The spectrum of microvascular patterns in adult diffuse glioma and their correlation with tumor grade.

BACKGROUND: Primary brain tumors constitute the leading cause of cancer-related mortality. Among them, adult diffuse gliomas are the most common type, affecting the cerebral hemispheres and displaying a diffuse infiltrative pattern of growth in the surrounding neuropil that accounts for about 80% of all primary intracranial tumors. The hallmark feature of gliomas is blood vessel proliferation, which plays an important role in tumor growth, tumor biological behavior, and disease outcome. High-grade gliomas exhibit increased vascularity, the worst prognosis, and lower survival rates. Several angiogenic receptors and factors are upregulated in glioblastomas and stimulate angiogenesis signaling pathways by means of activating oncogenes and/or down-regulating tumor-suppressor genes. Existing literature has emphasized that different microvascular patterns (MVPs) are displayed in different subtypes of adult diffuse gliomas. METHODS: We examined the distribution and biological characteristics of different MVPs in 50 patients with adult diffuse gliomas. Haematoxylin and eosin staining results, along with periodic acid-Schiff and CD34 dual-stained sections, were examined to assess the vascular patterns and correlate with different grades of diffuse glioma. RESULTS: The present observational study on adult diffuse glioma evaluated tumor grade and MVPs. Microvascular sprouting was the most common pattern, while a bizarre pattern (type 2) was associated with the presence of a high-grade glioma. Vascular mimicry was observed in 6% of cases, all of which were grade 4 gliomas. CONCLUSIONS: This study supplements the role of neo-angiogenesis and aberrant vasculature patterns in the grading and progression of adult diffuse gliomas, which can be future targets for planning treatment strategies.

Endoscopy-Assisted Microneurosurgery for Sella and Optic Foramen Invading Anterior Cranial Fossa Base Meningiomas.

BACKGROUND: Anterior skull base meningioma produces symptoms as a result of mass effect and neurovascular compression. The bony anatomy of the anterior skull base is complex and houses the critical cranial nerves and vessels. Traditional microscopic approaches remove these tumors effectively but require extensive brain retraction and bone drilling. Endoscope assistance offers the advantages of a smaller incision, less brain retraction, and bone drilling. The most significant advantage of endoscope-assisted microneurosurgery for lesions invading the sella and optic foramen is the complete resection of the sellar and foraminal components frequently responsible for recurrence. OBJECTIVE: In this report, we describe the technique of endoscope-assisted microneurosurgical resection of anterior skull base meningiomas invading the sella and foramen. METHODS: We present 10 cases and 3 case examples of endoscope-assisted microneurosurgery for meningiomas invading the sella and optic foramen. This report presents the operating room setup and surgical details to resect sellar and foraminal tumors. The surgical procedure is presented as a video. RESULTS: Endoscope-assisted microneurosurgery yielded excellent clinical and radiologic results and no recurrence at the last follow-up of meningiomas invading the sella and optic foramen. The present article discusses the challenges faced with endoscope-assisted microneurosurgery, techniques, and challenges in the procedure. CONCLUSIONS: Endoscope assistance enables complete tumor excision under vision with less retraction and bone drilling in anterior cranial fossa meningioma, invading the chiasmatic sulcus, optic foramen, and sella. The mixed use of microscope and endoscope makes it safer and saves time and is like bringing out the best of both worlds.

Systematic scoping review of papilledema in vestibular schwannoma without hydrocephalus.

