Primary intracranial intraventricular leiomyoma: a literature review.

Leiomyomas, benign tumors of well-differentiated smooth muscle and vascular collagenous tissue, usually occur in the uterus but can develop wherever smooth muscle is present. Primary intracranial leiomyomas are rare tumors. We present the case of a 40-year-old woman with a primary intraventricular leiomyoma. She consulted us for headache, dizziness, and black spots in her vision. Magnetic resonance images (MRI) disclosed a mass rooted in the posterior septum pellucidum. The tumor was totally excised by the senior author with no residual seen on intraoperative MRI. Pathological examination showed it to be a benign spindle-cell neoplasm. On the 6th month control MRI, there was no recurrence. We also reviewed articles relevant to primary intracranial leiomyomas.

Hypothalamitis: A Novel Autoimmune Endocrine Disease. A Literature Review and Case Report.

CONTEXT: The relationship between the endocrine system and autoimmunity has been recognized for a long time and one of the best examples of autoimmune endocrine disease is autoimmune hypophysitis. A better understanding of autoimmune mechanisms and radiological, biochemical, and immunological developments has given rise to the definition of new autoimmune disorders including autoimmunity-related hypothalamic-pituitary disorders. However, whether hypothalamitis may occur as a distinct entity is still a matter of debate. EVIDENCE ACQUISITION: Here we describe a 35-year-old woman with growing suprasellar mass, partial empty sella, central diabetes insipidus, hypopituitarism, and hyperprolactinemia. EVIDENCE SYNTHESIS: Histopathologic examination of surgically removed suprasellar mass revealed lymphocytic infiltrate suggestive of an autoimmune disease with hypothalamic involvement. The presence of antihypothalamus antibodies to arginine vasopressin (AVP)-secreting cells (AVPcAb) at high titers and the absence of antipituitary antibodies suggested the diagnosis of isolated hypothalamitis. Some similar conditions have sometimes been reported in the literature but the simultaneous double finding of lymphocytic infiltrate and the presence of AVPcAb so far has never been reported. CONCLUSIONS: We think that the hypothalamitis can be considered a new isolated autoimmune disease affecting the hypothalamus while the lymphocytic infundibuloneurohypophysitis can be a consequence of hypothalamitis with subsequent autoimmune involvement of the pituitary. To our knowledge this is the first observation of autoimmune hypothalamic involvement with central diabetes insipidus, partial empty sella, antihypothalamic antibodies and hypopituitarism.

Microneurosurgical removal of thalamic lesions: surgical results and considerations from a large, single-surgeon consecutive series.

OBJECTIVE: The object of this study was to present the surgical results of a large, single-surgeon consecutive series of patients who had undergone transcisternal (TCi) or transcallosal-transventricular (TCTV) endoscope-assisted microsurgery for thalamic lesions. METHODS: This is a retrospective study of a consecutive series of patients harboring thalamic lesions and undergoing surgery at one institution between February 2007 and August 2019. All surgical and patient-related data were prospectively collected. Depending on the relationship between the lesion and the surgically accessible thalamic surfaces (lateral ventricle, velar, cisternal, and third ventricle), one of the following surgical TCi or TCTV approaches was chosen: anterior interhemispheric transcallosal (AIT), posterior interhemispheric transtentorial subsplenial (PITS), perimedian supracerebellar transtentorial (PeST), or perimedian contralateral supracerebellar suprapineal (PeCSS). Since January 2018, intraoperative MRI has also been part of the protocol. The main study outcome was extent of resection. Complete neurological examination took place preoperatively, at discharge, and 3 months postoperatively. Descriptive statistics were calculated for the whole cohort. RESULTS: In the study period, 92 patients underwent surgery for a thalamic lesion: 81 gliomas, 6 cavernous malformations, 2 germinomas, 1 metastasis, 1 arteriovenous malformation, and 1 ependymal cyst. In none of the cases was a transcortical approach adopted. Thirty-five patients underwent an AIT approach, 35 a PITS, 19 a PeST, and 3 a PeCSS. The mean follow-up was 38 months (median 20 months, range 1-137 months). No patient was lost to follow-up. The mean extent of resection was 95% (median 100%, range 21%-100%), and there was no surgical mortality. Most patients (59.8%) experienced improvement in their Karnofsky Performance Status. New permanent neurological deficits occurred in 8 patients (8.7%). Early postoperative (< 3 months after surgery) problems in CSF circulation requiring diversion occurred in 7 patients (7.6%; 6/7 cases in patients with high-grade glioma). CONCLUSIONS: Endoscope-assisted microsurgery allows for the removal of thalamic lesions with acceptable morbidity. Surgeons must strive to access any given thalamic lesion through one of the four accessible thalamic surfaces, as they can be reached through either a TCTV or TCi approach with no or minimal damage to normal brain parenchyma. Patients harboring a high-grade glioma are likely to develop a postoperative disturbance of CSF circulation. For this reason, the AIT approach should be favored, as it facilitates a microsurgical third ventriculocisternostomy and allows intraoperative MRI to be done.

