Craniocerebral epidermoids and dermoids. A review of 44 cases

Role of stereotactic radiosurgery for intracranial epidermoid tumors: a systematic review to assess its safety, efficacy, and complication profile

BACKGROUND

Even a gross total resection of a benign epidermoid tumor (ET) carries a high risk of recurrence. The management strategy mostly involves redo surgical excision but at a significant cost of morbidity and mortality. The role of adjuvant radiation therapies in this scenario is still undefined.

OBJECTIVE

To evaluate the feasibility, safety, efficacy, and complication profile of radiosurgery as a standalone or adjuvant therapy for intracranial epidermoid in the published literature.

METHODOLOGY

Following PRISMA guidelines, a comprehensive search of the databases PubMed, Embase, Scopus, and Web of Science in published English language was conducted. We included studies with radiosurgery for benign ET and in patients with malignant transformation of ET (MTET). All studies were evaluated for tumor characteristics, pattern of treatment, dosimetric profile, outcome, and complications. We included all studies with at least one outcome of interest i.e. local control (LC); progression-free survival (PFS); symptomatic toxicity; disease progression; retreatment; and overall survival (OS); and cause-specific mortality.

RESULTS

The search revealed 403 articles, of which 6 and 8 studies with patients of benign ET and MTET respectively were included. 25 (65.7%) patients received primary SRS. 27 patients presented with hyperactive cranial nerve syndromes; 77.7% gained complete improvement. The overall median age was 46.7 years (22-67) and the median tumor volume ranged from 0.38 to 6.2cc in benign ET. Volumetric reduction was seen in 6 cases; progression was seen in 2 cases while ET remained stable in the rest. Mean follow-up duration ranged from 33.7 to 60 months, and no recurrence was reported at the latest follow-up in any case of benign ET. 9.5% of patients suffered from transient cranial nerve deficits with no prolonged adverse radiation effect. OS in the MTET group was 6 to 60 months following GKRS with 50% of patients alive at the latest follow-up.

CONCLUSION

SRS may be a promising treatment option for a conventionally benign and radioresistant ET making a meaningful change in the natural history of the disease. It is a valuable adjuvant technique in patients with MTET.

Ultrasound as a standalone tool for the management of pediatric calvarial dermoid cysts

PURPOSE

Calvarial dermoid and epidermoid cysts are benign lesions common in pediatric neurosurgery. Diagnosis is primarily clinical, with frequent but inconsistent use of imaging. Dermoids have been shown to possess distinct sonographic features, but ultrasound (US) remains underutilized in their management. The purpose of this study is to investigate the independent reliability of US in managing pediatric calvarial dermoids and distinguishing them from other calvarial lesions.

METHODS

A retrospective review of consecutive patients ≤ 21 years of age with surgically resected calvarial masses between 2017-2024 was performed. Demographic, clinical, and imaging data were analyzed. Pearson chi-squared tests were used for comparison of categorical variables and a binomial linear model was generated controlling for age, lesion tenderness, growth, and suture location.

RESULTS

Fifty-nine patients with 61 lesions (31 in females; median age 13 months) were included. Dermoids were more common in younger patients (median age 12 months), along suture lines, and were less likely to present with tenderness (p < 0.001) or rapid growth (p = 0.003). Ultrasound was used in 83% of cases and was the sole imaging modality in 33%. On multivariate analysis, suture location was a significant positive predictor of a dermoid diagnosis (OR = 8.08, 95% CI = 1.67-44.18), while rapid growth was a significant negative predictor (OR = 0.08, 95% CI = 0.003-0.80).

CONCLUSION

Ultrasound presents a sensitive and reliable method for the evaluation of most pediatric calvarial lesions, especially dermoid cysts, and warrants being part of standard workup. With appropriate patient selection, US obviates the need for additional imaging in pediatric patients.

The Subtotal Removal of a Suprasellar Dermoid Cyst Expanding Toward the Olfactory Nerves: A Case Report

Dermoid cysts (DCs) are benign congenital lesions that originate in the ectoderm cells produced during the formation of the neural tube. They are usually located at the cerebral midline, and, on rare occasions, at the suprasellar level. In this case report, we present a 17-year-old female patient with minimal symptoms (hyposmia) caused by a suprasellar dermoid cyst extending toward the anterior cranial fossa and the olfactory nerves with subsequent frontotemporal craniotomy and the subtotal removal of the tumor. Given the rare features of this case, the chosen surgical strategy achieved tumor subtotal resection and symptom remission.

Efficacy and safety of Dyna CT-assisted percutaneous balloon compression in the treatment of tumor-related trigeminal neuralgia: A single-center retrospective analysis

BACKGROUND

Percutaneous balloon compression (PBC) has been widely used in the treatment of trigeminal neuralgia (TN). Patients with tumor-related TN are typically treated by tumor resection. However, when craniotomy is not feasible, PBC may serve as a simple and effective method for pain relief. Currently, there is limited literature on the use of this technique in treating patients with tumor-related TN. In this study, we aim to evaluate the efficacy and safety of Dyna CT-assisted PBC in the treatment of tumor-related TN.

METHODS

From January 2018 to December 2023, a total of 19 patients with tumor-related TN underwent Dyna CT-assisted PBC at our institution. The modified Barrow Neurological Institute Pain Intensity Grading Scale and sensory reduction scores were employed to assess treatment outcomes. A retrospective analysis was conducted on the clinical characteristics, surgical efficacy, postoperative complications, and follow-up results of all patients.

RESULTS

Immediate and complete pain relief was observed in 18 patients following PBC, with one patient experiencing delayed recovery. Follow-up periods ranged from 4 to 62 months, revealing only 4 patients with pain recurrence at the last follow-up, and tumor-related TN patients with involvement of Meckel's cave were more prone to recurrence. No severe complications occurred throughout the follow-up period. Although facial numbness was reported in all 15 patients, jaw weakness in 8 patients, and postoperative headache in 7 patients, these symptoms resolved within a short period. There were no statistically significant differences in postoperative facial numbness and jaw weakness between tumor-related TN patients with or without Meckel's cave involvement. However, patients with Meckel's cave involvement were more likely to experience postoperative headaches. Patient satisfaction scores indicated a significant improvement in postoperative quality of life.

CONCLUSION

For patients with tumor-related TN, when craniotomy is not feasible, Dyna CT-assisted PBC proves to be a safe and effective alternative treatment. Additionally, we observed varying postoperative clinical outcomes based on the different sites of tumor compression on the trigeminal nerve. Patients with tumor-related TN not involving Meckel's cave exhibited more enduring clinical efficacy compared to those with Meckel's cave involvement.

Outcomes of Trigeminal Ganglion Sparing Surgical Resection of Nonacoustic Cerebellopontine Angle Tumors Causing Trigeminal Neuralgia

OBJECTIVE

Tumors may be responsible for up to 5% of trigeminal neuralgia cases. Predictors of long-term pain relief after surgical resection of various cerebellopontine angle tumor types are not well understood. Previous studies found that size and extent of resection predict long-term pain status, although resection of tumor involving the trigeminal ganglion may be associated with high morbidity. This study evaluated predictors of TN pain freedom after resection of a nonacoustic CPA tumor, with avoidance of any portion involving the TG.

METHODS

In a retrospective cohort study, we evaluated clinical outcomes and complications after surgical resection of nonacoustic CPA tumors with purposeful avoidance of the TG causing trigeminal neuralgia. The primary outcome was pain-freedom. We performed logistic regression analyses to examine the relationship between pain-freedom at last follow-up and age, side of symptoms, preoperative symptom duration, tumor diameter, tumor type, and concurrent neurovascular compression (NVC).

RESULTS

Of 18 patients with nonacoustic CPA tumors causing TN treated with surgical resection, 83.3% were pain-free at last follow-up (mean 44.6 months). Age (P = 0.12), side (P = 0.41), preoperative symptom duration (P = 0.85), tumor diameter (P = 0.29), tumor type (P = 0.37), and NVC presence (P = 0.075) were not associated with long-term pain freedom.

