol increased markedly, while plasma 17OH-progesterone increased only slightly. On increased hydrocortisone medication, there was no response of plasma estradiol to HMG. This first observation of a pubertal girl with 3 beta-hydroxysteroid dehydrogenase deficiency indicates that in this patient, the defect persists at a pubertal bone age and that it is not limited to the adrenals, but also affects the ovaries. Girls with this type of defect thus require estrogen replacement at a bone age of about 12 years. The large quantities of pregnanetriol in the urine are not due to an incomplete defect or an additional 21-hydroxylase deficiency, but most likely to the peripheral or hepatic conversion of 17OH-pregnenolone or delta 5-pregnenetriol.     

Prolactinoma causing secondary amenorrhea in a woman with Ullrich-Turner syndrome

This is the case report of a girl who was diagnosed as having Ullrich-Turner mosaic at the age of 12 years. She had normal pubertal development and menarche at the age of 15 years. The patient had regular menstrual cycles for 12 months before developing secondary amenorrhea. She was started on estrogen/gestagen replacement therapy by her gynecologist. Several months later a prolactinoma was diagnosed by laboratory and imaging techiques. A second-generation dopamine agonist led to almost regular cycles. Therefore, even in patients with susceptibility to ovarian failure secondary amenorrhea necessitates thorough diagnostic investigation. Copyrightz1999S.KargerAG,Basel     

Compartments and perivascular arrangement of the meninges covering the cerebral cortex of the rat

Summary The intercellular clefts of the brain and the leptomeninges, and the perivascular spaces were studied with reference to the results obtained in a previous study (Krisch et al. 1983). The spatial relationships of these compartments were analyzed at the electron-microscopic level. Horse-radish peroxidase (HRP) was injected into the brain or into the contralateral ventricle.The pattern of distribution of HRP depends on the boundary situation in the individual compartments. The inner and outer pial layers accompany the vessels intruding into the brain. In the Virchow-Robin space the pial funnel obliterates within a short distance. The inner arachnoid layer is continuous with the outer arachnoid layer when it covers the vessels traversing the meningeal space. The perivascular compartment is not in communication with the arachnoid space; moreover, the pial funnel within the Virchow-Robin space is sealed off against the arachnoid space.Thus, blood vessels traversing the meningeal spaces and subsequently penetrating the brain surface are exposed to the common intercellular compartment represented by the intercellular clefts of the brain and the leptomeninges; this compartment does not communicate with the other compartments. The cerebrospinal fluid located in this intercellular compartment is preferentially drained into the upper cervical lymph nodes.Supported by the Deutsche Forschungsgemeinschaft (Grant Nr. Kr 569/5) and the Stiftung Volkswagenwerk.     

A novel AAAS gene mutation (p.R194X) in a patient with triple A syndrome

OBJECTIVE: The clinical and molecular data of a patient with triple A syndrome are reported. PATIENT: A 21-year-old male who was diagnosed for adrenal insufficiency at the age of 2 years after a severe attack of adrenal crisis. At the age of 4 years, achalasia and alacrima were diagnosed. Puberty started at the age of 17 years. At the same time, symptoms of central, peripheral, and autonomic nervous system dysfunction were noted. Later on, at the age of 20 years, a bone age delay of 6 years and severe osteoporosis was diagnosed. RESULTS: A compound heterozygous AAAS mutation consisting of two mutations was found: a C > T transition in exon 7 resulting in a change of arginine at amino acid position 194 into a stop codon (Arg194X) at one allele, and a C > T transition in exon 12 resulting in a change of glutamine at amino acid position 387 into a stop codon (Gln387X) on the other allele. CONCLUSION: The mutation in exon 7 (p.R194X) of the AAAS gene is a novel mutation which has not been found in any other family so far, whereas the second was already found in some other families. This case adds to the clinical and molecular spectrum of triple A syndrome and may provide a new insight into the functions of AAAS gene.     

Ultrastructural investigation of the meningeal compartment of the blood-cerebrospinal fluid-barrier in rats and cats. A horseradish peroxidase study

The permeability of the meningeal blood vessels and cellular layers to horseradish peroxidase was studied 5, 10 and 15 minutes following intravasal or intraarachnoidal introduction of the marker. When applied intravasally, the horseradish peroxidase-containing solution easily passed through the walls of all meningeal vessels (dural, pial and the ones traversing the arachnoid space). The cells of the inner dural layer and dural neurotheliun delay the penetration of horseradish peroxidase into the cerebrospinal fluid-filled arachnoid space by 10 min--rats and 15 min--cats. The perivascular leptomeningeal cells and their processes restrict the passage of the marker into the arachnoid space in a similar way. These barrier functions of the leptomeningeal cells and the cells that comprise the interface zone between dura mater and the arachnoid are confirmed by experiments where the marker was injected into the arachnoid space.     