Endoscope-Assisted Contralateral Perimedian Supracerebellar Suprapineal Approach to Third Ventricle Surface of the Thalamus: 3-Dimensional Operative Video.

In managing thalamic gliomas, total surgical removal is the most effective way of increasing overall survival. However, the thalamus is a difficult target because of surrounding neurovascular structures. According to the lesion's size/location/growth pattern, relation to neighboring structures, and surgeon's experience, most thalamic lesions can be reached through one of the 4 free surfaces: lateral ventricle, velar, cisternal, and third ventricle surfaces of the thalamus (3VsT).1-3 Approaching the thalamic lesions through the lateral side disrupts the integrity of internal capsule and corona radiata; thus, we never prefer this approach. For the removal of the lesions on the 3VsT, a transcallosal approach can be considered, but with this approach, we cannot reach 3VsT without harming the velar surface. In this 3-dimensional video, we demonstrate an endoscope-assisted contralateral perimedian supracerebellar suprapineal (CPeSS) approach to a glioma on the 3VsT. The patient, a 49-yr-old man, had progressive dizziness for a month. With the patient in a semisitting position, total resection was achieved via the endoscope-assisted CPeSS approach. This approach is entirely transcisternal-transventricular and is a natural route to the 3VsT. Although the route is longer than the ipsilateral approach, it requires no retraction and provides more direct and wider visualization. It allows complete visualization of the lateral border of the lesion. A perimedian approach also avoids the major tentorial bridging veins, which are mostly at the midline. High-definition neuroendoscope was a great adjunct that helped to visualize residual tumors at hidden corners. We suggest this approach for thalamic lesions on the third ventricle surface of the thalamus. The patient consented to the publication of his images and a written consent was obtained.

Microneurosurgical Removal of a Globus Pallidus Tumor With Cottonoid-Guided Intraoperative Ultrasonography: 2-Dimensional Operative Video.

Neuronavigation systems are standard for guiding neurosurgery. Intraoperative-ultrasonography (ioUSG), a real-time neuronavigation modality used for 40-yr in neurosurgery, is easily available, low cost, and does not require excessive preparation. It provides accurate real-time data, even after brain shift. However, even with ioUSG, defining the surgical trajectory is not easy, especially for deep-seated lesions. We used a cottonoid-patty as a marker for ioUSG to define the location of the lesion and best trajectory for safe removal, especially of deep-seated lesions. After obtaining the patient's consent, we report the case of a 10-yr-old male who presented with a 2-mo history of right hemiparesis, gait disturbance, and right central facial paresis from a left-sided globus pallidus tumor. We chose a contralateral approach because of the cortical venous anatomy, nondominant right hemisphere, and right-handed surgeon. After a right parasagittal frontal craniotomy and interhemispheric exploration, a cottonoid-patty was placed as a marker for ioUSG to determine the callosotomy location. To confirm the route, ioUSG was repeated with a second cottonoid-patty placed inside the incision at the lateral side of the thalamostriate and anterior caudate vein junction. After confirming the trajectory, the tumor was removed with microneurosurgical techniques. Total removal was confirmed with ioUSG and intraoperative-magnetic resonance imaging. Early postoperative examination revealed improved muscle strength on the right hemiparetic side. Histopathological studies revealed a mixed germ-cell tumor. ioUSG is an efficient and accurate neuronavigation modality. Using a cottonoid-patty as a marker for ioUSG is valid and reliable in determining the surgical route, especially for deep-seated midline tumors.

The Use of Osirix for Surgical Planning Using Cranial Measures and Region of Interest Tools: Technical Note.

