Successful removal of meningioma of the pineal region after embolization

A 69-year-old female presented with a meningioma of the pineal region manifesting as gait disturbance and mental dysfunction. Magnetic resonance imaging revealed a homogeneously well-enhanced circumscribed round mass of about 5 cm in diameter in the pineal region. Angiography demonstrated that the tumor was fed mainly by the bilateral middle meningeal arteries (MMAs), and preoperative intravascular embolization was performed through the bilateral MMAs using estrogen-alcohol and polyvinyl acetate. The tumor was very soft and easily totally resected via the right occipital transtentorial approach. Preoperative embolization is a very useful technique to facilitate removal of deep-seated tumors.     

A case of foramen magnum meningioma in which case enhanced three-dimensional CT scan was valuable for preoperative evaluation of the surgical approach

We report a case of foramen magnum meningioma in which case enhanced three-dimensional CT scan was valuable for preoperative evaluation of the surgical approach. A 53-year-old woman had suffered from stiffness and pain in the left occipital region and numbness of the left side of the face for about 2 years before admission. She had also weakness and numbness of the left side of her body for about 2 months before admission, and dysphagia and pain in the occipital region and in the posterior region of the neck produced by straining for about 1 month before admission. Neurological examination revealed left hemiparesis, and hypalgesia and tactile hypesthesia of the left side of the body, including the face. Plain X-P was normal. Enhanced CT scan and gadolinium enhanced MRI revealed a well-enhanced mass attached to the left anterolateral part of the foramen magnum. The left occipital condyle was observed at the lateral side of the attachment part of this mass. Angiography revealed tumor feeders from the meningeal branches of the left vertebral artery and the left ascending pharyngeal artery. Enhanced three-dimensional CT scan clearly showed that the tumor was attached to the left anterolateral part of the foramen magnum, that the left occipital condyle was at the lateral side of the attachment part of this mass and that the jugular foramen and jugular tubercle were situated superolateral to the attachment part of this mass. Considering these factors, we decided that removal of the posterior part of the left occipital condyle was necessary, but removal of the left jugular tubercle was not necessary for a good operative view from the left posterior lateral direction. The tumor was totally removed successfully and good results were obtained by the transcondylar approach without removal of the jugular tubercle. Histology of the tumor revealed meningothelial meningioma. In this case, preoperative evaluation with enhanced three-dimensional CT scan was helpful for deciding the surgical approach. With enhanced three-dimensional CT scan, it is easy to judge whether removal of the posterior part of the occipital condyle and/or the jugular tubercle is necessary for a good operative view, and we can get good images revealing the relationships between the tumor and surrounding structures. Preoperative evaluation with enhanced three-dimensional CT scan is very useful especially in this kind of situation.     

Surgical management of meningiomas originating in Meckel's cave

OBJECTIVE: To define the difference of meningiomas that originate in the area of Meckel's cave (MC) (primary MC meningiomas) in regard to the different surgical approaches and postoperative results. METHODS: A retrospective analysis of all meningiomas involving the cranial base displayed 21 cases of meningiomas originating in MC (primary MC meningiomas). These cases were classified according to the tumor extension in four different types: Type I, tumors mainly confined to MC; Type II, MC meningiomas with extension into the middle fossa; Type III, MC meningiomas with extension into the posterior fossa; and Type IV, MC meningiomas with extension into both middle and posterior fossae. RESULTS: Trigeminal neuralgia resolved in all cases in this series, despite tumor type. Trigeminal hypesthesia showed postoperative improvement only in Type III MC meningiomas. In Types I and III, total removal without further morbidity was frequently achieved. Cavernous sinus infiltration, especially in Types II and IV, limited (in some cases) the extent of tumor extirpation. CONCLUSION: Types I, II, and III MC meningiomas have a good prognosis. In most cases, very good outcomes are achieved. Radical tumor removal can usually be achieved without further morbidity and with postoperative improvement of the preexisting symptoms, especially in Types I and III MC meningiomas. On the contrary, Type IV MC meningiomas are usually only subtotally resected. Surgery in such cases may carry a high risk of additional morbidity, especially with regard to the IIIrd, IVth, and VIth cranial nerves. The postoperative outcome regarding facial pain in cases of all tumor types is usually very good. Trigeminal hypesthesia may persist after tumor removal in the majority of cases.     

