Intracranial solitary fibrous tumor with delayed symptomatic metastasis to the lumbar spine: illustrative case.

BACKGROUND: Intracranial solitary fibrous tumors (SFTs), formerly known as hemangiopericytomas, are rare, aggressive mesenchymal extra-axial tumors typically treated via resection, often with preoperative embolization and postoperative radiation and/or antiangiogenic therapy. Although surgery confers a significant survival benefit, local recurrence and distant metastasis are not uncommon and may occur in a delayed fashion. OBSERVATIONS: The authors describe the case of a 29-year-old male who initially presented with headache, visual disturbance, and ataxia, and was found to have a large right tentorial lesion with mass effect on surrounding structures. He underwent tumor embolization and resection with gross total resection achieved and pathology consistent with World Health Organization grade 2 hemangiopericytoma. The patient recovered well, but 6 years later presented with low back pain and lower extremity radiculopathy and was found to have metastatic disease within the L4 vertebral body causing moderate central canal stenosis. This was successfully treated with tumor embolization followed by spinal decompression and posterolateral instrumented fusion. Metastasis of intracranial SFT to vertebral bone is exceedingly rare. To our knowledge this is only the 16th reported case. LESSONS: Serial surveillance for metastatic disease is imperative in patients with intracranial SFTs given their propensity and unpredictable time course for distant spread.

Differentiation of benign angiomatous and microcystic meningiomas with extensive peritumoral edema from high grade meningiomas with aid of diffusion weighted MRI.

OBJECTIVE: To determine whether angiomatous and microcystic meningiomas which mimic high grade meningiomas based on extent of peritumoral edema can be reliably differentiated as low grade tumors using normalized apparent diffusion coefficient (ADC) values. METHODS: Preoperative magnetic resonance imaging (MRI) of seventy patients with meningiomas was reviewed. Morphologically, the tumors were divided into 3 groups. Group 1 contained 12 pure microcystic, 3 pure angiomatoid and 7 mixed angiomatoid and microcystic tumors. Group 2 included World Health Organization (WHO) grade II and WHO grade III tumors, of which 28 were atypical and 9 were anaplastic meningiomas. Group 3 included WHO grade I tumors of morphology different than angiomatoid and microcystic. Peritumoral edema, normalized ADC, and cerebral blood volume (CBV) were obtained for all meningiomas. RESULTS: Edema index of tumors in group 1 and group 2 was significantly higher than in group 3. Normalized ADC value in group 1 was higher than in group 2, but not statistically significant between groups 1 and 3. CBV values showed no significant group differences. CONCLUSION: A combination of peritumoral edema index and normalized ADC value is a novel approach to preoperative differentiation between true aggressive meningiomas and mimickers such as angiomatous and microcystic meningiomas.

General technical considerations for the endovascular management of cerebral aneurysms.

Cerebral aneurysms pose a threat to patients because of their risk of rupture causing subarachnoid hemorrhage, and the goal of treatment is the exclusion of the aneurysm from the circulation to prevent bleeding (in the case of unruptured aneurysms) or rebleeding. This article analyzes the general technical factors associated with the endovascular treatment of cerebral aneurysms. It discusses issues with transarterial access; imaging of aneurysm size, morphology, and regional anatomy to determine the endovascular plan; the techniques for the major endovascular aneurysm devices; and periprocedural management issues to reduce potential treatment-related complications.

Evolving role of endovascular treatment for MCA bifurcation aneurysms: case series of 184 aneurysms and review of the literature.

OBJECTIVE: This study evaluates the role of endovascular therapy for middle cerebral artery (MCA) aneurysms and its evolution over time. We are reporting a large case series of 184 MCA aneurysms and comparative analysis of the literature. METHODS: This was a retrospective review of a prospectively maintained database including all patients with MCA bifurcation aneurysms embolized between 2000 and 2013. There were 184 aneurysms in 166 patients, with 71 ruptured and 113 nonruptured aneurysms. RESULTS: Stent assistance was required in 70 cases (38·0%) and 3 cases (1·6%) required 'Y' stenting. The initial rate of total aneurysm occlusion was 59·8% and at delayed follow up was 90·1%. Seven embolizations resulted in thrombo-embolic complications (3·8%), with no cases of aneurysm re-bleeding, wire perforations, or other hemorrhages. Three patients with ruptured aneurysms died of causes unrelated to the embolization, and none with nonruptured aneurysms died in the follow-up period (total mortality 1·6% at 30 days post-procedure). A total of seven aneurysms (3·9%) required retreatment with an average follow up of 41 months. Prior to dedicated aneurysm stents, 68·8% of patients underwent embolization with the remainder surgically treated. Following the introduction of aneurysm stents in 2002, 92·0% of MCA aneurysms treated were embolized. CONCLUSIONS: During the past decade we have seen a treatment paradigm shift in MCA aneurysm treatment from surgical treatment to endovascular treatment. Developments in 3D angiography, more compliant balloons, dedicated aneurysm stents, complex coils, and antiplatelet therapy regimes have led to this transition for safe and effective management of these patients.