BACKGROUND: During the surgery for intrinsic brain lesions, it is important to plan the proper site of the craniotomy and to identify the relations with the gyri and superficial veins. This might be a challenge, especially in small subcortical lesions and when there is a distortion of the cortical anatomy. MATERIALS AND METHODS: Using the free computer software Osirix, we have created a 3-dimensional reconstruction of the head and cerebral showing the gyri and superficial veins. With the aid of some tools, it is possible to create a colored image of the lesion and also to calculate the distance between the areas of interest and some easily identifiable structure, making it easier to plan the site of the craniotomy identify the topography of the lesion. RESULTS: The reconstructions were compared to the intraoperative view. We found this technique to be useful to help identify the gyri and cortical veins and use them to find the lesions. The use of a region of interest to show better the lesion under the cortical surface and in the three-dimensional reconstruction of the head was also helpful. CONCLUSIONS: This is a low-cost and easy technique that can be quickly learned and performed before every surgery. It helps the surgeon to plan a safe craniotomy and lesionectomy.

Microneurosurgical Removal of a Cervical Intramedullary Tumor Via Hemilaminoplasty: 3-Dimensional Operative Video.

Intramedullary tumors of the spinal cord are rare and account for 2% to 8.5% of all central nervous system tumors. In adults, ependymomas are the most common intramedullary tumors. The primary choice of treatment should be radical surgical removal, as this is curative for most tumors. Adequate tumor exposure is crucial and mostly achieved through standard laminectomy followed by midline myelotomy. However, extensive removal of posterior spinal elements may lead to worsening kyphotic deformities. After obtaining patient consent, this 3-dimensional video publication was prepared to present microneurosurgical removal of a C3-C6 cervical intramedullary tumor using right-sided hemilaminoplasty. C3-C6 hemilaminae were lifted en bloc. After dural and arachnoid incision, midline myelotomy was performed. Using microneurosurgical technique, the tumor was removed totally. After the dural closure, C3-C6 hemilaminae were placed into the previous position and reconstructed with mini-plates and screws. Preserving contralateral paraspinal muscles, spinous processes, midline spinal ligaments and bilateral facet joints helped maintaining the alignment of the spinal column. Comparing to laminectomy, hemilaminoplasty, decreases the postoperative pain and the total blood loss as only one side muscle dissection is enough. In the presented case, postoperative MRI showed total removal of the tumor. The final histopathology report indicated an ependymoma (WHO-Grade 2). Successful bone healing was demonstrated by postoperative cervical radiographs and CT scans. The patient has no postoperative neurological deficit. In conclusion, hemilaminoplasty is an effective and a less-invasive method in removal of intradural-intramedullary tumors with its advantages such as preventing the instability and reduction of blood loss and postoperative pain.

Cisterna magna reconstruction with arachnoid suturing in brainstem surgery.

We present an effective and easily applied technique for cisterna magna reconstruction with arachnoid suturing in brainstem surgery. Suturing with 10-0 monofilament was done in a patient with a medulla oblongata hemangioblastoma (diagnosed von Hippel-Lindau disease). Seven years later, follow-up imaging revealed a new lesion close to the previous one and the patient underwent reoperation. The craniotomy and dural incision were repeated, and the intact arachnoid was visualized with no meningocerebral adhesions. This technique preserves normal anatomic landmarks and facilitates and shortens dissection in reoperations, almost like a virgin case. We propose this technique for every lower brainstem and fourth ventricle procedure. The video can be found here: https://youtu.be/RKMcSoK6ycY.

Pontine cavernous malformation: microsurgery evading the floor of the fourth ventricle.

This video demonstrates resection of a left pontine cavernous malformation that is abutting the floor of the fourth ventricle (f4V). Even though accessing the lesion through the f4V seems to be reasonable, we used a lateral supracerebellar approach through the middle cerebellar peduncle to preserve especially the abducens and facial nuclei. After total resection the patient was neurologically intact at the 3-month follow-up. Postoperative MRI revealed 3.5-mm pontine tissue between the cavity and f4V that appeared to be absent in preoperative MRI. Approaching pontine lesions through the f4V is not the first choice. In our opinion, the philosophy of safe entry zones is a concept to be reassessed. The video can be found here: https://youtu.be/1Jh6giZc-48.

The paramedian supracerebellar-transtentorial approach to remove a posterior fusiform gyrus arteriovenous malformation.

