Background: Cladophialophora bantiana is a dematiaceous fungus that rarely infects the central nervous system (CNS). It is associated with a mortality rate of over 70% despite treatment. Case Description: An 81-year-old female with a remote history of renal cell carcinoma presented with progressive headache and an expressive aphasia for 3 days. Computed tomography imaging revealed a left frontotemporal mass with surrounding vasogenic edema. A left frontotemporal craniotomy was performed and cultures revealed C. bantiana. The initial management with IV voriconazole was unsuccessful and the patient had a recurrence of the cranial infection and developed pulmonary abscesses. Following the addition of oral flucytosine, the patient showed a significant improvement with a complete radiographic resolution of both the cranial and pulmonary lesions. Conclusion: C. bantiana involving the CNS is a rare and often fatal disease. Surgical management along with standard antifungal treatment may not provide definitive therapy. The addition of flucytosine to IV voriconazole resulted in a positive outcome for this patient who is alive, living independently 1 year from the original diagnosis. In this rare fungal infection, standard antifungal treatment may not provide adequate coverage and the utilization of additional therapy may be required.
Introduction Collision tumors present as histologically different juxtaposed neoplasms within the same anatomical region, independent of the adjacent cell population. De novo intracranial collision tumors involving metachronous primary brain neoplasms alongside dural meningiomatosis are not well documented in the literature. Clinical Presentation We present staged surgical management of a 72-year-old female with known left hemispheric stable dural-based convexity mass lesions over 10 years and new-onset expressive aphasia and headaches. MRI had revealed left supratentorial dural-based enhanced masses consistent with en plaque meningiomatosis. Embolization angiography showed an unusual tumor blush from an aberrant branch of anterior cerebral artery suggesting a deeper focal intra-axial nature; a stage 1 craniotomy for dural-based tumor resection was completed with diagnosis of a meningioma (WHO grade 1). Intraoperatively, a distinct intra-axial deep discrete lesion was verified stereotactically, concordant with the location of tumor blush. The patient made a complete neurological recovery from a transient postoperative supplemental motor area syndrome in a week. Subsequent postoperative follow-up showed worsening of right hemiparesis and MRI showed an increase in residual lesion size and perilesional edema, which prompted a stage 2 radical resection of a glioblastoma, WHO grade 4. She improved neurologically after surgery with steroids and physical therapy. At 15 months following adjuvant therapy, she remains neurologically intact throughout the postoperative course, with no recurrent tumor on MRI. Conclusion A de novo glioblastoma presented as a masquerading lesion within hemispheric convexity meningiomatosis in an elderly patient with no prior radiation/phakomatosis, inciting a non-causal juxtapositional coexistence. The authors highlight rare pathognomonic angiographic findings and the rationale for two-staged resections of these collision lesions that led to excellent clinicoradiological outcome.
Background: There are few clinical indicators beyond imaging to aid in the prediction of improvement after treatment for acute ischemic stroke. We aimed to identify patient characteristics that serve as predictors to identify patients who may be less likely to have a clinically significant improvement after treatment. Methods: We performed a retrospective chart review of ischemic stroke treatment cases (tPA, EVT or both) at Hartford Hospital between January 1st, 2020 to December 31st, 2021. Stroke was diagnosed with MRI imaging. Patients were divided into those who had early improvement and those who did not have early improvement. Early improvement was defined as a reduction in NIH of 50% or more at 24 hours post treatment. We excluded patients who did not receive a routine CT scan at 24-hours for surveillance of hemorrhage. We identified potential predictors by comparing two demographic (age, gender) and 19 patient health characteristics between groups. Any variables that were significantly different (P<.05) between groups were then examined as a predictor in a multivariate logistic regression analysis, while controlling for therapeutic intervention and time to treatment in the model. Results: A total of 363 patient records met inclusion criteria; 223 had early improvement and 140 did not. Patients were aged 71.74±15.65yr and 52.1% were female. There were eight potential predictors identified and included in the regression analysis. Higher blood pressure [odds ratio (OR)=0.991; 95% confidence interval (CI)=0.98, 1.00; P=.02], and statin use (OR=0.276; 95% CI=0.16, 0.47; P<.001) were associated with a decreased likelihood of early improvement. Conclusion: Our findings indicate that patients who are taking statins and/or have high blood pressure have a decreased likelihood of having an early improvement following stroke treatment. Clinicians should consider these factors when putting together treatment plans for ischemic stroke patients. The association between statin use as well as systolic blood pressure and improvement after stroke treatment should be further examined in a randomized controlled trial.
Introduction Duplicate cranial nerves are fundamentally rare anatomical variants. Few case reports have documented cranial nerve duplication. One previous case report has reported a vagus nerve with a smaller secondary accessory nerve component. We present the first reported case of duplicate vagus nerves identical in size and thickness with otolaryngological diagnostic confirmation. Case Description A 25-year-old woman with seizures refractory to medical management decided to undergo placement of a vagus nerve stimulator. During carotid sheath microdissection, two parallel nerve tracts were identified. The two nerves were identical in size and width. Proximal dissection confirmed that the two nerves were independent of one another and neither was a branching segment. To confirm duplicate vagus nerves, otolaryngology was consulted intraoperatively and the duplicate nerves were verified. The vagus nerve stimulator was placed in typical fashion around the medial nerve. Conclusion This is the first reported case of duplicate vagus nerves identical in size and with confirmation by otolaryngology. The authors would like to highlight the operative management of the vagus nerve stimulator placement as well as integrity of the diagnostic conclusions based on size, further dissection, and specialist consultation.
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