BACKGROUND: Vestibular schwannoma is a common pathology encountered by neurosurgeons worldwide. Often vestibular schwannoma presents with obstructive hydrocephalus. Papilledema is present in 8% of the patients with vestibular schwannoma, primarily due to obstructive hydrocephalus. Hyperproteinorrhachia is believed to be responsible for papilledema in the absence of hydrocephalus in vestibular schwannoma. However, there is a paucity of literature on the mechanism of papilledema in vestibular schwannoma patients with hydrocephalus. OBJECTIVE: The aim of this study was to conduct a scoping review of scientific literature on papilledema in vestibular schwannoma patients without hydrocephalus. METHODS: Design: This was a systematic scoping review and critical appraisal. Literature Search from PubMed was done following PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) and Joanna Briggs Institute guidelines for conducting and reporting scoping reviews. RESULTS: A total of seven studies, including eight patients, were identified for inclusion in the review. The studies were heterogeneous in terms of reporting for various variables. All the included studies were case reports, with the earliest publication in 1954 and the latest publication in 2020. The mean age of the patients in the included studies was 35 years, with a minimum age of 20 years and maximum age of 64 years. Approximately 62.5% were females, and 37.5% were males in the included study. Only three studies have studied cerebrospinal fluid (CSF) proteins levels in these patients. CONCLUSIONS: There is paucity in literature and a lack of evidence to conclusively state hyperproteinorrhachia as an antecedent to the development of papilledema in vestibular schwannoma patients without hydrocephalus. Younger age and female gender are risk factors for developing papilledema in the absence of hydrocephalus in vestibular schwannoma patients. Brainstem compression due to the large size of vestibular schwannoma can still have a patent aqueduct of Sylvius and no obstruction to CSF flow. The development of papilledema in vestibular schwannoma is a complex interplay of multiple factors that must be studied comprehensively for complete understanding.

Non-dysraphic extramedullary intradural spinal lipoma with neurocutaneous melanocytosis.

INTRODUCTION: Intradural spinal lipomas are very rare and constitute less than 1% of all spinal tumors. Such tumors are usually associated with spinal dysraphism and occur mostly in the lumbosacral or cervical region. Intradural spinal lipomas tends to be intramedullary or subpial. Meningeal melanocytoma is further rarer cases that comprise less than 0.1% of cases. These usually occur in the fifth or fifth decade and chances of malignant transformation are high. CASE REPORT: Here, we report an extremely rare case (first to the best of our knowledge) of a 9 years female child who presented to us with rapid progressing paraparesis. She was operated and found to have an intradural purely extramedullary spinal lipoma without spinal dysraphism. Moreover, she had melanin pigment deposits all over her meninges which is further rare. On presentation, the patient was bedridden but after surgery, the patient improved and could walk without support. CONCLUSIONS: To the best of our knowledge, this is the first case of spinal cord lipoma in dorsal location along with melanin pigments in the meninges. We discuss the pathogenesis, presentation and management of intradural extramedullary spinal lipomas.

Analysis of dynamic changes in optic nerve sheath diameter (ONSD) with ultrasound in post-craniotomy patients: Trends and correlation with computed tomography ONSD and Glasgow coma scale in post-operative period.

Objectives: Intracranial pressure (ICP) monitoring in patients with intracranial tumors undergoing craniotomy is usually done in perioperative period in intensive care unit. Invasive measurement of ICP, though considered as the gold standard, has its own limitations such as availability of expertise, equipment, and associated complications. Period of raised ICP in post-operative period may impact patient outcomes. Post-craniotomy computed tomography (CT) assessment is done routinely and may need to be repeated if indicated during post-operative stay. Utility of sonographic serial optic nerve sheath diameter (ONSD) assessment in post-operative monitoring of patients who have undergone elective craniotomy was explored in this study. The primary objective of the study was to measure the dynamic change in ONSD as compared to baseline pre-operative measurement in the first 3 postoperative days after elective craniotomy. The secondary objective of the study was to evaluate correlation between ONSD value with Glasgow Coma Scale (GCS) and post-operative CT findings. Materials and Methods: In this prospective, observational, and cohort study, we studied adult patients undergoing craniotomy for intracranial tumors. GCS assessment and sonographic measurement of ONSD were done preoperatively, immediate post-operative period, and 12, 24, and 48 h after surgery. CT scan to detect raised ICP was done at 24 h post-operative. Correlation of ONSD with GCS at respective period and correlation of CT scan finding with respective ONSD assessment were evaluated. Results: A total of 57 patients underwent elective craniotomy for intracranial tumors. Significant difference was observed in ONSD value depending on time of measurement perioperatively (χ2 = 78.9, P = 0.00). There was initial increase in the first 12 h followed by decrease in ONSD in the next 48 h. Negative correlation was observed between baseline ONSD and 12 h GCS (ρ = -0.345, P = 0.013). There was significant change in GCS scores based on the status of ONSD (raised or normal) at 12 h after surgery (P = 0.014). Significant correlation between USG ONSD and CT ONSD was observed (ρ = 0.928, P = 0.000). Optimal cutoff value of ONSD to detect raised ICP with reference to CT signs was 4.8 mm with 80% sensitivity and 95% specificity. Conclusion: ONSD undergoes dynamic changes, correlates with CT scan, and has good diagnostic accuracy to detect raised ICP post-craniotomy for intracranial tumors. It may serve as a useful tool in monitoring in resource-limited setup.