This is the case of a 14-year-old female who presented with headache and seizures. Cranial magnetic resonance imaging revealed an arteriovenous malformation (AVM) located at the posterior portion of the right-sided fusiform gyrus. Cerebral angiography showed that the AVM was fed mainly by branches from the inferior temporal trunk of the posterior cerebral artery. The main venous drainage was to the right transverse sinus through the tentorial vein. The AVM was totally excised through the paramedian supracerebellar-transtentorial approach with the patient in a semisitting position. Postoperative MRI and cerebral angiography confirmed the total resection. The patient was discharged on the 5th postoperative day without neurological deficit. The video can be found here: https://youtu.be/QPrUl8AP7G8 .

Evaluating the importance of the tentorial angle in the paramedian supracerebellar-transtentorial approach for selective amygdalohippocampectomy.

OBJECTIVE: A challenging step of the paramedian supracerebellar-transtentorial approach is to expose the anterior portion of the mediobasal-temporal region (MTR), a step that seems most affected by the steepness of the tentorium. The objective of this study was to define magnetic resonance imaging measurements that can predict the level of challenge in exposing the anterior portion of the MTR. METHODS: Cranial magnetic resonance imaging studies of 100 healthy individuals were examined. The tentorial and occipital angles were measured, and the amount of brain tissue that remained hidden on the microscopic view in front of the petrous apex was indirectly estimated. These measurements were statistically compared with the cephalic index of each person. RESULTS: The mean values for the tentorial and occipital angles were 42° (range 25°-53°) and 98° (range 69°-122°), respectively. The results proved that the higher the tentorial angle, the higher the occipital angle and the greater the amount of hidden brain tissue. Of 100 persons, 3 (3%) were found to be dolichocephalic, 23 (23%) were mesocephalic, and 74 (74%) were brachycephalic. Statistical analysis proved that individuals with a dolichocephalic cranial shape have lower tentorial and occipital angles. CONCLUSIONS: The results provide strong evidence proving that the lesser the tentorial and occipital angles, the easier the exposure of the anterior portion of the MTR during the paramedian supracerebellar-transtentorial approach. The tendency of the cranial shape toward dolichocephaly seems to have the same practical value in choosing the approach. It is easier to expose the anterior portion of the MTR in these individuals.

The paramedian supracerebellar-transtentorial approach to the entire length of the mediobasal temporal region: an anatomical and clinical study. Laboratory investigation.

OBJECT: The exploration of lesions in the mediobasal temporal region (MTR) has challenged generations of neurosurgeons to achieve an appropriate approach. To address this challenge, the extensive use of the paramedian supracerebellar-transtentorial (PST) approach to expose the entire length of the MTR, as well as the fusiform gyrus, was investigated. METHODS: The authors studied the microsurgical aspects of the PST approach in 20 cadaver brains and 5 cadaver heads under the operating microscope. They evaluated the features, advantages, difficulties, and limitations of the PST approach and refined the surgical technique. They then used the PST approach in 15 patients with large intrinsic MTR tumors (6 patients), tumor in the posterior fusiform gyrus with mediobasal temporal epilepsy (MTE) (1 patient), cavernous malformations in the posterior MTR including the fusiform gyrus (2 patients), or intractable MTE with hippocampal sclerosis (6 patients) from December 2007 to May 2010. Patients ranged in age from 11 to 63 years (mean 35.2 years), and in 9 patients (60%) the lesion was located on the left side. RESULTS: In all patients with neuroepithelial tumors or cavernous malformations, the lesions were completely and safely resected. In all patients with intractable MTE with hippocampal sclerosis, the anterior two-thirds of the parahippocampal gyrus and hippocampus, as well as the amygdala, were removed selectively through the PST approach. There was no surgical morbidity or mortality in this series. Three patients (20%) with high-grade neuroepithelial tumors underwent postoperative radiotherapy and chemotherapy but needed a second surgery for recurrence during the follow-up period. In all patients with MTE, antiepileptic medication could be decreased to a single drug at lower doses, and no seizure activity has occurred until this point. CONCLUSIONS: The PST approach provides the surgeon precise anatomical orientation when exposing the entire length of the MTR, as well as the fusiform gyrus, for removing any lesion. This is a novel technique especially for removing tumors involving the entire MTR in a single session without damaging neighboring neural or vascular structures. This approach can also be a viable alternative for selective removal of the parahippocampal gyrus, hippocampus, and amygdala in patients with MTE due to hippocampal sclerosis.