Combined supra/infratentorial-transsinus approach to large pineal region tumors

OBJECT: The authors sought to confirm that the combined supra/infratentorial-transsinus approach offers a safer means of resecting large pineal region tumors than other approaches currently being used. The aforementioned method provides a wider exposure of the pineal region with less brain retraction than the infratentorial-supracerebellar or the occipital-transtentorial approach alone and is applicable to some large and giant tumors of this area. This combined approach was used in six patients to remove large pineal region tumors including four tentorial meningiomas, one pineocytoma, and one epidermoid cyst. METHODS: The transverse sinus and tentorium were sectioned after review of preoperative angiographic studies, after taking intraoperative measurements of the venous pressure in the nondominant transverse sinus before and after clipping and while monitoring the somatosensory evoked potentials. The occipital lobe cortex and cerebellum were retracted slightly along the tentorium. Deep veins of the galenic system, the quadrigeminal area, and the tumor were well exposed. Before it was used for tumor resection the approach was studied in five cadaveric head specimens, and the projection of different approaches was compared radiologically. The tumors were removed in a gross-total manner in all patients, and none of the major veins of the galenic system was injured. Resuturing of the nondominant transverse sinus was performed postoperatively in one patient. One of the six patients experienced transient visual loss, and another suffered mild right sixth cranial nerve paresis; however, both recovered in 3 weeks. The wide exposure of the combined approach was also confirmed on radiological and anatomical studies. CONCLUSIONS: The combined supra/infratentorial-transsinus approach is preferred for the resection of certain large pineal region tumors.     

Anatomic variations of the coronary arteries

PURPOSE: To study the coronary arteries and their main branches showing the aspects of source, trajectory and anastomoses of these vessels at the subepicardial level. METHODS: The study was carried out on 110 adult human hearts, of both sexes, fixed in 10% formaldehyde solution. The pericardium was removed to expose the coronary arteries and their branches at the subepicardial level. RESULTS: In 38.18% of the cases the left coronary artery presented a trifurcation into anterior interventricular, circunflex and left marginal branches (35.70%) and into anterior interventricular, circunflex and lateral branches (64.30%). In 60% of the hearts examined, the left coronary artery presented a bifurcation into anterior interventricular and circunflex branches. In 1.82% of the cases these two branches arise directly from the aorta. An anastomosis, at the subepicardial level, between the anterior and posterior interventricular branches was observed in 56.36% of the hearts. In 88.18% the posterior interventricular branch arised from the right coronary artery, whereas in 11.82% this vessel arises from the circunflex branch. Anastomoses between the right coronary artery and the circunflex branch were found in 10% of the hearts (crux cordis). The dominance of the right coronary artery was present in 69.09% of the cases, of the left coronary artery in 11.82% and in 19.09% of the hearts had balanced distribution. CONCLUSION: The coronary arteries and their main branches present a great quantity of variations with regard to source, trajectory and anastomoses. This knowledge is important for the interpretation of coronary angiography and surgical myocardial revascularization.     

"En-bloc" vertebrectomy in the mobile lumbar spine

BACKGROUND: Primary tumors of the vertebral bodies have previously been treated with total or subtotal excision in a piecemeal fashion (intralesional excision). Radiation therapy has been used to help control tumor growth. Recurrence rates with an intralesional, piecemeal removal of vertebral tumors have been unacceptably high. This study describes a method to excise a lumbar vertebra "en-bloc," and in the process, to perform a marginal (extralesional) resection of a primary tumor of the mobile lumbar spine that allows for a potential surgical cure. METHODS: A combined posterior-anterior procedure allows for an extralesional, marginal resection of the tumor and the involved vertebra. All posterior bony elements, including the pedicles and the adjacent intervertebral discs, are removed via a posterior approach. An anterior, retroperitoneal approach is then used to remove the vertebral body/tumor as a single specimen. The nerve roots at the involved levels are spared and the spine is instrumented and fused both posteriorly and anteriorly. RESULTS: Three patients successfully had combined posterior-anterior resections of lumbar vertebral chordomas. No permanent neurological complications occurred. Overall morbidity of the procedure was acceptable. At 31-month follow-up, no tumor recurrence has been detected. CONCLUSIONS: "En-bloc" resection of a primary vertebral tumor of the lumbar spine is technically demanding, but potentially curative. The alternative approaches-intralesional excision, radiation therapy, or a combination-are unable to cure these tumors. Long-term, 10-year follow-up will be necessary to confirm whether this en-bloc approach provides a surgical cure.     