CONCLUSIONS

This study provides additional evidence that various tumor types causing TN may safely undergo surgical resection and decompression of the trigeminal nerve to treat TN. This study presents a cohort of patients that underwent resection of a nonacoustic CPA tumor, with purposeful avoidance of the TG to minimize complications, demonstrating high rates of long-term pain freedom.

Complex presentation of a left Fronto-zygomatic Dermoid cyst; a case report

We present a case of craniofacial dermoid cyst in a 50-year-old female. The patient's complaint was persistent refractory headaches with no other significant neurological symptoms. Diagnostic imaging revealed the presence of a lesion in the left fronto-zygomatic region. Surgical intervention involved a craniotomy that led to a successful excision of the dermoid cyst. The diagnosis was subsequently confirmed by histopathological analysis. This case underscored the importance of considering DC as a potential diagnosis for any craniofacial lesion, given their diverse presentations and associated complications.

Intrasellar Dermoid Cyst: Case Report of a Rare Lesion and Systematic Literature Review Comparing Intrasellar, Suprasellar, and Parasellar Locations

OBJECTIVE

Intracranial dermoid cyst (DC) is a rare benign, slow-growing lesion, most commonly arising along the midline. They can occur in the supratentorial compartment, very rarely involve the sellar region and only exceptionally are intrasellar. The aim of our study is to address the challenges in the diagnosis and management of sellar DCs.

METHODS

We performed a systematic review of sellar DCs, in keeping with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and described an intrasellar DC in a 32-year-old female who presented with bilateral blurring vision.

RESULTS

The review identified 4 intrasellar, 29 suprasellar, and 28 parasellar cases. Intrasellar DCs more likely present with progressive visual impairment and pituitary hormone dysfunctions during the fifth decade of life. Suprasellar and parasellar DCs are typically diagnosed during the third decade of life because of diplopia, ptosis, trigeminal hypoaesthesia/para-esthesia or cyst's rupture. Sellar DCs are typically hypodense on computed tomography scans and contain calcifications. Magnetic resonance imaging features include T1 hyperintensity, T2 heterogeneous intensity, no restriction on diffusion-weighted images, and no contrast enhancement. Surgery is the treatment of choice. Gross total resection is achieved in 60% of intrasellar and 61.9% of suprasellar and parasellar DCs. Early postoperative complications are reported in 40.0%, 16.7%, and 23.8% of intrasellar, suprasellar, and parasellar DCs, respectively.

CONCLUSIONS

Intrasellar DCs are rare lesions typically diagnosed later than suprasellar and parasellar DCs due to their different clinical presentations. However, they should be considered in the differential diagnosis of cystic lesions of the sella, including epidermoid cysts, craniopharyngiomas, Rathke's cleft cysts, and teratomas.

Epidermoid Cyst of the Brainstem in 3-Year-Old Child: A Rare Case Report

Epidermoid cysts are infrequent lesions occupying the intracranial space, comprising approximately 1-2% of all intracranial tumors. Brainstem epidermoids are exceptionally uncommon in children; up until now, only a few scattered case reports have been documented in the literature regarding this unique location. These cysts commonly arise from the inclusion of ectodermal elements during neural tube closure. Complete excision of these cysts is challenging due to their close proximity and adherence to the brainstem, which makes it difficult to achieve. As a result, recurrence of the cysts is not uncommon. We have reported a rare case of a 3-year-old with a 5-month history of progressive headache, imbalance while walking and progressive weakness in his right upper limb and lower limb along with difficulty in swallowing. On MRI Brain imaging study he had a pre-pontine epidermoid with intra-axial extension in the pons. The patient underwent retro-sigmoid/suboccipital craniotomy and microsurgical excision of the tumor, including the tumor capsule. After completing the surgery, the cavity was irrigated using a solution containing hydrocortisone and Ringer lactate to prevent the occurrence of aseptic meningitis. In the postoperative, the patient recovered without any complications, as all symptoms showed immediate improvement, and the lower cranial nerves returned to normal functioning.

Posterior Fossa Midline Epidermoid Tumors: Role of the Inferior Medullary Velum and a Proposed New Imaging Classification

BACKGROUND

Posterior fossa midline epidermoid tumors (PFMETs) include the epidermoid tumors of the cisterna magna (CM) and fourth ventricle (FV).

OBJECTIVE

To report tumor epicenter-based classification of PFMETs and its clinical and surgical implications with outcome.

METHODS

On retrospective analysis of operated cases of intracranial epidermoid tumors, 19 (N = 19) patients having tumor epicenter within FV, CM, or both were included. Cerebellopontine and prepontine cistern epidermoid were excluded. Tumor location was decided based on preoperative MRI and intraoperative findings. Major complication was defined as new onset or worsening of cranial nerve (CN) deficit, sensory motor impairment, or tracheostomy.

RESULTS

The mean (±SD) age of the patients was 42.0 ± 11.6 years (range 25-61 years), with no sex predilection (male:female: 1:0.9). The most common symptoms were cerebellar dysfunction, headache, vomiting, and diplopia. Common CNs affected were VII, V, lower cranial nerve, and VI. The PFMETs were classified based on tumor epicenter as type 1 (tumor epicenter in CM, n = 4/21.1%), type 2 (FV, n = 5/26.3%), and type 3 (involved CM and FV, n = 10/52.6%). Type 2 tumors had a higher incidence of raised intracranial pressure and only facial nerve palsy as preoperative CN deficit. Type 1 tumors had the least incidence of postoperative major complications. Type 3 tumors were the largest and had a greater incidence of brainstem adhesion and postoperative complications. The tumor size, duration of symptoms, and patient age were higher in patients with brainstem adhesion (5.3 ± 1.0 cm, 21 ± 16 months, 44.1 ± 9.2 years) as against its absence (4.8 ± 1.3 cm, 11.2 ± 7.3 months, 38.2 ± 11.7 years). Inferior medullary velum and tela choroidea have a critical role in tumorogenesis, tumor extension, and brainstem adhesion.

CONCLUSION

PFMETs can be classified into 3 subtypes based on tumor epicenter having clinical and surgical implications. Less aggressive dissection and near total excision in the presence of brainstem adhesion yield favorable outcomes.

Open surgery vs. stereotactic radiosurgery for tumour-related trigeminal neuralgia: A systematic review

BACKGROUND

Secondary trigeminal neuralgia is a facial pain in trigeminal nerve dermatome caused by an underlying disease, such as cerebellopontine angle tumours. Treatment options to relieve the pains were surgical tumour resection and stereotactic radiosurgery of the tumour or trigeminal nerve. This study aims to review the efficacy of open surgery and stereotactic radiosurgery and recommend the treatment of choice for secondary trigeminal neuralgia due to cerebellopontine angle tumours.

METHOD

The inclusion criteria were studies covering patients with trigeminal neuralgia associated with cerebellopontine angle tumours that were treated with either open surgery or stereotactic radiosurgery and reported pain outcomes after treatment. Non-English articles or studies with a population of less than five were excluded. We systematically searched studies from PubMed, Ebscohost, and Cochrane Library from inception until December 20, 2021. Several works of literature from manual search were also added. Selected articles were appraised using a critical appraisal tool for prognostic studies.

RESULT

Included articles were 26 retrospective studies and one prospective study comprising 517 patients. Of 127 schwannomas, 226 epidermoids, 154 meningiomas, and ten other tumours, 320 cases received surgical tumour excision with or without MVD, 196 had tumour-targeted radiosurgery, and 22 underwent nerve-targeted radiosurgery. In surgical series, 92.2 % gained pain improvement, 2.8 % were unchanged, and 4.5 % had recurrence; none of the patients had worsened outcomes. In cases treated with tumour-targeted radiosurgery, the improvement rate was 79.1 %, unchanged at 14.3 %, recurrence at 26.5 %, and worse symptoms rate after the intervention was 6.6 %. Six patients with recurrent pain after tumour-targeted radiosurgery received secondary nerve-targeted radiosurgery with improved outcomes. Only one patient in our review underwent primary nerve-targeted radiosurgery, and the result was satisfactory. One study treated 15 patients with a single session of tumour-targeted and nerve-targeted radiosurgery, with an improvement rate of 93.3 % and a recurrence rate of 21.4 %.