A Rare, yet Classic Case of Colloid Cyst of Third Ventricle.

Colloid cyst of third ventricle is a rare, benign, congenital lesion that usually presents with headache, and associated with altered cognition, nausea, vomiting, gait ataxia, and blurred vision. A large cyst/growing cyst can cause obstructive hydrocephalus leading to acute rapid neurological deterioration and sudden death. Here we report a classic clinical presentation and histopathological features of colloid cyst of third ventricle with specific emphasis on the importance of rapid diagnosis and management to avoid potentially fatal complications of this otherwise benign lesion. Newer modalities like neuroendoscopy or stereotactic aspiration of cyst are now the preferred choices of management. Awareness of this entity for early diagnosis and management with minimally invasive procedures such as neuroendoscopy or stereotactic aspiration of cyst is crucial for better prognosis and patient care.

Analysis of Giant Intraventricular and Extraventricular Epidermoids, Defining Risk Factors for Recurrence, an Institutional Experience.

BACKGROUND: Multicompartmental intraventricular epidermoids behave differently from multicompartmental extraventricular lesions and localized lesions during its management. Few studies are available which have analyzed risk factors separately in these groups of cases for recurrence of these lesions and time to recur. MATERIALS AND METHODS: In this retrospective observational study, 72 cases of intracranial epidermoid were treated over a span of 7 years. Cases were categorized into three groups. Group 1 comprised 15% (11/72) of cases with intraventricular multicompartmental, Group 2 with 22% (16/72) extraventricular giant tumors with multicompartmental involvement and size >4.5 cm, and Group 3 comprised 63% (45/72) of patients with lesions <4.5 cm and localized. Data pertaining to demography, clinical and radiological features, surgery performed, postoperative complication, histology, and follow-up were obtained from medical records available in the institute. RESULTS: The average duration to treat was 1.86 ± 0.52 (standard deviation [SD]) years, with headache as a major complaint in all the groups. Combined endoscope-assisted microsurgery was performed in 38.8% (28/72), microsurgery in 54.1% (39/72), and endoscopic excision in 6.9% (5/72) of cases. Tumor calcification was found in 23.6% (17/72) and preoperative capsular enhancement was seen in 19.4% (14/72) which persisted in 79% (11/14) of cases postoperatively on subsequent follow-up suggesting recurrence. On stepwise logistic regression analysis, preoperative capsular enhancement was a strong predictor of recurrence of tumor (P = 0.001). The average follow-up was 46 ± 14.92 (SD) months in Group 1, 52.34 ± 11.45 (SD) months in Group 2, and 63.36 ± 18.42 (SD) months in Group 3. CONCLUSION: Although the intracranial epidermoid is known to recur after long interval, tumor with specific characteristics can recur in short span of 5-6 years. Tumor characteristics such as preoperative capsular enhancement, multicompartmental distribution in vertebrobasilar territory, large size, and presence of calcification are strong predictors for recurrence. Performing endoscope-assisted microsurgery can decrease the postoperative morbidities but does not reduce the recurrence risk.