Atypical tumors of the facial nerve: case series and review of the literature.

OBJECT: The authors present a series of 4 patients with rare facial nerve tumors. The relevant literature is reviewed and is discussed regarding diagnostic features, the role of operative management, and surgical approach. METHODS: A retrospective chart review was conducted for patients with tumors of the facial nerve that were treated between 2008 and 2011. Patients undergoing observation with serial MRI and those who were treated with up-front radiosurgery and for whom tissue diagnosis was not available were excluded. In addition, patients with suspected vestibular schwannoma, facial nerve schwannoma, neurofibromatosis Type 2, and metastatic disease were also excluded. The charts of 4 patients (2 men and 2 women) with "atypical" tumors were reviewed and analyzed. RESULTS: A total of 12 patients with tumors of the facial nerve were identified during the study period. Patient characteristics, preoperative imaging, operative approach, tumor histology, and outcomes are described. CONCLUSIONS: Atypical facial nerve tumors must be distinguished from the more common facial nerve schwannoma. How the authors of this study treat rare facial nerve tumors is based on their experience with the more common facial nerve schwannomas, characterized by a slow progression of symptoms and growth. Less is known about the rare lesions, and thus a conservative approach may be warranted. Open questions include the role of radiosurgery, facial nerve decompression, and indications for resection of tumor and cable grafting for these rare lesions.

Management of multifocal and multicentric gliomas.

The diffuse nature of gliomas has long confounded attempts at achieving a definitive cure. The advent of computed tomography and magnetic resonance imaging made it increasingly apparent that gliomas could have a multifocal or multicentric appearance. Treating these tumors is the summit of an already daunting challenge, because the obstacles that must be surmounted to treat gliomas in general, namely, their heterogeneity, diffuse nature, and ability to insidiously invade normal brain, are more conspicuous in this subset of tumors.

Complications and outcomes after spinal deformity surgery in the elderly: review of the existing literature and future directions.

OBJECT: The elderly population (age > 60 years) is the fastest-growing age group in the US. Spinal deformity is a major problem affecting the elderly and, therefore, the demand for surgery for spinal deformity is becoming increasingly prevalent in elderly patients. Much of the literature on surgery for adult deformity focuses on patients who are younger than 60 years, and therefore there is limited information about the complications and outcomes of surgery in the elderly population. In this study, the authors undertook a review of the literature on spinal deformity surgery in patients older than 60 years. The authors discuss their analysis with a focus on outcomes, complications, discrepancies between individual studies, and strategies for complication avoidance. METHODS: A systematic review of the MEDLINE and PubMed databases was performed to identify articles published from 1950 to the present using the following key words: "adult scoliosis surgery" and "adult spine deformity surgery." Exclusion criteria included patient age younger than 60 years. Data on major Oswestry Disability Index (ODI) scores, visual analog scale (VAS) scores, patient-reported outcomes, and complications were recorded. RESULTS: Twenty-two articles were obtained and are included in this review. The mean age was 74.2 years, and the mean follow-up period was 3 years. The mean preoperative ODI was 48.6, and the mean postoperative reduction in ODI was 24.1. The mean preoperative VAS score was 7.7 with a mean postoperative decrease of 5.2. There were 311 reported complications for 815 patients (38%) and 5 deaths for 659 patients (< 1%). CONCLUSIONS: Elderly patient outcomes were inconsistent in the published studies. Overall, most elderly patients obtained favorable outcomes with low operative mortality following surgery for adult spinal deformity.

Intraoperative computed tomography registration and electromagnetic neuronavigation for transsphenoidal pituitary surgery: accuracy and time effectiveness.

OBJECT: The authors assessed the feasibility, anatomical accuracy, and cost effectiveness of frameless electromagnetic (EM) neuronavigation in conjunction with portable intraoperative CT (iCT) registration for transsphenoidal adenomectomy (TSA). METHODS: A prospective database was established for data obtained in 208 consecutive patients who underwent TSA in which the iCT/EM navigation technique was used. Data were compared with those acquired in a retrospective cohort of 65 consecutive patients in whom fluoroscope-assisted TSA had been performed by the same surgeon. All patients in both groups underwent transnasal removal of pituitary adenomas or neuroepithelial cysts, using identical surgical techniques with an operating microscope. In the iCT/EM technique-treated cases, a portable iCT scan was obtained immediately prior to surgery for registration to the EM navigation system, which did not require rigid head fixation. Preexisting (nonnavigation protocol) MR imaging studies were fused with the iCT scans to enable 3D navigation based on MR imaging data. The accuracy of the navigation system was determined in the first 50 iCT/EM cases by visual concordance of the navigation probe location to 5 preselected bony landmarks. For all patients in both cohorts, total operating room time, incision-to-closure time, and relative costs of imaging and surgical procedures were determined from hospital records. RESULTS: In every case, iCT registration was successful and preoperative MR images were fused to iCT scans without affecting navigation accuracy. There was 100% concordance between probe tip location and predetermined bony loci in the first 50 cases involving the iCT/EM technique. Total operating room time was significantly less in the iCT/EM cases (mean 108.9 ± 24.3 minutes [208 patients]) compared with the fluoroscopy group (mean 121.1 ± 30.7 minutes [65 patients]; p < 0.001). Similarly, incision-to-closure time was significantly less for the iCT/EM cases (mean 61.3 ± 18.2 minutes) than for the fluoroscopy cases (mean 71.75 ± 19.0 minutes; p < 0.001). Relative overall costs for iCT/EM technique and intraoperative C-arm fluoroscopy were comparable; increased costs for navigation equipment were offset by savings in operating room costs for shorter procedures. CONCLUSIONS: The use of iCT/MR imaging-guided neuronavigation for transsphenoidal surgery is a time-effective, cost-efficient, safe, and technically beneficial technique.