CONCLUSION

Open surgery releasing the nerve root from compressive lesions is advocated to be the first-line treatment to gain satisfactory outcomes. Total removal surgery is recommended if possible. Nerve-targeted radiosurgery should be reserved as a secondary treatment for recurrent cases.

Endoscopic Endonasal Surgery for Dermoid Cysts Arising From the Middle Cranial Fossa Floor: A Rare Case Series

OBJECTIVE

Dermoid cysts (DCs) are congenital, slowly growing, and may cause nervous system symptoms. Related literature is limited and mainly includes case reports. We report a case series of DCs originating from the middle cranial fossa floor (MCFF) and investigate their demographic information, clinical characteristics, imaging findings, surgical procedures, and prognostic outcomes.

METHODS

We reviewed the patients with DCs arising from the MCFF undergoing endoscopic endonasal surgery (EES) in our center between 2012 and 2022.

RESULTS

A total of 5 patients with DCs were enrolled (2 males and 3 females), with a mean age of 46.2 years at the onset. All DCs originated from the MCFF with 1 case involving the middle cranial fossa bone and another 1 case affecting the dura mater. One (20.0%) patient had neurological involvement. After admission, all patients received EES with a total resection rate of 100.0% (5 of 5). After a median follow-up of 73.2 months, all patients achieved complete clinical and radiological improvements. No surgical-related complications or relapses were observed during the long-term follow-up.

CONCLUSION

Endoscopic endonasal surgery is considered a safe and effective approach for the treatment of DCs in the MCFF. A larger sample size and longer follow-up time are needed.

Strategies for intraoperative management of the trigeminal nerve and long-term follow-up outcomes in patients with trigeminal neuralgia secondary to an intracranial epidermoid cyst

Background

Epidermoid cysts (ECs) are one of the most common causes of secondary trigeminal neuralgia (TGN). However, most previous studies have primarily focused on whether complete tumor resection was achieved, and few studies have discussed the primary goal of pain relief.

Objective

The present study provides intraoperative strategies for trigeminal nerve (TN) management in patients with TGN secondary to an EC and observed long-term follow-up outcomes.

Methods

A total of 69 patients with TGN secondary to an EC at our hospitals were included (January 2011–June 2021). The same surgical team performed all surgeries using a retrosigmoid approach. After EC removal, different methods for TN management were used, including microvascular decompression (MVD), sharp capsulectomy, nerve combing and embedded cholesterol crystal excision. The epidemiological, clinical, and surgical data were extracted.

Results

The total EC removal rate was 92.8% (64/69). All patients achieved initial pain relief postoperatively, and 12 patients (17.4%) experienced varying degrees of hemifacial hypesthesia, which was relieved within 3–6 months. Three patients (4.3%) reported partial pain recurrence within a median follow-up period of 5.5 (0.5–10.5) years, which was relieved completely after low-dose carbamazepine administration.

Conclusion

The primary goal of surgical tumor removal for patients with TGN secondary to an EC is relief of the main symptom of tormenting pain. The selection of an appropriate strategy for TN, including MVD, sharp capsulectomy, nerve combing or embedded cholesterol crystal excision, should depend on the patient's situation.

A Case of Dermoid Cyst Arising in the Temporal Lobe

Intracranial dermoid cysts are rare congenital lesions that result from abnormal sequestration of ectodermal cells during neural tube formation. These tumors are especially rare in lateral areas such as in the temporal lobe. In this study, we report a case of dermoid cyst located in the right temporal lobe. A 50-year-old man was referred for further treatment of a tumor. CT revealed a low-density mass lesion in the right temporal lobe, with calcification. MRI showed the lesion with high signal intensity on diffusion-weighted imaging, high-low mixed signal intensity on T1-weighted imaging, and iso-high signal mixed intensity on T2-weighted imaging; the capsule was enhanced with gadolinium. Differential diagnosis included dermoid cyst, epidermoid cyst, teratoma, and neurenteric cyst. We decided to perform surgery for the improvement of his symptom, histopathological diagnosis, and radical cure. A right temporal craniotomy was performed, and the tumor was found adherent to the surrounding brain tissue. The tumor was completely removed under subpial dissection. Hair was confirmed in the tumor content. On histopathology, the cyst wall was lined with stratified squamous epithelium, sebaceous glands, small vessel aggregates, and inflammatory infiltrate. Keratinized material and hair were found in the lumen. The patient was discharged 7 days after surgery with no new neurologic deficits. This case was unusual in terms of the effect of gadolinium enhancement on MRI, and the presence of adipose tissue and calcification were useful for diagnosis. It is vital to consider prevention of chemical meningitis due to intrathecal dissemination of the tumor content intraoperatively.

Conventional and advanced MR imaging findings in a cohort of pathology-proven dermoid cysts of the pediatric scalp and skull

BACKGROUND

In the pediatric population, dermoid cysts are among the most frequent lesions of the scalp and skull. Imaging plays a key role in characterizing scalp and skull lesions in order to narrow the differential diagnoses. In general, dermoids are described as heterogeneous T1-/T2-hypo- to hyperintense lesions on magnetic resonance imaging.

METHODS

The goal of this retrospective study is to evaluate the diffusion weighted imaging findings while reviewing the conventional T1-/T2-/T1+C-weighted MR characteristics in a pathology-proven series of 14 dermoids of the pediatric scalp and skull.

RESULTS

In our pediatric cohort (eight boys, six girls, age range 3-95 months), half of the dermoids were homogeneous T1-hypointense and homogeneous T2-hyperintense. We found a mixture of restricted (45.5%) and increased diffusion (54.5%) in dermoids. The vast majority of dermoids (91.7%) showed rim enhancement. Most dermoids (57.1%) were located at the midline and adjacent to one of its sutures.

CONCLUSIONS

This study suggests that dermoids may have more variable imaging appearances than hitherto assumed and are frequently seen in close proximity or adjacent to the anterior fontanelle.

Importance of appropriate surgical approach selection for radical resection of cerebellopontine angle epidermoid cysts with preservation of cranial nerve functions: our experience of 54 cases

BACKGROUND

Although many reports state that only the lateral suboccipital retrosigmoid approach (LSO) should be used for removal of cerebellopontine angle (CPA) epidermoid cysts, it is preferable to use various surgical approaches as appropriate for each patient, for radical resection with an optimal operative field under direct visualization, and for the preservation of cranial nerve (CN) functions. In the present study, we hence focused on the importance of surgical approach selection for removal of CPA epidermoid cysts and analyzed the results of CPA epidermoid cysts after surgery in our series.

METHODS

Fifty-four patients who underwent surgery for CPA epidermoid cysts were retrospectively analyzed, regarding their surgical approaches, removal rates, preservation rates of CN function 1 year after surgery, and recurrence. Surgical approaches were selected for patients according to the size and extension of the tumor.

RESULTS

Surgical approaches consisted of LSO (20 cases), anterior transpetrosal approach (ATP; 3 cases), combined transpetrosal approach (27 cases), and ATP + LSO (4 cases). Mean tumor content removal and capsule removal rates were 97.4% and 78.3%, respectively. Preservation rates of facial nerve function and useful hearing were 94.4% and 90.7%, respectively. The mean postoperative follow-up time was 62.8 months, and there were two cases of recurrence requiring reoperation about 10 years after surgery.

CONCLUSIONS

For CPA epidermoid cyst surgeries, selection of the appropriate surgical approach for each patient and radical resection with an optimal operative field under direct visualization enable tumor removal without the need for reoperation for a long time, with preservation of CN functions.

