Gliosarcoma with primitive neuronal, chondroid, osteoid and ependymal elements.

A 51-year-old man presented with a 2-week history of malaise. MRI revealed a large solid and cystic lesion with ring enhancement measuring 6.5 cm in diameter in the right frontal lobe. Histologically, the tumor consisted of various components: diffuse growth of atypical astrocytic cells consistent with glioblastoma, fascicular proliferation of atypical spindle cells such as fibrosarcoma, clusters of primitive neuronal cells, and foci of ependymal cells. The sarcomatous component also focally exhibited chondroid and osteoid differentiation. Immunohistochemically, tumor cells in the primitive neuronal component were immunoreactive for synaptophysin and CD56. The spindle cells were immunopositive for Slug and Twist, regulators of epithelial-mesenchymal transition. Direct DNA sequencing demonstrated C228T mutation in the TERT promoter in astrocytic, sarcomatous and primitive neuronal components, suggesting their identical origin. Although a few cases of gliosarcoma with primitive neuronal differentiation have previously been described, the finding that neuronal, glial and sarcomatous components share an identical mutation of the TERT promoter has not been reported. The tumor recurred at the original site 11 months after the first surgery. Interestingly, the recurrent tumor was composed exclusively of a glioblastomatous component, unlike past cases of recurrent gliosarcoma.

Preoperative embolization of intracranial meningiomas using n-butyl cyanoacrylate.

INTRODUCTION: Preoperative embolization for intracranial meningioma has been controversial for several decades. This study retrospectively reviewed our experience using n-butyl cyanoacrylate (n-BCA) to identify the factors for effective devascularization and procedure-related complications. METHODS: Fifty-seven patients who underwent preoperative embolization with n-BCA were analyzed to collect the following data: age, sex, tumor size, location, pathology, and presence or absence of pial arterial supply. The predictive factors for total devascularization and complications were examined using univariate and multivariate analyses. RESULTS: Injected n-BCA penetrated into the tumor vessels in 51 cases (89%) but resulted in feeder occlusion in 6 (11%). Angiographic total devascularization was achieved in 29 cases (51%) and partial devascularization in 28 (49%). Small size, superficial location, and absence of pial supply were independent factors for total devascularization. No major complication was encountered, but asymptomatic or transient adverse events occurred in nine patients and were significantly associated with elderly patients and large tumors. CONCLUSION: Preoperative embolization for intracranial meningiomas using n-BCA can attain effective devascularization without major complications. The effect of preoperative embolization on surgical resection or patient outcome is still unknown.

Visual outcomes of endovascular and microsurgical treatment for large or giant paraclinoid aneurysms.

BACKGROUND: The optimal treatment for large or giant paraclinoid aneurysms is still controversial. The present study evaluated the results of endovascular coiling and microsurgical clipping with special reference to visual outcomes. METHODS: The clinical data and treatment outcomes of 39 cases of large (>15 mm) paraclinoid aneurysms were retrospectively reviewed. Presenting symptoms were subarachnoid hemorrhage in 16 aneurysms and visual impairment in 18. Twenty-one aneurysms were treated by endovascular therapy and 18 were treated by direct surgery. RESULTS: Maximal aneurysm diameter ≥25 mm and preoperative visual acuity <20/100 were significantly related to poor visual outcome in univariate analysis. However, preoperative visual acuity was the only significant prognostic factor in multivariate analysis (odds ratio [OR] 0.12, 95 % confidence interval [CI] 0.01-0.95, p = 0.04). Although patients treated with endovascular coiling tended to have more favorable outcome than those with surgical clipping, adjustment for other confounding factors reduced the OR of favorable outcome following each treatment modality to nearly one (OR 1.14, 95 % CI 0.17-7.46, p = 0.89). Deteriorations in the visual field showed different patterns: upper visual field deficit after endovascular coiling, and inferior nasal quadrantanopia after microsurgical clipping. CONCLUSIONS: Preoperative visual acuity was the only independent predictor of visual outcome in patients with large paraclinoid aneurysms. Although adjusted visual outcomes with microsurgical clipping and endovascular coiling were almost the same, selection of the optimal treatment for each aneurysm is essential with recognition of the potential risks and mechanisms of visual impairment.

Mattress anastomosis in micro vascular reconstruction: technical note.

BACKGROUND: Superficial temporal artery-to-middle cerebral artery (STA-MCA) anastomosis is a common procedure for neurosurgeons. The surgery necessarily requires accurate and speedy manipulation of microscope, for which a specific training is needed. Unexpected bypass occlusion sometimes happen during surgery. OBJECTIVE: Generally, conventional interrupted or continuous suture has been used for vascular anastomosis, despite various ideas have been attempted in the other surgery fields. We propose a horizontal mattress suture technique for intracranial microvascular bypass surgery. This is the first report ever published on intracranial vascular anastomosis. METHODS: We had four patients of STA-MCA bypass surgery with "mattress anastomosis" from March to May of 2012. RESULTS: During the procedure, there was no bypass occlusion and good patency was confirmed in all cases. CONCLUSION: Intimae of the recipient and the donor blood vessel contact each other precisely with this technique. Although a long-term assessment of patency is needed, it is useful for the intracranial bypass surgery.

Facial neuropathy due to axonal degeneration and microvasculitis following gamma knife surgery for vestibular schwannoma: a histological analysis. Case report.

Complete facial palsy (House-Brackmann Grade VI) developed in a 63-year-old man with a vestibular schwannoma 25 months after he had undergone two gamma knife surgeries performed 33 months apart and involving a cumulative dose of 24 Gy directed to the tumor margin at the 50% isodose line. Magnetic resonance imaging demonstrated tumor enlargement with central nonenhancement, which initially had been recognized 21 months after the second radiosurgery. Microsurgery was performed to achieve total removal of the tumor. Histological and immunohistochemical examinations of the facial nerve specimen removed from the edge of the tumor revealed a loss of axons, proliferation of Schwann cells, and microvasculitis. In this case, microvasculitis and axonal degeneration were probably the major causes of the radiation-induced facial neuropathy.

Primary epithelioid hemangioendothelioma originating in the lower petroclival region: case report.

BACKGROUND: We report the first case of primary epithelioid hemangioendothelioma (EH) originating in the lower petroclival region. CASE DESCRIPTION: A 55-year-old female presented with a 45-year history of subclinical atrophy on the right side of her tongue and a 15-year history of hoarseness. Neuroimaging revealed an expansile, homogeneously enhanced intraosseous mass with bony shell and honeycomb configuration in the petroclival region. A right far lateral transcondylar approach was utilized for subtotal removal of the tumor, which demonstrated high vascularity in the petroclival bone. Histopathological and immunohistochemical examination confirmed the diagnosis of EH. Because of the intermediate malignancy, adjuvant gamma knife radiotherapy was performed for the residual mass 5 months after surgery. CONCLUSION: EH rarely occurs in the skull base region. The appearance of surrounding bony structure and rich vascularity are important findings for the differential diagnosis. A far lateral transcondylar approach provides sufficient exposure of the jugular tubercle and lower clivus. Additional radiotherapy may be recommended for residual tumors with a high MIB-1 labeling index.