Ventral extradural spinal meningeal cyst causing cord compression: neurosurgical treatment

Spinal extradural meningeal cysts are typically formed by a thin fibrotic membranous capsule, macroscopically similar that of an arachnoid membrane, filled by cerebro spinal fluid and related to a nerve root or to the posterior midline. Ventral location is extremely rare and when it occurs they usually cause spinal cord herniation through the ventral dural gap. A 61 year-old man who began with a two years long history of insidious tetraparesis, spasticity and hyperreflexia in lower extremities, and flaccid atrophy of upper limbs, without sensory manifestations, is presented. Investigation through magnetic resonance imaging demonstrated an extensive spinal ventral extradural cystic collection from C6 to T11. The lesion was approached through a laminectomy and a cyst-peritoneal shunt was introduced. The cyst reduced in size significantly and the patient is asymptomatic over a 48 months follow-up. This is the first reported case of a spontaneous ventral extradural spinal meningeal cyst causing cord compression. Cyst-peritoneal shunt was effective in the treatment of the case and it should be considered in cases in which complete resection of the cyst is made more difficult or risky by the need of more aggressive surgical maneuvers.

Cistos meníngeos extradurais espinhais são formados tipicamente por estreita cápsula membranosa fibrótica, macroscopicamente semelhante a uma membrana de aracnóide, repleta de líquor e relacionada com uma raiz nervosa ou com a linha média posterior. Eles são extremamente raros em posição anterior e, quando ocorrem, habitualmente causam herniação da medula espinhal pela falha dural ventral. O caso de um homem de 61 anos de idade que iniciou com tetraparesia, espasticidade e hiperreflexia em membros inferiores, e flacidez com hipotrofia nos membros superiores, sem manifestação sensitiva, é apresentado. A investigação com ressonância magnética demonstrou extensa coleção cística extradural ventral à medula de C6 a T11. A lesão foi abordada diretamente via laminectomia com introdução de derivação cisto-peritoneal, reduzindo o cisto e tornando o paciente assintomático com um seguimento de 48 meses. Este é o primeiro caso relatado de cisto meníngeo extradural ventral espontâneo causando compressão medular. A derivação cisto-peritoneal se mostrou eficaz no tratamento do caso e deve ser considerada em situações em que a ressecção completa do cisto esteja impossibilitada, ou dificultada pela necessidade de manobras cirúrgicas mais agressivas e arriscadas.

[Meningiomas in pediatric patients: report of 2 cases]. / Meningiomas em pacientes pediátricos: relato de 2 casos.

Meningiomas correspond to 1% - 4% of primary intracranial tumors in pediatric group, with their incidence raising according to age. There is not gender prevalence, in spite of some authors describe a male tendency opposed to female one in adulthood. At present study we describe two cases of pediatric meningiomas reviewing clinical, radiological and histological aspects of these lesions. The authors review also treatment options and prognosis of childhood meningiomas. A two-year-old boy was admitted with seizures. Computerized tomography showed a right parietal lesion, which was totally resected. Histological features were compatible with meningioma. After 17 months the child is doing well, with no deficits or seizures. The second case is a 12-year-old girl, with a headache complain. During investigation, a CT revealed a right frontal lesion. She was operated under a right frontal craniotomy with total tumor resection. Nowadays she is asymptomatic, 20 months after surgery. Despite meningiomas in pediatric group are uncommon; they should be included in differential diagnosis list of expansive intracranial lesions of childhood.

Bilateral pallidotomy for generalized dystonia.