An Intracranial Extradural Dermoid Cyst Presenting with Two Dermal Sinuses and an Abscess in a Child

Dermoid cysts account for only a small fraction of intracranial masses, with extradural dermoid cysts being considered a much rarer entity than those located intradurally. Intracranial dermoid cysts vary in clinical presentations: some maybe asymptomatic whilst others harbor features of raised intracranial pressure, neurological deficits, or even aseptic meningitis. Dermoid cysts may also present with cutaneous lesions. Herein, we report a rare case of a 1-year-old female presenting with a midline, scalp abscess. Brain MRI revealed an intracranial, extradural tumor, with features suggestive of a dermoid cyst, unusually located in the crista galli, and complicated by the formation of two cutaneous sinus tracts. After identification and characterization by MRI, bitemporal craniotomy was performed with complete excision of the mass and sinus tracts. Histological analysis confirmed dermoid cyst as the final diagnosis. Postoperatively, the patient recovered fully and had no evidence of recurrence in subsequent visits. The case mentioned above highlights the rarity of such a presentation for an intracranial extradural dermoid cyst and the vitality of early imaging for midline cutaneous lesions for identification of intracranial extensions and avoidance of detrimental consequences.

Infratentorial abscess secondary to dermal sinus associated with dermoid cyst in children: Review of the literature and report of a rare case

Background:

Dermal sinus is usually located at either end of neural tube but most commonly lumbosacral. When occipital, it extends caudally and is mostly localized in the midline position or in the cavity of the fourth ventricle. It could communicate with the skin through a fistula with potential risk of deeper abscesses. Posterior fossa abscess secondary to dermal sinus associated with intracranial dermal cyst is an uncommon pathology.

Case Description:

A 24-month-old girl was admitted to our institution with a cutaneous fistula in the midline of the occipital region. Brain imaging showed an infratentorial intradiploic cyst with peripheral enhancement to contrast medium. The mass showed hyperintensity on T1-weighted sequences, with the lower signal on T2-weighted images. A suboccipital craniotomy was performed with evacuation of the abscess and excision of the capsule. Contextually a 3 cm whitish and encapsulated cystic mass with hair component was extracted. Histology confirmed the diagnosis of abscess associated with dermal cyst and dermal sinus. The patient condition improved and 15 days after excision, was discharged. The postoperative MRI showed total removal of the lesion. A 36-month follow-up highlighted no evidence of recurrence.

Conclusion:

Posterior fossa dermoid cyst should be considered in all children with a cutaneous fistula. Early neurosurgical treatment of these benign tumors should be performed to prevent the development of severe intracranial infection. Best results are associated with early diagnosis and complete removal of the abscess. The present work further reviews the few similar cases that have been reported in the literature confirming the need for future research.

Surgical management of cerebellopontine angle epidermoid cysts: an institutional experience of 10 years

BACKGROUND

Cerebellopontine angle (CPA) epidermoids, although of benign nature, are of considerable neurosurgical interest because of their close proximity and adherence to the cranial nerves and brain stem. In this paper, we describe our experience and attempt to correlate the final outcomes with the extent of surgical removal. The main objectives were to study various modes of surgical management of CPA epidermoids with regard to removal and preservation of the cranial nerves and also to evaluate the role of endoscopic assisted microsurgical excision thereby minimizing recurrences. This case series is one of the largest series reported so far worldwide.

MATERIALS AND METHODS

From 2006 to 2016, 139 patients with CPA epidermoids were operated at Grant Medical College and J. J. Hospital, Mumbai. All patients underwent detailed magnetic resonance imaging (MRI) of brain. Lesions were classified according Rogelio Revuelta-Gutiérrez et al. with respect to their anatomic extent: grade I- within the boundaries of the CPA, grade II- extension to the suprasellar and perimesencephalic cisterns, and grade III-parasellar and temporomesial region involvement. Retrosigmoidal and sub temporal approaches were taken to excise the lesions. Endoscopic assisted microsurgical excision was done in cases with extensions beyond the CPA. Patient follow-up was based on outpatient repeated brain MRI studies.

RESULTS

The mean duration of symptoms before surgery was 42 months (range, 2 months to 6 years). The mean follow-up period was 27 months (range, 2-60 months). The main presenting sympt om was headache in 69% (96/139) of the cases and trigeminal neuralgia in 30% cases was the second most common cause of consultation. Seventy-five percent of patients had some degree of cranial nerve (CN) involvement. Retrosigmoid approach was taken in 92% patients and 7 patients with supratentorial extension were operated by combined retrosigmoidal and subtemporal approach. Endoscopic assisted microsurgical excision was done in 40% cases. Use of angled views by an endoscope helped to excise residual tumor in 47 (83%) patients. Complete excision was achieved in 67% of cases. In 33% patients, small capsular remnants could not be removed completely because of their adherence to vessels, brainstem and cranial nerves. Compared with their preoperative clinical status, 74% improved and 20% had persistent cranial nerve deficits in the first year of follow up.

CONCLUSIONS

Epidermoid cysts are challenging entities in current neurosurgery practice due to tumor adhesions to neurovascular structures. Meticulous surgical technique with the aid of neurophysiological monitoring is crucial to achieve safe and effective total or subtotal removal of these lesions. A conservative approach is indicated for patients in whom the fragments of capsule is adhered closely to blood vessels, nerves, or the brainstem, in order to avoid risk of serious neurological deficits related to an inadvertent damage of these structures. Use of angled views by endoscope at the conclusion of the surgery may assure the surgeon of total removal of the tumor.

Giant Intradiploic Epidermoid Cyst in the Occipital Bone: A Case Report

Epidermoid cysts are uncommon intracranial tumors. As one of the extradural types of epidermoid cysts, intradiploic epidermoid cysts are even rarer tumors and occur in any part of the skull. We herein report a rare case of a giant intradiploic epidermoid cyst of the occipital bone. A 57-year-old woman presented with a 1-year history of localized headache in the occipital area. CT and MRI showed an extradural mass measuring 50×70 mm in the occipital bone with bony destruction. The patient underwent surgical resection. The tumor was completely removed with its capsule. There was no extension to the intradural space. The pathological report confirmed that the tumor was an epidermoid cyst. Follow-up MRI 24 months after the operation showed no recurrence. The headache was well controlled without any medications. We report a rare case of intradiploic epidermoid cyst with clinical and radiologic features and surgical treatment. It is important to consider this diagnosis for a patient with persistent regional headache with or without a growing scalp mass.

Giant Epidermoid Cyst of Posterior Fossa-Our Experience and Literature Review

INTRODUCTION

Intracranial epidermoid cysts are the most frequent congenital intracranial lesion. They rare and benign tumors that can present in different clinical situations depending on location and extension of the disease. Diagnosis is obtained with radiological imaging with RM and non-enhanced TC as elective investigating methods. Elective treatment is surgery, based on total/subtotal excision sparring healthy neurovascular structures, considering the benign nature of this lesion.

CASE REPORT

In this study we present the case of a 79-year-old woman affected by recidivist epidermal cyst of the posterior fossa. Clinical presentation was characterized by positional subjective vertigo, intense headache localized in the right part of the head increased by Valsalva maneuver and retroarticular subcutaneous swelling. Radiological investigation found a giant epidemoid cyst of the posterior fossa (8,4 x 4,8 x 5,8 cm), treated with surgery. In the postoperative, the patient was fine and no neurological deficit has been encounterd.

REVIEW

In this study, we present a review of the literature regarding giant epidermoid cysts of posterior fossa. Only 11 cases were reported before ours, which actually is one of the largest ever described.

Epidermoid cyst of the anterior clinoid process: report of a unique finding and literature review of the middle cranial fossa locations

BACKGROUND

Epidermoids cysts are relatively rare, benign, congenital tumours, representing from 0.3% to 1.8% of all intracranial lesions. When extradural, they are most commonly reported in the temporal or parietal bones as intradiploic lesions; when intradural their most common location is the cerebellopontine angle and less frequently the middle cranial fossa. Herein we present a unique case of an extradural-intraosseous epidermoid cyst of the anterior clinoid process, integrating our single-case experience into a focused literature review of these lesions, when located in the middle cranial fossa.

CASE DESCRIPTION

A 49 years old man came to our attention with history of head trauma. Urgent brain CT and elective brain MRI showed imaging suggestive for an anterior clinoid process epidermoid cyst. Through a pterional approach, the lesion was completely removed with microsurgical endoscope assisted technique. MRI at one year follow up showed no recurrence.