Endoscopic-Assisted Microsurgery for Vestibular Schwannomas: Operative Nuances.

Vestibular schwannoma surgery is a challenging operative procedure. Intricate anatomy of vital neurovascular structures demands a meticulous planning and execution. The cerebellopontine angle is an unforgiving area of skull bases surgery which can have grave implications on patient outcome even after a successful tumor removal. As more and more tumors are being detected at early stage, functional preservation of seventh and eighth nerve complex is increasingly being demanded. The key to any minimally invasive approach is to minimize the collateral damage while ensuring complete tumor removal. Binocular microscopy is the workhorse for illumination and dissection via retrosigmoid approach. However, as instrumentation has improved, endoscopic dissections are increasingly being performed. The following video presents the step-by-step nuances for an endoscope-assisted microsurgery for small vestibular schwannomas with stress on endoscopic drilling of the meatal wall to deliver out intracanacular tumor while preserving the labrynthine structures.

A scoping review to understand the indications, effectiveness, and limitations of cabergoline in radiological and biochemical remission of prolactinomas.

Cabergoline has long been used in the medical management of prolactin-secreting pituitary adenomas. However, there is contradicting and inadequate evidence on the efficacy of cabergoline in achieving radiological and biochemical remission in prolactinoma. This article presents scoping review of evidence in cabergoline achieving radiological and biochemical remission in cases of prolactinoma. We have used a recommended scoping review methodology to map and summarize existing research evidence and identify knowledge gaps. The review process was conducted according to the PRISMA-ScR guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews). The selection of studies was based on the criteria defined. Essential information such as reference details, study characteristics, topics of interest, main findings, and the study author's conclusion are presented in text and tables. With the study selection process, eight publications were finally included-one systematic review and meta-analysis, one RCT, and six primary studies. Cabergoline is effective in achieving biochemical and radiological remission in cases of prolactinoma. We identified several knowledge gaps with the scoping review and directions for future studies. Future studies, including randomized studies, will help address challenging questions associated with the management of prolactinoma.

Squash smear cytology of pituitary granular cell tumor: A case report and review of literature with special emphasis on cytological differential diagnosis in pituitary region.

Neurohypophysis granular cell tumor (NGCT) is a rare entity and is classified under thyroid transcription factor 1 (TTF-1) expressing tumors of pituitary. It is considered as an uncommon differential during sellar and suprasellar mass evaluation. Its intraoperative squash cytology is distinct and has rarely been reported in literature. A 65-year-old female presented with reduced vision of right eye and history of seizures. Radiological findings revealed a sellar/suprasellar mass with mass effect on optic chiasma. Intraoperative squash neurocytology examination showed a spindle cell lesion with abundant granular cytoplasm in tumor cells. Subsequent histopathology and immunohistochemistry confirmed the diagnosis of granular cell tumor. Granular cell tumor remains one of the sellar/suprasellar surprises. Its intraoperative neurocytology is unique and should be considered while evaluating a sellar/suprasellar mass. A case of sellar granular cell tumor with its intraoperative squash cytology, histopathology along with a review of literature is being presented with special emphasis on cytological differential diagnosis in pituitary region.

Anterior Transpetrosal Approach for Petroclival Meningioma: Operative Nuances.

Petroclival meningiomas are unique neurosurgical challenges that require planning an approach to the retrosellar and upper and mid retroclival locations. The classical subtemporal-transtentorial approach went into disrepute due to excessive brain retraction. To resolve this challenge Buchenek and Kukwa introduced extradural approach with drilling of the petrous bone and called it the extended middle fossa approach. It was Kawase et al who modified the extended middle fossa approach initially for dealing with basilar trunk aneurysms. This anterior transpetrosal approach has been described below for dealing with the petroclival meningiomas.