Endoscopic biopsy of pineal tumors: two burr hole trans-foramen of Monro approach and endonasal trans-tuber cinereum approach.

INTRODUCTION: The pineal region is a challenging area for neurosurgeons due to its innate anatomical features, such as its deep location, surrounding large draining veins, and adjacent critical neural structures. DISCUSSION: There is a high proportion of malignant tumors in the pineal gland, especially in children, and they are frequently accompanied by obstructive hydrocephalus. These cases require that surgical procedures can make a pathological diagnosis to guide further treatment strategies and immediately resolve increased intracranial pressure. Simultaneous endoscopic third ventriculostomy and biopsy have been regarded as the first-line surgical intervention before establishing a definite treatment plan. However, it is not always successful because various factors affect the surgical procedures, such as the location and extent of the tumor, degree of ventriculomegaly, location and size of the massa intermedia, and size of the foramen of Monro. CONCLUSION: Here, we briefly reviewed the points to be considered in endoscopic biopsy of pineal tumors and introduced an alternative surgical procedure, the endoscopic endonasal trans-tuber cinereum approach, to surmount the anatomical hurdles.

Case Report: Lipoma of the Tuber Cinereum Mimicking a Pituitary Gland Abnormality in a Girl With Central Precocious Puberty.

Introduction: Magnetic Resonance Imaging (MRI) is the best approach to investigate the hypothalamic-pituitary region in children with central precocious puberty (CPP). Routine scanning is controversial in girls aged 6-8 year, due to the overwhelming prevalence of idiopathic forms and unrelated incidentalomas. Cerebral lipomas are rare and accidental findings, not usually expected in CPP. We report a girl with CPP and an unusually shaped posterior pituitary gland on SE-T1w sequences. Case Description: A 7.3-year-old female was referred for breast development started at age 7. Her past medical history and physical examination were unremarkable, apart from the Tanner stage 2 breast. X-ray of the left-hand revealed a bone age 2-years ahead of her chronological age, projecting her adult height prognosis below the mid parental height. LHRH test and pelvic ultrasound were suggestive for CPP. Routine brain MRI sequences, SE T1w and TSE T2w, showed the posterior pituitary bright spot increased in size and stretched upward. The finding was considered as an anatomical variant, in an otherwise normal brain imaging. Patient was started on treatment with GnRH analogue. At a thorough revaluation, imaging overlap with adipose tissue was suspected and a new MRI scan with 3D-fat-suppression T1w-VIBE sequences demonstrated a lipoma of the tuber cinereum, bordering a perfectly normal neurohypophysis. 3D-T2w-SPACE sequences, acquired at first MRI scan, would have provided a more correct interpretation if rightly considered. Conclusion: This is the first evidence, to our knowledge, of a cerebral lipoma mimicking pituitary gland abnormalities. Our experience highlights the importance of considering suprasellar lipomas in the MRI investigation of children with CPP, despite their rarity, should the T1w sequences show an unexpected pituitary shape. 3D-T2w SPACE sequences could be integrated into standard ones, especially when performing MRI routinely, to avoid potential misinterpretations.

Symptomatic osteolipoma of the tuber cinereum masquerading as calcified retroclival mass.

We present a case of symptomatic osteolipoma of the tuber cinereum in a 51 year old male with rapid visual deterioration over several months leading to bilateral visual loss. Preoperatively the lesion masqueraded as a calcified retroclival mass. Intracranial osteolipomas are rare benign lesions that are usually asymptomatic and have an indolent course. Additionally, we discuss our intraoperative findings highlighting the technical challenges encountered along with a review of the English language literature on histologically proven intracranial osteolipomas.

Precocious puberty produced by an osteolipoma of the tuber cinereum.

Central precocious puberty (CPP) is fairly common in girls. In most girls, the etiology for the CPP is unknown. Among the more rare causes of CPP in girls are central nervous system tumors and hamartomas. Osteolipoma of the tuber cinereum, which is the most commonly diagnosed at autopsy, has been reported as a cause of CPP. We describe an 8-year-old girl with central precocious puberty in whom MRI demonstrated a lesion compatible with osteolipoma. Her symptom was breast development that begun at age 7 years and 9 months. Her case history, laboratory studies and imaging are presented. Her puberty was rapidly progressive. She was treated successfully with a GnRHa (Triptorelin 3.75 mg IM q 4 weeks). Her case brings to the forefront the need to perform an MRI in children with rapidly progressing puberty.

