Middle meningeal artery embolization for chronic subdural hematoma with cerebrospinal fluid hypovolemia: A report of 2 cases

BACKGROUND

Chronic subdural hematoma (CSDH) with cerebrospinal fluid hypovolemia syndrome (CHS) remains refractory to standard treatment with hematoma drainage by burr hole and irrigation and/or epidural blood patch. Previously, we reported the utility of middle meningeal artery (MMA) embolization for intractable CSDH. In this study, we present the usefulness of MMA embolization as a treatment for CSDHs with CHSs.

CASES

We present two cases of CSDHs with CHSs occurring in patients, 1 treated with burr hole craniotomy and irrigation, and the other treated with the epidural blood patch. Both patients exhibited similar-appearing bilateral relatively-thin hematomas, hyperplasia, and enhanced contrast effects in the dura mater, and extradural hygroma in the cervical portion on enhanced magnetic resonance imaging scans. Also, to reviewing prior literature and imaging findings, they had already undergone conventional treatment. We added MMA embolization treatment and they followed a good course.

RESULTS

Despite the known intractable outcomes of patients with CSDHs with CHSs, MMA embolization worked well in the current case series.

CONCLUSION

MMA embolization might be considered as a preferred therapeutic option for CSDHs with CHSs in order to buy time before the epidural blood patch starts working.

Expression of Bcl-2, Bcl-x, and Bax proteins in astrocytomas in relation to patient survival

The Bcl-2 family is composed of a group of related proteins that either prevent or promote apoptosis. This study was undertaken to assess the prognostic value of Bcl-2, Bcl-x, and Bax in patients with astrocytomas. Tissue samples from 104 astrocytomas (WHO grade 2, 21 cases: grade 3, 49 cases; grade 4, 34 cases), including 68 primary and 36 recurrent tumors, were examined immunohistochemically for Bcl-2, Bcl-x, and Bax expression. Patient charts were reviewed for clinical presentation, and survival was followed. The mean values of the Bcl-2, Bcl-x, and Bax labeling indexes (LI) were 15.9 +/- 13.1%, 53.2 +/- 35.3%, and 25.9 +/- 23.2%, respectively. Statistical analysis showed that the Bcl-x LI of high-grade (grade 3 or 4) astrocytomas was higher than that of low-grade (grade 2) tumors (P = 0.0064). There were no significant differences in patient survival between the high- and low-LI groups of Bcl-2, Bcl-x, and Bax. Since the mechanism and regulation of apoptosis are still unclear, it seems difficult to use the Bcl-2 family as a biological marker in predicting the prognosis of patients with astrocytomas.

Primary Ewing's sarcoma/peripheral primitive neuroectodermal tumor at the vertex of the skull with elevated serum carcinoembryonic antigen: case report

A primary Ewing's sarcoma arising in the skull is relatively rare. Although a small number of case reports noted elevated carcinoembryonic antigen (CEA) in patients with primary central nervous system (CNS) neoplasms, there is no report of Ewing's sarcoma/peripheral primitive neuroectodermal tumor (PNET) with elevated serum levels of CEA. A 7-year-old boy who had episodes of headache and vomiting had noticed a solid mass in the vertex of the head. Imaging studies revealed a large intra- and extracranial tumor at the vertex of the skull. Hematological examination demonstrated high serum levels of CEA: 91.09 ng/ml. The patient initially underwent an embolization of the bilateral middle meningeal arteries with Gelfoam particles. One week later, the patient was operated on and a subtotal resection of the tumor was performed. On histopathological and molecular genetic examination, the tumor was diagnosed as a Ewing's sarcoma/peripheral PNET. Immunohistochemical study showed strongly positive staining for CEA in the tumor cells. The serum level of CEA was normalized at 0.83 ng/ml after the tumor was removed and the boy underwent radiotherapy and 3 courses of chemotherapy. This is the first reported case of a primary Ewing's sarcoma/peripheral PNET at the vertex of the skull with elevated serum CEA.