Adolescents' perceived weight associated with depression in young adulthood: a longitudinal study

Objective: The objective of this study is to examine whether adolescents’ measured BMI and self‐ or mother's perception of weight status at age 14 are associated with depression at age 21. Research Methods and Procedures: The study participants were a subsample of 2017 participants of the Mater–University of Queensland Study of Pregnancy and Its Outcomes, a population‐based birth cohort study, which commenced in 1981 in Brisbane, Australia, for whom measured BMI at ages 14 and 21 and information on self‐reported mental health problems were available at the age 21 follow‐up. A total of 1802 individuals had measured BMI and reported weight perception in a supplementary questionnaire at 14 years, and their self‐reported mental health problems were reported at 21 years. Mental health was measured using Center for Epidemiology Studies Depression Scale and Young Adults Self‐Reported depression/anxiety at 21 years of age. Results: We found that both young adult males and females who perceived themselves as overweight at age 14 had more mental health problems compared with those who perceived themselves as the right weight. When we combined adolescents’ weight perception with their measured BMI categories, weight perception but not measured overweight was associated with mental health problems for males and females at age 21. This association remained after adjusting for potential confounders, including adolescents’ behavioral problems, family meals, diet, physical activity, and television watching. Conclusions: This study suggests that the perception of being overweight during adolescence is a significant risk factor for depression in young adult men and women. The perception of being overweight during adolescence should be considered a possible target for a prevention intervention.     

Intracranial arachnoid cysts in a chimpanzee (Pan troglodytes)

An intracranial arachnoid cyst was detected in a 32-year-old, 44.6-kg, female chimpanzee at the Primate Research Institute, Kyoto University. Magnetic resonance imaging (MRI) and computed tomography (CT) were performed and the cognitive studies in which she participated were reviewed. MRI revealed that the cyst was present in the chimpanzee’s right occipital convexity, and was located in close proximity to the posterior horn of the right lateral ventricle without ventriculomegaly. CT confirmed the presence of the cyst and no apparent signs indicating previous skull fractures were found. The thickness of the mandible was asymmetrical, whereas the temporomandibular joints and dentition were symmetrical. She showed no abnormalities in various cognitive studies since she was 3 years old, except a different behavioural pattern during a recent study, indicating a possible visual field defect. Detailed cognitive studies, long-term observation of her physical condition and follow-up MRI will be continued.     

Effects of prolonged treatment with cyanoketone on the zona fasciculata of rat adrenal cortex

Summary We have examined IgG Fc receptor (FcR) activity of human and rabbit arachnoid granulations and leptomeninges using antibody (IgG)-coated erythrocytes (EIgG), covalently crosslinked IgG dimers, trimers and oligomers, immune complexes, aggregated Fc fragments and a monoclonal anti-human neutrophil Fc receptor antibody, 3G8. EIgG bound specifically to cells of the leptomeninges and arachnoid granulations; uncoated erythrocytes, F(ab) ₂-coated, or IgM-coated erythrocytes failed to bind. The specificity of this interaction was demonstrated by inhibition studies. Monomeric IgG and Fc fragments blocked EIgG adherence, whereas bovine serum albumin (BSA), Fab fragments of IgG and the monoclonal anti-neutrophil FcR antibody failed to inhibit EIgG adherence. Monomeric IgG inhibited FcR function in a dose-dependent fashion; maximal inhibition was achieved at 1.7 × 10^-5M IgG, indicating a relatively low avidity receptor. Oligomers of IgG inhibited EIgG adherence more effectively and inhibition was directly related to oligomer size. Additionally, these tissues were positive for specific and non-specific esterases. These studies suggest that the CSF pathway from the perivascular spaces to the arachnoid granulations plays a protective role in the clearance of IgG and IgG immune complexes in infections and immune-mediated disorders.Work partially supported by PHS Grant #Ca 38055, National Cancer InstituteWork primarily supported by the Veterans Administration Merit Program     

Long-term follow-up of spontaneous development in a boy with familial male precocious puberty

BACKGROUND/AIMS: Limited data are available about spontaneous growth, pubertal growth spurt and the long-term outcome of patients suffering from familial male precocious puberty (FMPP). We report on a boy with FMPP whose growth pattern and pubertal development was studied longitudinally without treatment. METHODS: Long-term prospective follow-up without treatment of a 6.2-year-old boy with FMPP having inherited a mutation of the LH receptor gene (A568V) from his father. RESULTS: The pubertal growth spurt was of unusual maximal amplitude (growth rate 12.4 cm/year at the age of 5-6 years) and of extraordinary duration lasting for 5.2 years from age 3.8 to 9.0 years. No deterioration of height potential was observed. Height (174 cm) was within target height range (171.5-188.5 cm) at age 13 years. No central precocious puberty occurred. CONCLUSION: FMPP is an experiment of nature demonstrating that the amplitude and duration of the pubertal growth spurt are much more variable than previously described. Furthermore, this case emphasizes that the indication for treatment is highly dependent on intrafamilial and individual factors.