PMC3420431_01
Patient A's imaging: (a) T2 MRI of the brain on admission. (b) Preoperative ventriculogram, performed through the ventricular reservoir. There is contrast within the ventricle, but it does not pass into the catheter track or the edematous white matter surrounding the catheter. (c) T2 MRI on postoperative day eight demonstrating decreased area of hyperintensity in the white matter compared to preoperative imaging.
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At this time, he had received four rounds of IT cytarabine liposomal injection, the most recent two days prior to admission. An MRI of the brain on admission demonstrated new, significant edema surrounding the track of the ventricular catheter (Figure 1(a)). Omnipaque into the reservoir and obtaining a CT later that day demonstrated a patent catheter without contrast extravasation into the surrounding parenchyma (Figure 1(b)). On admission, his strength was 4/5 in his left upper extremity and 3/5 in his left lower extremity. MRI (T2 sequence) of the brain on postoperative day eight showed improvement of the cerebral edema compared to preoperative imaging (Figures 1(a) and 1(c)).
Patient B's imaging: (a) T2 MRI of the brain on admission. (b) CT of the brain on admission. (c) CT on postoperative day two, which shows resolution of the cyst and the white matter hypodensity.
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Her admission MRI and CT of the brain showed edema surrounding the catheter track, but they also demonstrated a cyst within the edematous white matter and abutting the catheter (Figures 2(a) and 2(b)). Postoperative MRI was not performed; however, a CT of the head on postoperative day two showed significant decrease in cerebral edema and in the size of the cyst compared to her preoperative CT (Figures 2(b) and 2(c)).
Histopathology of brain biopsies. (a) The cortex from patient A is essentially unremarkable. There is no neuronal loss or gliosis, no tumor, and no inflammation. H&E, 200x. (b) The white matter from patient A is markedly gliotic, with many large astrocytes, and is also vacuolated from edema. H&E, 200x. (c) The cortex from patient B is similarly unremarkable. H&E, 200x. (d) The white matter from patient B has perivascular infiltrates of foamy macrophages along with many large astrocytes. H&E, 200x.
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The cortex was minimally gliotic, with no demonstrable loss of neurons and with no malignant cells or inflammatory infiltrates (Figure 3(a)). The white matter, however, was markedly gliotic with numerous large reactive astrocytes, and its background is vacuolated from edema (Figure 3(b)). The tissue excised from this patient also had both cortex and white matter, and the cortex was unremarkable (Figure 3(c)). The white matter had many large astrocytes consistent with gliosis, foci of perivascular infiltrates of foamy macrophages, and intervening early necrosis (Figure 3(d)).