METHODS

Current literature on epidermoid cysts located in middle cranial fossa was reviewed. A total of 22 papers, containing 70 epidermoid cyst were selected for the review. Symptoms at presentation; anatomic location; surgical approach; extent of resection and recurrence; outcome after surgery and at follow up were analysed for each case.

CONCLUSIONS

In the 70 published cases of middle fossa epidermoid cysts, the majority presented with trigeminal neuralgia. Most of the cases were operated through a pterional approach, while recent literature showed an increasing interest in endonasal endoscopic techniques. Subtotal resection is not a straight predictive value for recurrence; post-operative neurological deficits incidence is low and generally resolve at follow-up.

Surgical Treatment of Secondary Trigeminal Neuralgia Induced by Cerebellopontine Angle Tumors: A Single-Center Experience

OBJECTIVE

Secondary trigeminal neuralgia (TN) caused by cerebellopontine angle (CPA) tumors are rare, although TN may be a primary manifestation in the neurosurgery department. In this study, we aimed to retrospectively assess patients with CPA tumor-induced TN from a single center.

METHODS

Of 819 consecutive patients with TN treated at our center between 2007 and 2017, 36 with CPA tumor-induced TN were enrolled, and their medical and surgical records were analyzed.

RESULTS

The 36 patients accounted for 4.4% of all patients with TN. A comparison of patients with classic and tumor-induced TN indicated significant intergroup differences in the mean age at surgery (58.94 vs. 49.33 years, P = 0.000), the mean age at onset of TN (52.01 vs. 38.04 years), and affected side (298/485 vs. 22/14 in left/right, P = 0.006); no such difference was noted in the sex ratio (0.598 vs. 0.385, P = 0.214). The rates of excellent, good, and fair clinical outcomes were 80.56%, 13.89%, and 2.78%, respectively. The offending vessels found during surgery included the superior and anterior inferior cerebellar arteries in 3 and 4 cases, respectively. Postoperative complications included aseptic meningitis (1 case), facial numbness (2 cases), hearing disturbance (3 cases), facial palsy (4 cases), hemorrhage (1 case), and diplopia (2 cases).

CONCLUSIONS

Secondary TN caused by CPA tumors is not as frequent as classic TN. Compared with classic TN, tumor-induced TN is characterized by symptom onset and surgery at a younger age. Direct compression rather than chemical irritation is the cause of secondary TN.

Intratumoral Rathke's Cleft Cyst Remnants Within Craniopharyngioma, Pituitary Adenoma, Suprasellar Dermoid, and Epidermoid Cysts: A Ubiquitous Signature of Ectodermal Lineage or a Transitional Entity?

BACKGROUND

The authors present cystic epithelial masses in the suprasellar region which on histopathology revealed 4 mixed tumors having simple cuboidal epithelium of Rathke's Cleft Cyst (RCC) elements trapped within pituitary adenoma, epidermoid cyst, dermoid cyst, and papillary craniopharyngioma respectively.

OBJECTIVE

To highlight the developmental theory of ectodermal continuum in the realm of suprasellar epithelial cystic lesions and examines the cardinal aspects that distinguish RCC from its confounder, ciliary craniopharyngioma.

METHODS

The authors performed a medical chart review on 4 patients who had coexisting RCC with craniopharyngioma, pituitary adenoma, suprasellar dermoid, and epidermoid cysts.

RESULTS

This series of unique suprasellar lesions elucidate the spectrum of cases from Rathke's cyst to other suprasellar epithelial cysts including a recently identified clinical entity called ciliary craniopharyngioma, which authors feel is a misnomer. The authors also report the first case of ruptured dermoid cyst admixed with elements of Rathke's cyst elements and xanthogranuloma in neurosurgical literature.

CONCLUSION

We propose that the new entity of ciliary craniopharyngioma could be just another variant of RCC elements nested within a typical papillary or adamantinomatous lesion. Further study is warranted to understand the implications of natural history with tumors containing RCC elements.

Risk of Intracranial Extension of Craniofacial Dermoid Cysts

BACKGROUND

Dermoid cysts are benign lesions lined by keratinizing squamous epithelium that also contain epidermal adnexa (hair follicles, hair shafts, sebaceous glands, and both apocrine and eccrine sweat glands) and mesodermal derivatives (smooth muscle fibers, vascular stroma, nerves, and collagen fibers). Craniofacial dermoid cysts represent approximately 7 percent of all dermoids and have an incidence ranging between 0.03 and 0.14 percent.

METHODS

The authors conducted a single-center, consecutive, nonrandomized comparative case series over a 20-year period of all patients treated surgically for craniofacial dermoid at the Royal Children's Hospital in Melbourne, Australia. Six hundred forty-seven patients had craniofacial dermoids and adequate information to be included in the study. The authors also conducted a thorough review of the literature using the MEDLINE and Embase databases.

RESULTS

Six hundred forty-seven patients amounted to 655 lesions in our case series. The age at surgery ranged from 2 months to 18 years, with an average age of 25.65 months. The depth of the lesions was stratified using a classification system, and the risk of intracranial extension was assessed using these data. Midline nasal lesions are established as high risk by other studies, but frontal, temporal, and occipital lesions were found to be as risky if not more risky for intracranial extension.

CONCLUSIONS

Several classification systems for craniofacial dermoid cysts have used both broader anatomical locations and physical characteristics to group these lesions and identify those warranting preoperative imaging. The authors propose a system using more specific classification of anatomical location to assist in the prompt identification of high-risk lesions and facilitate sound preoperative planning.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Endoscopic endonasal surgery for epidermoid and dermoid cysts: a 10-year experience

OBJECTIVE

Epidermoid and dermoid cysts may be found along the cranial base and are commonly resected via open transcranial approaches. The use of endoscopic endonasal approaches for resection of these tumors has been rarely reported.

METHODS

The authors retrospectively reviewed the medical records of 21 patients who underwent endoscopic endonasal surgery for epidermoid and dermoid cyst resection at the University of Pittsburgh Medical Center between January 2005 and June 2014. Surgical outcomes and variables that might affect the extent of resection and complications were analyzed.

RESULTS

Total resection (total removal of cyst contents and capsule) was achieved in 8 patients (38.1%), near-total resection (total removal of cyst contents, incomplete removal of cyst capsule) in 9 patients (42.9%), and subtotal resection (incomplete removal of cyst contents and capsule) in 4 patients (19%). Larger cyst volume (≥ 3 cm3) and intradural location (15 cysts) were significantly associated with nontotal resection (p = 0.008 and 0.0005, respectively). In the whole series, surgical complications were seen in 6 patients (28.6%). No complications were observed in patients with extradural cysts. Among the 15 patients with intradural cysts, the most common surgical complication was postoperative CSF leak (5 patients, 33.3%), followed by postoperative intracranial infection (4 patients, 26.7%). Larger cysts and postoperative CSF leak were associated with intracranial infection (p = 0.012 and 0.028, respectively). Subtotal resection was marginally associated with intracranial infection when compared with total resection (p = 0.091). All patients with neurological symptoms improved postoperatively with the exception of 1 patient with unchanged abducens nerve palsy.

CONCLUSIONS

Endoscopic endonasal approaches may be effectively used for resection of epidermoid and dermoid cysts in carefully selected cases. These approaches are recommended for cases in which a total or near-total resection is possible in addition to a multilayer cranial base reconstruction with vascularized tissue to minimize the risk of intracranial infection.

Focal traumatic rupture of a dermoid cyst in a pediatric patient: case report and literature review

BACKGROUND

Dermoid cysts are rare congenital teratomas that can occasionally rupture and cause chemical meningitis, neurological deficit, or hydrocephalus. Rarely, dermoid cysts in the pediatric population can rupture spontaneously and even more rarely rupture due to trauma. To date, there are only five documented cases of traumatic rupture of a dermoid cyst. A 2-year-old male presented with 5 days of left eye ptosis and ophthalmoplegia after suffering a fall and was found to have a ruptured left anterior clinoid dermoid cyst that was surgically resected. The patient had significant improvement postoperatively.