Extra-axial ependymoma--case report

A 13-year-old boy presented with a very unusual ependymoma extending extra-axially. Computed tomography demonstrated a tumor with a cyst and calcification adjacent to the dura and extending over the right occipital and parietal lobes. The cyst wall and solid tumor were enhanced postcontrast. Magnetic resonance imaging revealed that the solid tumor was isointense on T1-weighted images and a mixed iso- and high-intensity on T2-weighted images. The solid tumor and tissue surrounding the cyst were enhanced markedly by gadolinium-diethylenetriaminepentaacetic acid. Sagittal and coronal images demonstrated a multilocular tumor shadow. Cerebral angiography demonstrated a tumor fed by a posterior branch of the right middle meningeal artery but no feeders from the internal carotid and vertebral arteries. The tumor was removed en bloc. The histological diagnosis was clear cell-type ependymoma.     

A case of migraine with aura associated with meningioma

We reported a case of migraine with aura associated with meningioma. A 66-year-old female visited to our department in 1985, with occipital throbbing pain following visual hallucination and nausea. She had been diagnosed as migraine. CT scan, magnetic resonance image and angiography showed a right occipital tumor, which was totally removed in 1990. Postoperatively, the migraine disappeared completely. The tumor was histologically diagnosed as fibroblastic meningioma. We supposed that the migraine had been associated with meningioma. Although some previous papers reported correlation with brain tumor and migraine, as example of arteriovenous malformation or angioma, migraine associated with meningioma is very rare. In arteriovenous malformation, pathophysiology of migraine is unclear, but induction of circulatory disturbance in the distribution of the posterior cerebral, posterior communicating and basilar artery is supposed. And then a space occupying lesion in the occipital lobe is possible to cause in the circulatory disturbance of the posterior cerebral and basilar artery. In the diagnosis of migraine, we should consider its relation to brain tumors, such as meningioma.     

The importance of pial blood supply to the development of peritumoral brain edema in meningiomas

In a retrospective analysis, the authors studied the pial and dural blood supplies in 74 intracranial meningiomas and quantified their associated peritumoral brain edema (PTBE). The extent and localization of pial blush in relation to the total tumor volume were determined angiographically. The amount of edema and tumor size were calculated using computerized tomography. The edema-tumor volume ratio was defined as Edema Index (EI). There were 49 meningiomas with PTBE; of those tumors, 46 were supplied by pial vessels, and three were supplied exclusively by dural vessels. Tumors without PTBE showed no pial blush. The mean EI in meningiomas with pial blush was significantly larger (EI = 3) than in meningiomas without pial supply (EI = 1.1; p < 0.0001). Meningiomas with a smaller pial supply than dural supply had a significantly smaller mean EI than tumors with a pial supply equal to or greater than the dural supply (EI = 2.9 vs. EI = 3.7; p < 0.015). In 69.9% of cases with pial blood supply, major portions of the edema were located adjacent to the tumor region supplied by pial vessels. Edema index differences among tumors of different subgroups, as defined by size or histology, were significantly related to the pial supply in each subset. Thus, pial blood supply may be associated with the development of PTBE in meningiomas.     

