Surgical resection of gliomas in the dominant inferior frontal gyrus: Consecutive case series and anatomy review of Broca's area.

INTRODUCTION: There is a general lack of consensus on both anatomic definition and function of Broca's area, often localized to the pars triangularis (pT) and pars opercularis (pOp) of the left inferior frontal gyrus (IFG). Given the belief that this region plays a critical role in expressive language functions, resective surgery is often avoided to preserve function. However, the putative role of Broca's area in speech production has been recently challenged. The current study aims to investigate the plausibility of glioma resection and neurological outcomes in "Broca's area". METHODS: We report a single-surgeon, consecutive case series feasibility study describing the resection of gliomas within the IFG. Presentation, mapping, functional outcome, and extent of resection variables were considered for analysis. RESULTS: All included patients had tumors located in the traditional "Broca's area", eight (53.33 %) additionally extending into the insular and subinsular regions. All patients except for one, presented with speech-language deficits preoperatively. Awake brain surgery for tumor resection with direct cortical and subcortical stimulation and intraoperative neuropsychological evaluation was carried out in all individuals. During stimulation, positive speech-language sites within the IFG were identified in ten patients. Two patients (13.33 %) experienced a decline in naming during intraoperative cognitive monitoring and thirteen (86.66 %) had a stable performance throughout surgery. At two-week follow-up, all patients had recovery of language functions compared to initial presentation. Overall extent of resection (EOR) was 60.35 % ( ± 29.60) with residual tumor being the greatest within the insular and subinsular areas. EOR was stratified in anatomical regions within the IFG, being the pOr the area with the greatest EOR (97.4 %), followed by the pT (84.1 %), pOp (83.8 %), and vPMC (80 %). CONCLUSION: The belief that Broca's area is not safe to resect is challenged. Adequate mapping and careful patient selection allow maximum safe resection of tumors located in the traditional "Broca's area", with low risk of postoperative morbidity.

Temporal pole blurring in temporal lobe epilepsy revealed by 3D Edge-Enhancing Gradient Echo MRI.

While abnormalities of the hippocampus have been well characterized in temporal lobe epilepsy, various additional temporal lobe abnormalities have also been described. One poorly understood entity, the so-called temporal pole blurring (TPB), is one of the more frequently described neocortical abnormalities in TLE and is thought to represent dysmyelination and axonal loss due to chronic electrical perturbations in early age-onset temporal lobe epilepsy. In this study, we describe the first reported cases of TPB diagnosed by a recently described MRI sequence known as 3D Edge-Enhancing Gradient Echo (3D-EDGE), which has an effective "myelin weighting" making it exquisitely sensitive to this temporal pole dysmyelination. The value of detection of TPB lies in lateralizing seizure onset, as well as predicting a lower baseline neuropsychological performance compared to temporal lobe epilepsy without TPB. Additionally, it is critical to not mistake TPB for alternative diagnoses, such as focal cortical dysplasia or neoplasm.

Improved detection of focal cortical dysplasia using a novel 3D imaging sequence: Edge-Enhancing Gradient Echo (3D-EDGE) MRI.

Epilepsy is a common neurological disorder with focal cortical dysplasia (FCD) being one of the most common lesional causes. Detection of FCD by MRI is a major determinant of surgical outcome. Evolution of MRI sequences and hardware has greatly increased the detection rate of FCD, but these gains have largely been related to the more visible Type IIb FCD, with Type I and IIa remaining elusive. While most sequence improvements have relied on increasing contrast between gray and white matter, we propose a novel imaging approach, 3D Edge-Enhancing Gradient Echo (3D-EDGE), to directly image the gray-white boundary. By acquiring images at an inversion time where gray and white matter have equal signal but opposite phases, voxels with a mixture of gray and white matter (e.g., at the gray-white boundary) will have cancellation of longitudinal magnetization producing a thin area of signal void at the normal boundary. By creating greater sensitivity for minor changes in T1 relaxation, microarchitectural abnormalities present in FCD produce greater contrast than on other common MRI sequences. 3D-EDGE had a significantly greater contrast ratio between lesion and white matter for FCD compared to MP2RAGE (98% vs 17%; p = 0.0006) and FLAIR (98% vs 19%; p = 0.0006), which highlights its potential to improve outcomes in epilepsy. We present a discussion of the framework for 3D-EDGE, optimization strategies, and analysis of a series of FCDs to highlight the benefit of 3D-EDGE in FCD detection compared to commonly used sequences in epilepsy.