SIGNIFICANCE

To the authors' knowledge, this is the first reported case in the literature of a ruptured dermoid cyst after trauma in a pediatric patient and the first case of a traumatically ruptured dermoid cyst presenting with neurological deficit.

Management of a rare case of intraventricular ruptured dermoid cyst and chemical meningitis

INTRODUCTION

Intraventricular dermoid cyst are very rare benign tumour. Due to benign nature, it may go un-noticed for years and might present with sudden rupture. Ruptured cyst can cause chemical meningitis, hydrocephalus, seizures etc. Due to lack of data, there are no defined guidelines about its management. We are reporting an interesting case of ruptured intraventricular dermoid cyst and chemical meningitis, who was managed successfully and will review the literature.

CASE REPORT

A 48 years male patient was brought with complaint of sudden mental deterioration, irritability, headache, vomiting for 3 days. He had history of seizures for 1 year. On examination, his higher mental functions were deteriorated, had neck rigidity and left lower limb weakness. CT/MRI brain confirmed diagnosis of right frontal horn ruptured dermoid cyst with scattered fat droplets, hydrocephalus and ventriculitis. Excision of cyst was done via right trans-sulcal (superior frontal sulcus) approach. Patient recovered well.

DISCUSSION

Intraventricular dermoid cyst are a rare benign lesion. Due to potential of rupture, it must be surgically treated. Steroids should be used to treat chemical meningitis. Various individual case reports have shown good outcome after surgical management.

CONCLUSION

We recommend early surgery, thorough ventricular wash with ringer lactate, post-operative extraventricular drain and steroid cover to manage ruptured cyst and chemical meningitis.

Child dermoid cyst mimicking a craniopharyngioma: the benefit of MRI T2-weighted diffusion sequence

BACKGROUND

Brain dermoid cysts are very rare lesions. Although benign, these cysts may be associated with devastating complications due to mass effect or meningitis. The discovery of completely asymptomatic dermoid cysts in the pediatric population is exceedingly rare. Despite the advances in imaging modalities, it sometimes remains difficult to exclude the differential diagnosis of craniopharyngioma.

CASE REPORT

We describe a 12-year-old boy addressed for suspicion of craniopharyngioma diagnosed by decreased visual acuity, bitemporal hemianopia and a CT scan showing a large hypodense suprasellar lesion with intralesional calcifications. Despite the unusual localization and size of this lesion, the absence of dermal sinus commonly found, and before visualizing a hyperintense mass on MRI-diffusion, the diagnosis of craniopharyngioma was ruled out in favor of a dermoid cyst. Radical excision was performed.

CONCLUSION

In the suprasellar area, craniopharyngioma and dermoid cyst may have very similar radiological aspects: low density masses on CT scan and a hyperintense signal on T1-weighted MRI sequences with a variable signal on T2-weighted sequences. Hitherto, only two cases in literature have described suprasellar dermoid cyst. Their initial diagnosis was facilitated by the presence of a dermal sinus.

Endoscopic Transnasal Transpterygoid Excision of an Infratemporal Dermoid Cyst

OBJECTIVE

Intracranial dermoid cysts are rare, slow-growing masses of sellar, parasellar regions, and posterior cranial fossa. The symptomatology of these cysts depends on the localization and presence of rupture. The preoperative diagnosis of these cysts by imagining techniques is distinctive as they have characteristic appearances.

PATIENT

Endoscopic transnasal transpterygoid approach to infratemporal fossa for an extradural dermoid cyst of a 24 year-old woman is presented in this clinical report. Headache, dizziness, and retro orbital pain were her main complaints and diagnostic imagining studies designated an intracranial dermoid cyst preoperatively. The cyst was excised uneventfully with no recurrence 6 months after the operation.

CONCLUSION

Surgery of intracranial lesions neighboring critical vital neurovascular structures can be challenging to the surgeon. Alternative minimal invasive approaches should always be considered for averting life-threatening complications.

Gamma knife radiosurgery for cerebellopontine angle epidermoid tumors

Background:

Intracranial epidermoid tumors are commonly found in the cerebellopontine angle where they usually present with either trigeminal neuralgia or hemifacial spasm. Radiosurgery for these tumors has rarely been reported. The purpose of this study is to assess the safety and clinical outcome of the treatment of cerebellopontine epidermoid tumors with gamma knife radiosurgery.

Methods:

This is a retrospective study involving 12 patients harboring cerebellopontine angle epidermoid tumors who underwent 15 sessions of gamma knife radiosurgery. Trigeminal pain was present in 8 patients and hemifacial spasm in 3 patients. All cases with trigeminal pain were receiving medication and still uncontrolled. One patient with hemifacial spasm was medically controlled before gamma knife and the other two were not. Two patients had undergone surgical resection prior to gamma knife treatment. The median prescription dose was 11 Gy (10–11 Gy). The tumor volumes ranged from 3.7 to 23.9 cc (median 10.5 cc).

Results:

The median radiological follow up was 2 years (1–5 years). All tumors were controlled and one tumor shrank. The median clinical follow-up was 5 years. The trigeminal pain improved or disappeared in 5 patients, and of these, 4 cases stopped their medication and one decreased it. The hemifacial spasm resolved in 2 patients who were able to stop their medication. Facial palsy developed in 1 patient and improved with conservative treatment. Transient diplopia was also reported in 2 cases.

Conclusion:

Gamma knife radiosurgery provides good clinical control for cerebellopontine angle epidermoid tumors.

Massive Intradural Dermoid Cyst Without Sinus Tract

Dermoid cysts can present as a rare, benign, congenital intracranial tumor of neuroectoderm origin trapped during embryogenesis. Past clinical reports have reported lesions in the posterior fossa, at the midline, and in the intradural region all in conjunction with a superficial sinus tract. The authors present a unique patient of a completely intracranial, intradural, dermoid tumor of the midline cerebellum devoid of any evidence of sinus tract. The histological characteristics, radiological features, and management of this unusual patient are described.

Dermoid Cyst of the Prepontine Cistern and Meckel's Cave: Illustrative Case and Systematic Review

Objective  Dermoid cysts are benign, congenital malformations that account for ∼0.5% of intracranial neoplasms. The authors describe a 42-year-old female with a prepontine dermoid cyst who underwent apparent gross total resection (GTR) but experienced cyst recurrence. To date, very few cases of prepontine dermoid cysts have been reported. The prevalent region where these cysts are located can be difficult to determine. In addition, the authors systematically review the literature to characterize the clinical presentation, anatomical distribution, and surgical outcomes of intracranial dermoid cysts. Design  Systematic review. Setting/Participants  PubMed, Web of Science, and Scopus databases. Main Outcome Measures  Extent of resection, symptom improvement, and recurrence rates. Results  A total of 69 patients with intracranial dermoid cysts were identified. Three (4.3%) intracranial dermoid cysts were located in the prepontine cistern. The average age of patients was 33.3 years. The most common presenting symptoms were headache (52.2%) and visual disturbances (33.3%). Intracranial dermoid cysts were distributed similarly throughout the anterior, middle, and posterior cranial fossae (29.0%, 36.2%, and 29.0%, respectively). GTR was achieved in 42.0% of cases. Thirty-four (49.3%) patients experienced symptom resolution. Recurrence rate was 5.8% at a mean follow-up of 2.1 years. Conclusions  Intracranial dermoid cysts most often present as headaches and visual disturbances. Intracranial dermoid cysts were found in the anterior, middle, and posterior cranial fossae at similar frequencies but with clear predilections for the Sylvian fissure, sellar region, and cerebellar vermis. Outcomes following surgical excision of intracranial dermoid cysts are generally favorable despite moderate rates of GTR.

Osteolytic Skull Lesions-Our Experience

Objective:

To present an overview of varied clinical presentations, investigations and treatment options for Osteolytic skull lesions.

Study Design:

It is a prospective study.

Materials and Methods:

We conducted this study from January 2013 to December 2015 in the Department of Neurosurgery, Nil Ratan Sircar Medical College and Hospital, Kolkata. During this period, 14 patients presented with osteolytic skull lesions through the outpatient department. All patients were thoroughly investigated with appropriate hematological and radiological investigations and treated following admission, and surgery was performed in the Neurosurgery Department. All were followed regularly in OPD.