Meningiomas of the lateral ventricles of the brain in children

Meningiomas of the lateral ventricles of the brain are rare tumours, accounting for approximately 0.5-5% of all intracranial meningiomas. Their natural history and symptomatology and the possibilities of early diagnosis are presented. The intraventricular location of the slow-growing benign mass provides a compensatory mechanism in the form of reserve space, which contributes to the delay in clinical demonstration of symptoms and signs. This makes the choice of diagnostic procedure an essential problem. CT and MRI are useful in detecting these masses, and magnetic resonance angiography (MRA) has also proved to be of great value in demonstrating the vascular supply of the tumour. This paper deals with two cases. In case 1 CT, MRI and MRA and in case 2 CT examination proved to be very useful. The tumours were removed by a transcortical approach in the posterior area.     

Serum calcium, magnesium and inorganic phosphorous levels during various phases of menstrual cycle

BACKGROUND/AIM: Hepatic tumors with elements of both hepatocellular and cholangiocellular carcinoma are occasionally encountered; however, the independent and simultaneous occurrence of different epithelial malignant tumors in different lobes is rare. This is a case report of resected double cancer in different lobes of the liver. MATERIALS AND METHODS: A 73 year old Japanese man, with hepatic mass and a history of peritonitis and hepatitis, underwent laparotomy and hepatic resection of the posterior inferior and the left lateral segment, and cholecystectomy for cholecystlithiasis with left-sided gallbladder at our hospital in 1991. RESULTS: The tumor, located in the posterior inferior segment, a yellow-white, round, highly circumscribed mass with a thick capsule, was about 9.0 by 8.0 cm in size. The other tumor located in the left lateral segment, grayish-white on the cut section, was approximately 5.0 by 4.0 cm. CONCLUSION: In our case, it is unlikely the tumor in the right lobe metastasized to the left lobe and transformed into a different type. The two tumors showed clearly different microscopic features. Improved imaging will increase the frequency and number of double cancer diagnosis. This additional data may shed light on the pathogenesis and etiology of double cancer.     

Validation of left ventricular volume measurements by gated SPECT 99mTc-labeled sestamibi imaging

BACKGROUND: Originally, the authors used a combined transcranial-transmalar approach for removal of sphenoorbital tumors. METHODS: More recently, when computed tomography (CT) scanning became available, surgical management of sphenoorbital meningiomas included resection of the hyperostosis in the pterional region, orbital roof and lateral wall, and middle fossa floor. Thereafter, intradural and intraorbital components are removed, as well as infiltrated dura mater. Finally, a periosteal flap is placed over the dural defect and bone reconstructed with methylmethacrylate. RESULTS: Of 25 patients, there was only one death and all but one showed very good to moderate response to treatment. Four recurrences were observed. CONCLUSIONS: Surgical management cannot be uniform in all cases, but must be adapted to each form of presentation. On the basis of the satisfactory results achieved, we feel justified in advising the technique described above with its current modifications.     

A large vertebrobasilar junction aneurysm grown at the proximal end of basilar artery fenestration--usefulness of balloon occlusion test with 99mTc-HMPAO SPECT under induced hypotension and consideration in therapeutic strategies

A 48-year-old lady suffered a transient loss of consciousness. CT and MRI revealed a large vascular lesion compressing the left lower pons. Angiography revealed a large aneurysm at vertebro-basilar junction, dome of which projected anteriorly and left to midline. Her previous vertebral angiogram taken 10 years ago when she suffered a subarachnoid hemorrhage from the left MCA aneurysm, had showed a fenestration of lower basilar artery without apparent aneurysm. Bilateral super-selective vertebral angiograms revealed that the aneurysm arose at the proximal end of the fenestration, and vertebrobasilar junction was incorporated into the aneurysm indicating broad neck aneurysm. The left posterior communicating artery was well developed. Balloon test occlusion (BTO) of bilateral vertebral artery was performed under normotension and induced hypotension. 99mHM-PAO SPECT was used to examine cerebral blood flow (CBF) during hypotensive BTO. The patient tolerated the test and CBF imaging showed insignificant sight decrease in bilateral cerebellar hemispheres. Exploration of the aneurysm was carried out by the right far lateral suboccipital approach. Bilateral vertebral arteries and the right segment of the basilar artery fenestration were identified. Neck clipping of the aneurysm with reconstruction of the parent vessels were tried with fenestrate clip. However, narrow operative field and large dome of the aneurysm made it hard to identify the left segment of the fenestration. Neck clipping was given up and clipping of bilateral vertebral arteries were performed distal to posterior inferior cerebellar artery with three body clippings. The patient showed moderate postoperative left lower nerve palsy, which was gradually improved in several weeks. Follow-up angiography revealed no opacification of the aneurysm.(ABSTRACT TRUNCATED AT 250 WORDS)     