Sudden death due to a colloid cyst of the third ventricle: report of three cases with a special sign at autopsy.

Colloid cysts of the third ventricle are rare benign cysts but they may be potentially life-threatening. Three cases of sudden death resulting from colloid cysts of the third ventricle are presented. The first and second cases were treated for migraine headaches. In the first case, the patient was a 24-year-old woman who presented to the hospital with a severe headache and was sent back home after medical treatment. Six hours later, she was found dead in her bed. The second case was a 21-year-old woman who experienced a severe headache, dizziness and vomiting 1 day prior to her death. She was transported to the hospital, where she was pronounced dead upon arrival. The third case was a 25-year-old man who experienced headaches and vomiting and was diagnosed with and medically treated for sinusitis. He lost consciousness and was taken to hospital, where he was pronounced dead on arrival. During the autopsy of all three cases, there was a grey transillumination area observed that occurred due to the stretching of tissue at the base of brain between the corpus mamillare and chiasma opticum. Dissection of the brain revealed a colloid cyst of the third ventricle. To avoid such fatal complications, prompt diagnosis using CT or MRI is essential in patients who have a long-standing history of intermittent headaches. During the autopsy of the sudden deaths of people with medical antecedents of headaches, if a grey color is observed between the chiasma opticum and the corpus mamillare in the base of the brain, a colloid cyst should be considered and this region should be dissected and examined carefully.

Intratentorial osteochondrolipoma in a 9-year-old boy.

Intracranial osteolipomas and chondromas are rare benign tumors. Forty-five chondromas, mostly supratentorial, have been reported in the literature since 1981, with origins most commonly in the sellar regions. Twenty-one osteolipomas have been described to date, usually located near the tuber cinereum or the corpus callosum. The authors present a case of an osteochondrolipoma arising from the tentorium diagnosed in a pediatric patient at the age of 9 years. The case and treatment are discussed, and a review of the literature is provided.

Variations of endoscopic ventricular anatomy in children suffering from hydrocephalus associated with myelomeningocele.

Thirty-four patients less than 4 months old and suffering from hydrocephalus associated with myelomeningocele (MM) underwent endoscopic surgery to treat the hydrocephalus. The myelomeningocele was treated prior to our surgical intervention. We have found that different endoscopic anatomies of the ventricles exist between patients.

MR imaging and spectroscopy of a tuber cinereum hamartoma in a patient with growth hormone deficiency and hypogonadotropic hypogonadism.

To our knowledge, this is the first report of hypogonadotropic hypogonadism, or growth hormone deficiency, in a patient without non-Pallister-Hall syndrome who had hypothalamic hamartoma diagnosed on the basis of MR imaging and MR spectroscopy findings. On short-TE proton MR spectra, the N-acetylaspartate concentration in the hamartoma was lower than that in the thalamus but similar to that in the amygdala. However, myo-inositol concentration was elevated in the hamartoma compared with that in the amygdala and thalamus. This report stresses the advantages of short-TE spectroscopy and demonstrates that regional variations in spectra should be considered when reference structures are used.

Symptomatic osteolipoma of the tuber cinereum. Case report.

The authors present a case of an ossified lipoma located at the tuber cinereum. Intracranial osteolipomas are rare lesions that occur in the region of the tuber cinereum. Almost all reported cases have been incidental autopsy findings. This report, however, involves a young girl who presented with an ovarian cyst and signs of precocious puberty, in whom a typical osteolipoma was surgically removed. This is the first case of hypothalamic osteolipoma presenting with endocrinological disturbances that has been published to date.

Hamartoma of the suprasellar cistern in a 5-year-old girl.

A 5-year-old girl with precocious puberty secondary to a suprasellar hamartoma is presented. Magnetic resonance imaging (MRI) revealed a lesion without attachment to the tuber cinereum or the mamillary bodies. Total resection of the tumour was performed.

Hypothalamic osteolipoma: a case report.

The authors present a case of an ossified lipoma at tuber cinerum, an incidental finding when performing an autopsy of a 61-year old male. A tight connection to right communicans posterior artery led first to the diagnosis of a calcified saccular aneurysm, but histologic examination revealed an osteolipoma consisting of mature adipose tissue and formation of bone. Intracranial lipomas are neither hamartomas nor true neoplasms, but they are more likely to be congenital malformations. The recent literature is reviewed, and the two most current embryologic concepts of the development of intracranial lipomas are discussed.