Results:

Total 14 patients were included in the study. Amongst these 7 were male and 7 female. Age group of patients ranged from 5 to 72 years. Of 14 cases, three cases had dermoid cyst, four cases had metastasis, and one each case had epidermoid cyst, intradiploic meningioma, benign cystic lesion, tuberculosis, histiocytosis X, hemangioma, and osteomyelitis. All underwent diagnostic/therapeutic procedures and referred for Radio or chemotherapy where indicated.

Conclusion:

All scalp/skull lesions need careful clinical correlation, appropriate radiological investigations to establish diagnosis and subject them to suitable treatment.

Considerations in the management of congenital cranial dermoid cysts

OBJECTIVE Congenital dermoid cysts (CDCs) develop from the entrapment of the surface ectoderm along the lines of embryonic fusion and have a capacity to grow. Given this capacity for continual expansion, the timing of removal and anticipation of possible epidural extension is important. METHODS The authors retrospectively reviewed records of patients with the diagnosis of dermoid cyst presenting over a period of 10 years. Baseline characteristics, histological reports, and surgical records were collected and analyzed. Only those patients with histological confirmation of dermoid cyst were included in the study. RESULTS One hundred fifty-nine (64 male and 95 female) patients were studied. The average age at the time of surgery ranged from 1 month to 63 years (mean 3.55 ± 9.58 years, median 11 months). Eighteen (11.3%) CDCs were in the midline anterior fontanelle, 52 (32.7%) were frontozygomatic, 14 (8.8%) occurred along the coronal sutures, and 75 (47.2%) occurred along the lambdoid sutures. In 74 (46.5%) cases the cysts were found to insignificantly erode the cranium, 30 (18.9%) eroded through a partial thickness of the cranium, 47 (29.6%) eroded through the full thickness of the cranium, and 8 (5.0%) eroded through the full thickness of the cranium and demonstrated epidural extension. The study population showed female predominance (n = 95, 59.7%). Although cyst location and patient sex were not found to vary significantly with cranial involvement (p = 0.196 and p = 0.066, respectively), delay in time to surgery did vary significantly (p < 0.00001). CONCLUSIONS Congenital cranial dermoid cysts found in infants and children are best removed early.

Predictors of Outcomes in Fourth Ventricular Epidermoid Cysts: A Case Report and a Review of Literature

OBJECTIVE

To present an illustrative case of fourth ventricular epidermoid cyst and review the literature to identify predictors of surgical outcomes.

METHODS

A case of fourth ventricular epidermoid cyst is presented and a systematic review of 5 popular databases was performed by independent authors. Stepwise logistic regression was performed to identify clinical predictors of outcomes.

RESULTS

A 21-year-old woman presented with 3 months of headaches and visual obscurations and was diagnosed with a multilobulated mass in the fourth ventricle. The patient underwent suboccipital craniotomy. Complete removal of the mass was achieved and the final diagnosis was consistent with an epidermoid cyst. The systematic review identified 23 studies that reported 37 patients. Mean age was 42.8 years. Mean length of time between symptom onset and diagnosis was 4.43 years. Age (P = 0.049) and duration of symptoms (P < 0.001) were significantly different between patients who experienced symptom improvement and those who did not. Duration of symptom onset to diagnosis was a significant predictor of poor outcomes (odds ratio, 1.19, 95% confidence interval, 1.003-4.785).

CONCLUSIONS

Our review found that in patients with fourth ventricular epidermoid cysts, unfavorable outcomes were predicted by older age and by longer intervals from symptom onset to diagnosis. Clinicians should maintain a high index of suspicion for fourth ventricular epidermoid cysts in patients presenting with cerebellar signs and visual disturbances.

Role of MRI in Diagnosis of Ruptured Intracranial Dermoid Cyst

Introduction:

Intracranial dermoid cystic tumors account for <1% of all intracranial masses.

Case report:

A 52-year-old male, having headaches, nausea and is presented with a history of 2 episodes of new onset seizures. On presentation, the patient had a normal physical exam, including a complete neurological and cranial nerve exam.

Methods:

Precontrast MRI; TSE/T2Wsequence in axial/coronal planes; 3D – HI-resolution T1W sagittal; FLAIR/T2W axial; FLAIR/T2W, Flash/T2W oblique coronal plane, GRE/T2W axial. Post-contrast TSE/T1W sequence in axial, coronal and sagittal planes. Diffusion weighted and ADC mapping, postcontrast: TSE/T1W sequence in axial, coronal and sagittal planes.

Results:

Subsequent MRI of the brain revealed an oval and lobulated 47x34x30mm (TRxAPxCC) non-enhancing T1-hyperintense mass in right cavernous sinus, with compression of surrounding mesial temporal lobe and right anterolateral aspect of mesencephalon. Findings are consistent with ruptured dermoid cyst, given the evacuated sebum content at its lower half. Sebum particles in millimetric sizes are seen within right Sylvian fissure, anterior horns of lateral ventricles and to a lesser extent within left Sylvian fissure, right parietal sulci, cerebral aqueduct, and basal cisterns. No restricted diffusion is seen, eliminating the possibility of epidermoid. A shunt catheter is evident traversing between right lateral ventricle and right parietal bone; besides, slit-like right lateral ventricle is noted (likely secondary to over-draining shunt catheter).

Conclusion:

Intracranial dermoid cysts are benign rare slow-growing tumors that upon rupture, however, widespread presence of T1 hyperintense droplets and leptomeningeal enhancement can be noted–making MRI the best imaging modality for diagnosis of this rare entity.

Brainstem epidermoid cyst: An update

The incidence of epidermoid tumors is between 1% and 2% of all intracranial tumors. The usual locations of epidermoid tumor are the parasellar region and cerebellopontine angle, and it is less commonly located in sylvian fissure, suprasellar region, cerebral and cerebellar hemispheres, and lateral and fourth ventricles. Epidermoid cysts located in the posterior fossa usually arise in the lateral subarachnoid cisterns, and those located in the brain stem are rare. These epidermoids contain cheesy and flaky white soft putty like contents. Epidermoid cysts are very slow growing tumors having a similar growth pattern of the epidermal cells of the skin and develop from remnants of epidermal elements during closure of the neural groove and disjunction of the surface ectoderm with neural ectoderm between the third and fifth weeks of embryonic life. We are presenting an interesting case of intrinsic brainstem epidermoid cyst containing milky white liquefied material with flakes in a 5-year-old girl. Diffusion-weighted imaging is definitive for the diagnosis. Ideal treatment of choice is removal of cystic components with complete resection of capsule. Although radical resection will prevent recurrence, in view of very thin firmly adherent capsule to brainstem, it is not always possible to do complete resection of capsule without any neurological deficits.

Insular and Sylvian Fissure Dermoid Cyst with Giant Cell Reactivity: Case Report and Review of Literature

BACKGROUND

Dermoid cysts are rare intracranial tumors that are most commonly found infratentorially and along the midline. Characterized by slow growth and often found incidentally, these lesions can nonetheless have severe complications, notably rupture leading to chemical meningitis. They infrequently present as a supratentorial and lateralized mass. As such, sylvian fissure dermoid cysts are exquisitely rare. We present a rare case of a dermoid cyst with giant cell reactivity suggestive of focal rupture and chronic inflammation.

CASE DESCRIPTION

A 61-year-old female presented with new-onset seizures. Magnetic resonance imaging revealed a right insular mass measuring 4.3 × 4.5 cm with compression of the ipsilateral frontal and temporal lobes. The mass was nonenhancing; however, it was bright on diffusion-weighted imaging, suggesting a dermoid cyst. She underwent craniotomy for tumor resection. Histologic analysis revealed keratinizing squamous epithelium, sebaceous glands, and hair follicles associated with giant cell reaction involving the capsule of the cyst consisted with dermoid cyst. At 2.5 years post operation, she is seizure free and without evidence of recurrence.