Lipoma of the Larynx and Other Differential Diagnoses.

Fatty lesions in the head and neck region are uncommon but can present in any subsite, including rarely the larynx. Most commonly, the fatty lesion is a benign lipoma and an incidental finding as in this case. However, the lesion must be differentiated from other fatty lesions such as liposarcoma, lipoblastoma, and hibernoma. Accurate diagnosis on imaging can prevent unnecessary biopsy and more importantly worry for the patient. We report a case of an incidental lipoma within the vocal folds of the larynx.

Klippel-Trenaunay-Weber Syndrome with Atypical Presentation of Cerebral Cavernous Angioma: A Case Report and Literature Review.

BACKGROUND: Klippel-Trenaunay-Weber syndrome (KTWS) is a rare syndrome characterized by the triad of cutaneous hemangiomas, venous varicosities, and osseous-soft tissue hypertrophy of the affected limb. Clinical manifestations, genetic testing, and radiologic imaging are the key steps in diagnosing this syndrome. CASE DESCRIPTION: An 18-month-old boy was brought for follow-up brain magnetic resonance imaging (MRI) with a history of right lower limb hypertrophy, cutaneous varicosities, and hemangiomas diagnosed at birth. A baseline MRI at 12 months revealed multiple hemorrhagic lesions within the cerebrum, the largest in the right temporal lobe, which was treated surgically at the age of 18 months because of its rapid growth. This is the youngest patient with KTWS treated surgically for intracranial hemangiomas. CONCLUSION: KTWS is a rare disease with a wide range of manifestations. Multisystemic evaluation of this group of patients should be performed to identify cavernous hemangiomas at the early stage of life and adequately treat them in the future. Treatment of KTWS patients with cavernous hemangiomas should not be different from the treatment of patients with any other hemangiomas, and surgical intervention should be considered on a case-to-case bases.

Ectopic pituitary adenomas: common presentations of a rare entity.

PURPOSE: Ectopic pituitary adenomas (EPA) are rare tumors thought to arise from embryological remnants along the route of normal pituitary migration. Clinically, these tumors vary in hormonal activity and can exert mass effect based on location and size. METHODS: We performed a single-center retrospective analysis of patients with diagnosis of ectopic pituitary adenoma from 2001 to 2018. RESULTS: Five patients were identified with EPA: a 48-year-old woman with suprasellar EPA treated with transsphenoidal removal of the tumor, a 44-year-old woman with cavernous EPA treated with transsphenoidal removal of the tumor, a 48-year-old woman with sphenoid EPA treated with cabergoline, a 45-year-old man with clival EPA treated with cabergoline and transsphenoidal surgical resection, and a 54-year-old man with clival EPA treated with cabergoline therapy. CONCLUSIONS: EPA should be considered as a differential diagnosis of juxta-sellar lesions. Appropriate hormonal testing may lead to early diagnosis, avoidance of unnecessary biopsy or surgery, and improved outcomes.

Trigeminal Neuralgia Caused by Dural Arteriovenous Fistula in Meckel Cave Treated with Gamma Knife Radiosurgery.

BACKGROUND: Classic trigeminal neuralgia is an often debilitating condition that frequently results from vascular compression at the root entry zone of the trigeminal nerve. We report a case of dural arteriovenous fistula surrounding the trigeminal nerve from near the root entry zone extending as far ventral as the Meckel cave treated solely with Gamma Knife radiosurgery. CASE DESCRIPTION: A 71-year-old woman presented with a history of persistent attacks of right facial pain after failed conservative management. Magnetic resonance imaging of the brain demonstrated dilated vasculature in the right cerebellopontine angle, and diagnostic cerebral angiography revealed a dural arteriovenous fistula surrounding the right trigeminal nerve. Stereotactic radiosurgery using Gamma Knife was performed. At 6-month follow-up, she was symptom-free with decreased caliber of abnormal vascularity surrounding the trigeminal nerve on magnetic resonance imaging. CONCLUSIONS: This case suggests that trigeminal neuralgia associated with dural arteriovenous fistula can potentially be treated with Gamma Knife radiosurgery; however, more extensive studies and long-term follow-up to evaluate vessel patency will be necessary to elucidate further the role of stereotactic radiosurgery alone in treating this entity.