OBJECTIVE: To evaluate the efficacy and safety of bilateral pallidotomies in five patients with generalized dystonia. BACKGROUND: Generalized dystonias are frequently a therapeutic challenge, with poor responses to pharmacological treatment. GPi (globus pallidus internus) pallidotomies for Parkinson's disease ameliorate all kinds of dyskinesias/dystonia, and recent studies reported a marked improvement of refractory dystonias with this procedure. METHODS: Five patients with generalized dystonias refractory to medical treatment were selected; one posttraumatic and four idiopathic. The decision to perform bilateral procedures was based on the predominant axial involvement in these patients. Dystonia severity was assessed with the Burke-Fahn-Marsden Dystonia Scale (BFM). Simultaneous procedures were performed in all but one patient, who had a staged procedure. They were reevaluated with the same scale (BFM) by an unblinded rater at 1, 2, 3, 30, 60, 90, 120 and 180 days post-operatively. RESULTS: The four patients with idiopathic dystonia showed a progressive improvement up to three months; the patient with posttraumatic dystonia relapsed at three months. One patient had a marked improvement, being able to discontinue all the medications. A mean decrease in the BFM scores of 52,58% was noted. One patient had a trans-operative motor seizure followed by a transient hemiparesis secondary to rack hemorrhage; other was lethargic up to three days after the procedure. CONCLUSIONS: Our results show that bilateral GPi pallidotomies may be a safe and effective approach to medically refractory generalized dystonias; it can also be speculated that the posttraumatic subgroup may not benefit with this procedure.

[Spinal cord ganglioglioma: case report]. / Ganglioglioma da medula espinhal: relato de caso.

Gangliogliomas are rare tumors of the CNS, representing only 2.7-3.8% of primary tumors of the CNS, and the intramedullary location accounts 7.6-14.3% of cases. The main goal of treatment is the total resection, preserving as much as possible the patients neurological function. Adjuvant therapy as radiotherapy is reserved to cases of progression of disease after surgery or in such lesion with more aggressive biological behavior. In this article we report the case of a patient with a intramedullary ganglioglioma involving spinal levels T5 to T10, who was operated in our service, and we review the literature analyzing various aspects, including the modalities of treatment which can be used in this kind of lesion.

Pleomorphic xanthoastrocytoma: report of a case diagnosed by intraoperative cytopathological examination.

The authors present an unusual case of a 13-yr-old boy with a 3-mo history of seizures. A CT scan showed a contrast-enhancing mass located in the left temporal lobe. The patient underwent a stereotatic-guided craniotomy; intraoperative cytological diagnosis was performed by the smear technique, showing a pleomorphic xanthoastrocytoma. The tumor was totally resected. Definitive diagnosis was established by examination of paraffin-embedded material. Six months after the surgical intervention, the patient is doing well, with no radiological evidence of recurrence. The cytological differential diagnosis of giant cell lesions of the central nervous system is emphasized.

Radiosurgery and stereotactic radiation therapy of skull base meningiomas: proposal of a grading system.

OBJECTIVE: The development of a grading system to guide treatment selection, and predict treatment difficulty and outcome of skull base meningiomas infiltrating the cavernous sinus which are managed by stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT), based on an 8-year experience with stereotactic radiation of skull base meningiomas. METHODS: T1 gadoliniun-enhanced magnetic resonance imaging (MRI) of 40 patients with skull base meningiomas, with or without prior surgery, who underwent radiosurgery or stereotactic radiation therapy from 1991 to 1998 at the UCLA Medical Center were reviewed, and the result of treatment was related to the tumor grade. Grade was based on tumor infiltration of the cavernous sinus and extension into adjacent structures. Treatment was performed with a linac-based system. The dose prescribed to the periphery of the tumor for SRS patients (n = 34) ranged from 12 to 22 Gy, and the maximum dose delivered to the tumor ranged from 24 to 46 Gy. SRT (n = 6). Treatment was planned using a single isocenter, usually prescribed to the 90% isodose volume, bringing the fractionation scheme to the maximal tolerance of the optic apparatus. The periphery dose ranged from 24 to 46 Gy with a maximum dose of 45 to 51 Gy. Clinical and MRI follow-up was performed every six months for the first 3 years and every year thereafter. RESULTS: Grade I meningiomas were restricted to the cavernous sinus (n = 12). Grade II cavernous sinus meningiomas extended to the clivus and/or the petrous bone, without compression of the brainstem (n = 9). Grade III meningiomas had superior and/or anterior extension with compression of the optic nerve or tract (n = 9). Grade IV tumors compressed the brain stem (n = 8), and Grade V were bilateral lesions (n = 2). Tumor control rates were 90% for Grade I, 86% for Grade II, 86% for Grade III, 42% for Grade IV and no control for tumors Grade V. Complications were not related to tumor grade. CONCLUSION: This grading system correlated with outcome and difficulty in planning radiosurgery. Failure of treatment was more likely to occur in patients with higher Grade tumors.