Saccular aneurysms of meningeal artery: case report

OBJECTIVE AND IMPORTANCE: A rare observation of double saccular aneurysms of the meningeal artery is presented. CLINICAL PRESENTATION: This 22-year-old man was referred to the Neurosurgical Institute with a suspicion of an aneurysm of the anterior communicating artery. Bilateral angiography of the carotid arteries was performed 1 week after the subarachnoid hemorrhage, but the aneurysms were not visualized. Routine angiography of both carotid arteries and selective studies of the left vertebral artery were performed again, and angiography of the right carotid artery revealed an aneurysm. The patient's neurological state at the time of admission was normal. Fundoscopic examination revealed papilledema and conjunctival injection of the left eye. INTERVENTION: The patient was treated using a right pterional approach. One aneurysm had caused spontaneous subarachnoid hemorrhage. The aneurysms were removed using a direct approach, with histological examination of dura matter fragment containing both aneurysms. The results of the patient's 2-week follow-up examination were normal. Follow-up angiography of the right carotid artery showed absence of the aneurysm with a clip on the branch of meningeal artery. CONCLUSION: Saccular aneurysms of the meningeal artery can be manifested by subarachnoid hemorrhage, and intradural arterial aneurysms are similar to saccular cerebral vessel lesions structurally.     

Transchoroidal approach to the third ventricle: an anatomic study of the choroidal fissure and its clinical application

OBJECTIVE: We review the anatomic features of the lateral ventricle, the foramen of Monro, the third ventricle, and the choroidal fissure, and we describe the transchoroidal approach to the third ventricle. This approach consists of opening the taenia fornicis of the choroidal fissure in the body of the lateral ventricle and approaching the third ventricle between the two internal cerebral veins. This route allows further posterior enlargement of the foramen of Monro without sacrificing any neural structures. When necessary, the anterior septal vein can be sacrificed. METHODS: Twenty adult cadaveric brains and four adult cadaveric heads were studied, using a magnification ranging from 3 times to 40 times, after perfusion of the arteries and veins with colored latex. RESULTS: The choroidal fissure is a natural cleft between the thalamus and the fornix, and it is identified by following the choroid plexus in the lateral ventricle. The choroid plexus in the body of the lateral ventricle originates from the tela choroidea of the roof of the third ventricle and is apparently attached to the fornix by the taenia fornicis and to the thalamus by the taenia choroidea. The taenia is actually the ependyma that covers the internal wall of the ventricular cavity and the choroid plexus. CONCLUSION: An understanding of the choroidal fissure is fundamental for use of the transchoroidal approach. Unlike transforaminal, subchoroidal, subforniceal, and interforniceal approaches to the third ventricle, which sacrifice some neural or vascular structures, the transchoroidal approach follows a natural route, and certainly it is one of the options to be considered when entry into the third ventricle is required.     

Krypton laser suture lysis

PURPOSE: To analyze indocyanine green angiography (ICGA) features in two cases of sympathetic ophthalmia using a standard angiography protocol for posterior uveitis. METHODS: Report on two patients who suffered from penetrating ocular injuries 45 and 8 years before sympathetic ophthalmia was diagnosed and confirmed by histopathological examination of the enucleated eye. In addition to routine examination and fluorescein angiography, initial and follow-up ICGAs were performed. RESULTS: The first patient, with a phthisic right eye following s shotgun injury, consulted 6 months after cataract extraction in his good left eye for progressive visual loss due to a neovascular membrane in a moderately inflamed eye. The second patient consulted 8 years after a perforating injury of his right eye by a metallic foreign body because of recent visual loss and inflammation in his good left eye. ICGA of both patients showed numerous hypofluorescent dark dots visible at the intermediate phase, some becoming isofluorescent at the late phase and resolving after long-term corticosteroid therapy, others remaining hypofluorescent until the late phase. CONCLUSION: The two patterns of hypofluorescent areas, either persisting throughout angiography or fading in the late phase, were interpreted respectively as cicatricial and active lesions. ICGA gave determining additional information on choroidal involvement and on subsequent evolution of lesions.     