Acute obstructive hydrocephalus due to a large posterior third ventricle choroid plexus cyst.

We present the case of a child in whom acute hydrocephalus developed secondary to obstruction of the foramen of Monro by a choroid plexus cyst. The patient was seen in the emergency department with fevers, acute onset of headaches, and lethargy. Computed tomography demonstrated dilated lateral and third ventricles with a relatively normal-sized fourth ventricle. An external ventricular drain was placed. Despite decompression of the lateral ventricles, follow-up magnetic resonance imaging demonstrated a dilated third ventricle with a possible thin-walled mass extending from the foramen of Monro into the posterior portion of the third ventricle. The patient subsequently underwent endoscopic fenestration of the cyst with endoscopic third ventriculostomy. Although two other cases of symptomatic choroid plexus cysts of the third ventricle have been previously reported in children, our paper highlights the possibility of endoscopic cyst fenestration together with a third ventriculostomy as a treatment option in cases where the cyst extends into the posterior third ventricle. Despite adequate decompression, we were concerned that due to CSF pulsations the remnant cyst wall could result in acute aqueduct obstruction and subsequent hydrocephalus.

Historical characterization of trigeminal neuralgia.

TRIGEMINAL NEURALGIA IS a well known clinical entity characterized by agonizing, paroxysmal, and lancinating facial pain, often triggered by movements of the mouth or eating. Historical reviews of facial pain have attempted to describe this severe pain over the past 2.5 millennia. The ancient Greek physicians Hippocrates, Aretaeus, and Galen, described kephalalgias, but their accounts were vague and did not clearly correspond with what we now term trigeminal neuralgia. The first adequate description of trigeminal neuralgia was given in 1671, followed by a fuller description by physician John Locke in 1677. André described the convulsive-like condition in 1756, and named it tic douloureux; in 1773, Fothergill described it as "a painful affection of the face;" and in 1779, John Hunter more clearly characterized the entity as a form of "nervous disorder" with reference to pain of the teeth, gums, or tongue where the disease "does not reside." One hundred fifty years later, the neurological surgeon Walter Dandy equated neurovascular compression of the trigeminal nerve with trigeminal neuralgia.

Entrapment of the glossopharyngeal nerve in patients with Eagle syndrome: surgical technique and outcomes in a series of 5 patients.

OBJECT: Eagle syndrome is characterized by unilateral pain in the oropharynx, face, and earlobe, and is caused by an elongated styloid process or ossification of the stylohyoid ligament with associated compression of the glossopharyngeal nerve. The pain syndrome may be successfully treated with surgical intervention that involves resection of the styloid process. Although nerve decompression is routinely considered a neurosurgical intervention, Eagle syndrome and its treatment are not sufficiently examined in the neurosurgical literature. METHODS: A review was performed of cases of Eagle syndrome treated in the Department of Neurosurgery at the University of Illinois at Chicago Medical Center over the last 7 years. The clinical characteristics, radiographic imaging, operative indications, procedural details, surgical morbidity, and clinical outcomes were collected and analyzed. RESULTS: Of the many patients with facial pain treated between 2001 and 2007, 7 were diagnosed with Eagle syndrome, and 5 of these patients underwent resection of the elongated styloid process. There were 4 women and 1 man, ranging in age from 20 to 68 years (mean 43 years). The average duration of disease was 11 years. In all patients, a preoperative workup revealed unilateral or bilateral elongation of the styloid process. All patients underwent resection of the styloid process on the symptomatic side using a lateral transcutaneous approach. There were no surgical complications. All patients experienced pain relief immediately after the operation. At the latest follow-up (average 46 months, range 7 months to 7.5 years) all but 1 patient maintained complete pain relief. In 1 patient, the pain recurred 12 months postoperatively and additional interventions were required. CONCLUSIONS: Eagle syndrome may be considered an entrapment syndrome of the glossopharyngeal nerve. It is a distinct clinical entity that should be considered when evaluating patients referred for glossopharyngeal neuralgia. The authors' experience indicates that patients with Eagle syndrome may be successfully treated using open resection of the elongated styloid process, which appears to be both safe and effective in terms of long-lasting pain relief.