Interesting case - 3.10.2013

This is an example of a case that in and of itself is not esoteric or difficult. However, it is of interest in that it serves as an example that in neuropathology (particularly at the time of frozen section), one needs to keep the differential diagnosis as wide as possible... The pertinent clinical details are as follows: 12 year-old male.

MRI - T1

MRI - T2

MRI - T1 post-gadolineum administration

Now, this is the moment of truth. Before you even look at your frozen section / smear preparation slides, what is your differential diagnosis? Be honest!

H&E - Low power

H&E - High Power (majority of tumor)

H&E - High power (single field demonstrated this structure)

Hopefully this entity was in your radiologic differential diagnosis.

Click here for the diagnosis...

Interesting case - 10.3.2012

Here's a rather interesting case that I recently encountered. This is an example of a neoplasm that many neuropathologists will admit to the "internal eye roll" when it arrives at their microscope. However, once in a while, this tumor presents itself in a rather interesting fashion. This case is an example of the latter.

This patient is a 20-year-old male who presented with worsening headaches, tinnitus, problems with balance, and several unspecified focal neurologic deficits. An MRI was performed.

Pre-op MRI: T1 post-gadolineum

Pre-op MRI: T1 post-gadolineum

Because of significant (and obvious) compression of adjacent brain structures, Neurosurgery commenced tumor debulking. Neuropathologic examination revealed the tumor below...

H&E - High magnification

H&E - High magnification

H&E - High magnification

H&E - Intermediate magnification

GFAP immunostain

This case presents several burning questions for you to answer... 

• What is the most appropriate name for the tumor?
• What WHO grade will you assign the tumor?
• Besides the name and grade of the tumor, what other clinically-relevant details are present (hint - Neuroradiology!)

Click here for the case discussion...

Interesting case - 4.7.2012 - Back in business!

Finally got settled in the new house, finished changing offices at work (bigger & better!), and have Internet hooked up. Moved three times in three months. That's what you get with a short sale... Good deal, many headaches!

Anyhow, back to business. This case is tangentially-related to Neuropathology; I have been told that the posts are rather one dimensional, so I thought I'd mix it up. Here it goes...

This patient was a 47-year-old male with a history of post-inflammatory mitral valve stenosis, status-post mitral bioprosthetic valvuloplasty. His post-operative course was characterized by endocarditis requiring prolonged antibiotic therapy. He presented to the hospital with critical mitral stenosis. He died before planned surgical intervention. Examination of the inner aspect of cranium revealed the rather interesting finding demonstrated in the photo below.

Cranium, inner diploe

Another organ, the thyroid gland, demonstrated a similar abnormality. The gross and microscopic features are demonstrated below.

Thyroid, gross

Thyroid, microscopic

This is another one of those "Aunt Minnie" diagnoses... Easy if seen before, challenging if not. Good luck!

Click here for the diagnosis...

Interesting case - 1.29.2012

Here's a case that I've been wanting to post for awhile, but I held out for some time, as I wanted to include the slide in the first annual "LLUMC Holiday Neuropathology Challenge" (Thanks to Dr. Jack Raisanen at UTSW for the inspiration!). Now that the competition is over, and the champions have been announced, I can go ahead and share the case.

This was an autopsy brain from a 8-year-old male who died from sequelae of congenital heart disease. At one point, a possible intracranial vascular malformation was suspected, so he underwent cerebral angiography, which was negative. His terminal course was characterized by circulatory collapse. Examination of the histologic sections from the midbrain disclosed the abnormality below...

The remainder of the brain parenchyma was free of inflammation, hypoxic/ischemic changes, etc...

This lesion is quite the "head scratcher". This is one of those "lesions" that is difficult to recognize for those who are uninitiated, but is quite characteristic (i.e. an "Aunt Minnie").

Click here for the diagnosis...

Interesting case - 12.27.2011

Here's a consult case that came through recently. This patient was a 52-year-old male with a skull base mass anterior to the foramen magnum. Surgical resection yielded the following specimen...

This tumor carries a quite short differential diagnosis. Routine histology will get you 90% of the way... Immunohistochemical stains will "seal the deal". Prior to reading the case discussion, one should formulate your differential diagnosis and decide which immunostains that you would order...

Click here for the diagnosis...

Interesting case - 12.10.2011

I am still amazed at the number of interesting and strange CNS tumors that I have encountered here at the new job. The hospital, while not especially large, is exceedingly busy, and serves as a major referral center for the inland and surrounding desert communities of Southern California. Even on general sign out days, it  often seems that even "simple" cases present unique diagnostic challenges. Enough musing; on to the case...

This patient was a 13-year-old female who presented with progressively worsening headaches and difficulty concentrating at school. The results of subsequent neuroimaging are shown below...

Sagittal T1 Post

Sagittal T2

Coronal T2

Obviously, neurosurgery was consulted shortly thereafter. Intraoperatively, the tumor was found to be well-circumscribed, predominantly intraventricular, and firm. Selected photomicrographs below demonstrate the diagnostic histopathologic features...

H&E - low magnification

H&E - low magnification

H&E - high magnification

H&E - high magnification

No hints necessary. Special stains were performed, the results of which you will soon know.

Click here for the diagnosis...

Interesting case - 11.2.2011

I apologize. It's been awhile since I posted an interesting case. I am fortunate that I see plenty of interesting cases. I've been saving them and adding them to my collection. The hard part is finding time to post them. It's odd how little time that there is left in the day after working. Enough excuses. Here's another case...

This patient was a 35-year-old female who presented with nonspecific complaints of headache and a single unwitnessed possible seizure. Her past medical history was noncontributory. An MRI demonstrated the following abnormality...

Coronal T2

Coronal T1 post-contrast

Sagittal T1 post-contrast

Neurosurgery was consulted; a stereotactic biopsy was undertaken shortly thereafter.

H&E

H&E

H&E

Your mission, should you choose to accept it, is to arrive at the correct diagnosis. If your computer is windows-based, it will self-destruct in 10,9,8,7... (<-- if you didn't get the joke, it's a satire of the old mission impossible TV show to poke fun of PCs...)

Bonus points for naming the eponymously-named cells which suggest the proper etiology.

Hint - remembering the entire radiologic differential diagnosis for ring-enhancing lesions in the CNS will significantly narrow the differential diagnosis.

Click here for the case discussion...