Endolymphatic sac tumors: report of three cases

OBJECTIVE AND IMPORTANCE: We present three cases of endolymphatic sac tumors and review the previously published cases. Despite frequent extension to the cerebellopontine angle, these rare tumors have only recently been recognized by neurosurgeons. CLINICAL PRESENTATION: A 26-year-old man developed a progressive hearing loss, revealing an intrapetrous retrolabyrinthine tumor on the right side. A 28-year-old woman experienced a left cerebellopontine angle syndrome, with a lytic intrapetrous mass extending into the cerebellopontine angle. A 38-year-old woman presented with an intracranial hypertension syndrome caused by a tumor of the jugular foramen. INTERVENTION: For the first and second patients, the tumors originated from the operculum of the endolymphatic sac. Total removal was achieved, via a transpetrosal approach, in these two cases. No recurrence was detected after a 20-month follow-up period. For the third patient, the tumor originated from the distal part of the sac. Recurrence was observed 8 years after subtotal removal via a retrosigmoid route. Histological analysis revealed a papillary-cystic adenocarcinomatous pattern in all cases, without features of aggressiveness. CONCLUSION: Endolymphatic sac tumors are locally invasive neoplasms characterized by bipolar intrapetrous and posterior fossa involvement. The anatomic complexity of the endolymphatic sac may explain the distinct patterns of extension of these tumors. Early radical surgery is related to good outcomes.     

Intrasellar meningioma: case report and review of the literature

BACKGROUND: Intrasellar meningioma is a rare clinical entity, and surgical resection may be difficult when it is hypervascularized. METHODS: A case of subdiaphragmatic hypervascular intrasellar meningioma with attachment to the dura of the anterior wall of the sella turcica is described. Literature review of 18 cases with operatively confirmed intrasellar meningioma discloses unexpected intraoperative bleeding and relatively low resectability of the tumor are also described. RESULTS: We used preoperative endovascular embolization of feeding arteries, and resected a hypervascular intrasellar meningioma by a combined transsphenoidal-transcranial approach safely and without massive bleeding. CONCLUSIONS: Preoperative endovascular embolization of feeding arteries and combined transsphenoidal-transcranial approach are useful for the surgical resection of hypervascular intrasellar meningiomas.     

Cystic meningiomas resembling glial tumors

BACKGROUND: Meningiomas can be associated with peripheral or intratumoral cysts. Meningiomas with intratumoral cysts, also called "true cystic" meningiomas, are rare and can frequently be confused with glial or metastatic tumors. METHODS: We report three cases of "true cystic" meningiomas and discuss the preoperative evaluation, etiology, and surgical treatment of these cystic lesions with reference to the literature. RESULTS: Magnetic resonance imaging (MRI) and computed tomography (CT) studies usually display a cystic lesion close to the dura with or without enhancement of the cyst wall. Multiplanar MRI scans are very useful to show the presence of a solid tumor or some dural enhancement. Some cases of "true cystic" meningiomas however, are still erroneously preoperatively diagnosed. Complete surgical removal of the tumors and of the entire cyst wall was performed in our cases. Despite the absence of a typical ring enhancement of the cystic lesion in two cases, histopathologic studies displayed the presence of tumor cells on the cyst wall of both cases. CONCLUSIONS: Tumor cells can be present on the cyst wall and therefore can be one of the causes of tumor recurrence if not totally removed. Accurate preoperative radiologic diagnosis (multiplanar MR images) and intraoperative histopathologic studies are fundamental in that they will definitely influence the surgical strategy and outcome.