Background and Purpose: While microsurgical clipping has been the choice of treatment for anterior communicating artery (ACoA) aneurysm, endovascular embolization is increasingly popular for treating intracranial aneurysms. Previous studies showed that in terms of mortality (i.e., death) and morbidity (i.e., functional outcome, independent living, rebleeding) rates, the clinical outcomes of coil embolization for intracranial aneurysms are as good as or even better than those of surgical clipping. However, little is known about the impact of these treatments on the cognitive functions of those survived after the treatment. Thus, the present study is designed to examine the cognitive deficits of patients treated with either surgical clipping or coil embolization. Method: Eighteen patients with a ruptured ACoA aneurysm were recruited. Half of them had undergone surgical clipping and the other half had endovascular embolization. Standardized neuropsychological tests were employed to assess their memory, executive function, motor ability, language and visual perceptual abilities. Results: The performance of the patients was in general poorer than that of the normal control subjects on tests of verbal memory, flexible thinking, ability to resist interference and motor control. However, in terms of severity, the patients who received surgical clipping demonstrated more severe impairment than those had endovascular embolization on these cognitive domains. In addition, while 33% of patients in the clipping group showed impairments on memory and executive function, no patient in the embolization group demonstrated these impairments. Conclusions: Patients with ACoA aneurysm demonstrated impaired verbal memory, executive function and motor abilities while their language and visual perception abilities remained relatively intact. However, when comparing the effect of treatment choice on the cognitive functions of these patients, the present results favored the coil embolization as the patients treated with coil embolization demonstrated significantly fewer severe cognitive deficits than patients who had undergone surgical clipping.

A 56 year old man with previously unsuspected recurrence of squamous cell carcinoma of the oesophagus presented with dyspnoea. Bronchoscopy and computed tomography suggested bronchopneumonic changes with an infectious cause. He suffered a rapidly deteriorating course and died despite active treatment, including antibiotics and mechanical ventilation. Necropsy revealed a florid pulmonary tumour microembolism mimicking alveolitis. No bronchopneumonia was seen. The emboli arose from loosely attached tumour vegetations in the tricuspid valve. In a patient with known malignancy, tumour microembolism should be considered as an uncommon cause of rapid respiratory failure, refractory to antibiotic treatment. O esophageal carcinoma is relatively common in Japan and Southern China.1 Because of the anatomical position of the oesophagus, complete resection of the tumour is difficult. Prognosis is generally poor and the five year recurrence rate is 10%. We describe a case of unsuspected recurrence of oesophageal carcinoma, resulting in florid pulmonary tumour microembolism and rapidly progressive fatal respiratory failure. CASE REPORTA 56 year old man with squamous cell carcinoma of the oesophagus was treated with chemotherapy and radiotherapy three years previously. The tumour initially resolved but recurred one year later. He underwent a three staged oesophagectomy and was disease free for two years. He presented to our hospital because of worsening shortness of breath for one week. He was afebrile and initial microbiological investigations were all negative. High resolution computed tomography (CT) of the lung revealed patchy areas of mainly peripheral alveolar opacification in the mid and lower zones bilaterally. The CT changes were suggestive of an infective or idiopathic alveolitis ( fig 1A). The impression from bronchoscopy was that of pneumonia. Echocardiography showed mild tricuspid regurgitation, with right ventricular dilatation. Despite aggressive antibiotics and mechanical respiratory support, his condition worsened and he developed respiratory failure. The patient succumbed rapidly the next day. Necropsy revealed ''consolidations'' of both lungs, especially the lower lobes. Friable vegetations were also seen loosely attached to the tricuspid valves ( fig 1B). Large emboli were not detected in the major pulmonary vessels. Distorted anatomy with fibrosis around the duodenum, in keeping with previous surgery, was also noted.Microscopy revealed that the tricuspid vegetation consisted of fibrin and squamous carcinoma cells ( fig 1C), with myocardial sparing. The lung showed tumour plugs in nearly all the medium to small sized pulmonary arteries, in addition to the capillaries, without spreading into the adjacent alveolar spaces. The arterial wall appeared to be normal. There was no intimal thickening. Pneumonic changes were not apparent ( fig 1D).In the fibrotic adhesion around the duodenum, nests of squamous carcinoma cells were seen infiltrating the submucosa without disrupting the duodenal mucosa. The tumour infi...

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An unusual cause of superior vena cava obstruction S uperior vena cava (SVC) obstruction is commonly seen in patients with intrathoracic malignancies. Most cases are due to extrinsic compression by tumour masses. We present the case history of a man with SVC obstruction due instead to an intraluminal tumour which turned out to be adenocarcinoma of an unknown primary.A 54 year old chronic smoker presented with a 2 week history of progressive facial swelling and dyspnoea. Physical examination revealed signs of SVC obstruction. A CT scan of the thorax showed an expansile tumour mass located within and obstructing the lumen of the SVC lumen (fig 1). Neither CT scanning nor ultrasonography of the abdomen and pelvis showed any evidence of malignancy. Thoracotomy revealed an intracaval tumour obstructing the SVC and invading up to the level of the innominate veins. No primary or secondary tumours could be found. Subtotal tumour resection under extracorporeal circulatory bypass was performed followed by construction of a vascular bypass between the left brachiocephalic vein and right atrium.Histological examination confirmed adenocarcinoma (fig 2) without any features pointing to a specific primary origin. Immunohistochemical analysis showed positive staining for cytokeratin 7 (CK7) but not for CK20, CEA, thyroid transcription factor-1 (TTF-1), thyroglobulin, and hepatocyte paraffin antibody 1 (HepPar-1), suggesting that the primary tumour might have originated from the lungs or pancreaticobiliary tract. The patient received postoperative radiotherapy to the residual mass followed by platinum based chemotherapy.While SVC obstruction is not an uncommon presenting feature of certain cancers, 1 2 most cases are due to extrinsic compression. Primary or metastatic cancer presenting as an obstructive mass within the SVC is very rare. Reported histology in the literature include thymic carcinoma, primary leiomyosarcoma of the SVC, invasive thymoma, paraganglioma, follicular carcinoma of the thyroid, renal cell carcinoma, and lymphoma. Adenocarcinoma of uncertain primary origin presenting initially and solely as an intraluminal SVC tumour is extremely rare. Learning pointsN Intraluminal tumour is a rare cause of SVC obstruction. N Establishing a histological diagnosis is challenging because the tumour is inaccessible to percutaneous biopsy. Despite reports of the use of a transvenous catheter for biopsy, thoracotomy remains an important option for obtaining histology and treatment for patients with isolated intraluminal SVC tumour.

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