CONCLUSION

The dermoid cyst in our patient was not grossly ruptured, but histopathologic analysis revealed giant cell reactivity, which may indicate focal rupture or chronic inflammation. The relationship between rupture of dermoid cysts and inflammation is not well elucidated. It is not known whether symptoms occur immediately after rupture or as an acute manifestation of a chronic process following rupture. As these lesions are quite rare and rupture is even rarer, more diligence on our part regarding details of histopathology for dermoid cysts is necessary.

Treatment of epidermoid tumors with gamma knife radiosurgery: Case series

Background:

Epidermoid tumors (ETs) are benign lesions that are treated mainly by means of surgical resection, with overall good results. External beam radiotherapy is an alternative treatment for those recurrent tumors, in which a second surgery might not be the best choice for the patient. A little information exists about the effectiveness of gamma knife radiosurgery for the treatment of newly diagnosed and recurrent ETs. We present three cases of ETs treated with gamma knife radiosurgery.

Case Description:

Case 1 is a 21-year-old female with an ET located in the left cerebellopontine angle (CPA) with symptoms related to VIII cranial nerve dysfunction. Symptom control was achieved and maintained after single session radiosurgery with gamma knife. Case 2 is a 59-year-old female patient with the history of trigeminal neuralgia secondary to a recurrent ET located in the left CPA. Significant pain improvement was achieved after treatment with gamma knife radiosurgery. Case 3 is a 29-year-old male patient with a CPA ET causing long lasting trigeminal neuralgia, pain relief was achieved in this patient after gamma knife radiosurgery.

Conclusion:

Long-term symptom relief was achieved in all three cases proving that gamma knife radiosurgery is a good and safe alternative for patients with recurrent or nonsurgically treated ETs.

Cerebellopontine angle epidermoid cysts: clinical presentations and surgical outcome

Epidermoid cysts constitute less than 1% of intracranial tumors with the majority of them involving cerebellopontine angle (CPA). Although several mechanisms for cranial nerve dysfunction due to these tumors have been proposed, no direct evaluation for hyper- or hypoactive dysfunction has been done. In this case series, pathophysiology of cranial nerve dysfunction in CPA epidermoid cysts was evaluated with special attention to a new mechanism of capsule strangulation caused by stratified tumor capsule. Twenty-two cases with epidermoid cysts of CPA micro-neurosurgically treated in our departments since 2005 were reviewed. Clinical status of the patients before the surgery and post-operative functional outcome were recorded. Available data from the English literature were summarized for comparison. Mass reduction of cyst contents in most cases was usually associated with prompt and marked improvement of the symptoms suggesting neuroapraxia caused by compression of the tumor content and/or mild ischemia. Among them, two cases showed strangulation of the affected nerves by the tumor capsule whose preoperative dysfunction did not improve after surgery in spite of meticulous microsurgical removal of the lesion. Involved facial and abducent nerves in these two cases showed distortion of nerve axis and nerve atrophy distal to the strangulation site. We report the first direct evidence of etiology of cranial nerve dysfunction caused by cerebellopontine angle epidermoid tumors. Young age and rapidly progressive neurological deficit might be the characteristics for strangulation of the affected nerves by the cyst capsule. Even though the number of cases might be limited, immediate decompression and release of the strangulating band might be urged in such patients to prevent irreversible deficits.

A Ruptured Dermoid Cyst of the Cavernous Sinus Extending into the Posterior Fossa

Supratentorial dermoid cysts are uncommon to develop in the cavernous sinus. We present a ruptured dermoid cyst of the cavernous sinus extending into the posterior fossa. The patient was a 32-year-old female who complained occipital headache, blurred vision, and tinnitus over 4 years. Brain magnetic resonance (MR) imaging revealed an enhanced tumor in the right cavernous sinus extending into the right temporal base and the posterior fossa with findings of ruptured cyst. Surgical resection was performed, and pathological findings were confirmed to be a dermoid cyst. We report a second case with ruptured dermoid cyst of the cavernous sinus extending into the posterior fossa.

Giant intracranial epidermoids: is total removal feasible?

OBJECT

Epidermoid tumors arise from misplaced squamous epithelium and enlarge through the accumulation of desquamated cell debris. Optimal treatment consists of total removal of the capsule; therefore, giant and multicompartmental tumors are particularly challenging. A conservative attitude in handling the tumor capsule is common given concerns about capsule adherence to neurovascular structures, and thus the possibility of recurrence is accepted with the intent of minimizing complications. This study focuses on the outcome of surgery in patients with giant epidermoid tumors for which total capsule removal was the aim.

METHODS

The authors conducted a retrospective analysis of all patients with giant epidermoid tumors treated by the senior author (O.A.), who pursued total removal of the capsule through skull base approaches. Patients were divided into 2 groups: one including patients with de novo tumors and the other consisting of patients who presented with recurrent tumors.

RESULTS

Thirty-four patients had undergone 46 operations, and the senior author performed 38 of these operations in the study period. The average tumor dimensions were 55 × 36 mm, and 25 tumors had multicompartmental extensions. Total removal of the tumor and capsule was achieved with the aid of the microscope in 73% of the 26 de novo cases but in only 17% of the 12 recurrent tumor cases. The average follow-up among all patients was 111 months (range 10–480 months), and the average postsurgical follow-up was 56.8 months (range 6–137 months). There were 4 recurrences in the de novo group, and every case had had a small piece of tumor capsule left behind. One patient died after delayed rupture of a pseudoaneurysm. In the de novo group, the average preoperative Karnofsky Performance Scale (KPS) score was 71.42%, which improved to 87.14% on long-term follow-up. In the group with recurrences, the KPS score also improved on long-term follow-up, from 64.54% to 84.54%. In the de novo group, 3 cases (11.5%) had permanent cranial nerve deficits, and 4 cases (15.4%) had a CSF leak. In the recurrence group, 3 cases (25%) had new, permanent cranial nerve deficits, and 1 (8.3%) had a CSF leak. Two patients in this group developed hydrocephalus and required a shunt.

CONCLUSIONS

Total removal of the capsule of giant epidermoid tumors was achieved in 73% of patients with de novo tumors and was associated with improved function, low morbidity and mortality, and a lower risk of recurrence. Surgery in patients with recurrent tumors was associated with higher morbidity and persistence of the disease.

Endoscopic endonasal surgery for nonadenomatous sellar/parasellar lesions

INTRODUCTION

This article demonstrates the experience with endoscopic transphenoidal anterior skull base surgery for lesions other than pituitary adenomas. The spectrum of lesions, results, and complications are presented.

PATIENTS AND METHODS

This series includes patients with 102 lesions other than pituitary adenomas operated upon using the endoscopic approach. The results and complications were reviewed retrospectively.

RESULTS

The most common lesions treated were Rathke Cleft Cysts (n = 39) and craniopharyngiomas (n = 18) in a total of 82 tumors. There were 8 patients with inflammatory lesions, and the remainder had a variety of unusual pathologies. Complications other than diabetes insipidus (n = 12) were uncommon, with 6 postoperative cerebrospinal fluid leaks.

CONCLUSIONS

The endoscopic anterior skull base approach is highly effective in treating a large variety of lesions other than pituitary adenomas. The adoption of the nasoseptal flap for closure has markedly reduced the incidence of spinal fluid leaks, and is used routinely for lesions that violate the intracranial compartment.

Analysis of the growth pattern of a dermoid cyst

Dermoid cysts are rare lesions of the CNS with a slow rate of growth. For this reason, they are rarely discovered during infancy. Although benign, these cysts may be associated with devastating complications due to mass effect or meningitis. The discovery of completely asymptomatic dermoid cysts in the pediatric population is exceedingly rare; however, correct and prompt diagnosis is crucial for early surgical treatment to minimize morbidity and mortality. The authors report the unique case of a posterior fossa dermoid cyst discovered in a 5-month-old girl and monitored for 2.5 years with serial imaging studies before performing a resection. The imaging characteristics of dermoid cysts are reviewed, and the challenges associated with the radiographic diagnosis of such lesions are discussed. Analyzing the growth of this particular cyst on MRI allowed comment, for the first time to the authors' knowledge, regarding the growth rate of dermoid cysts. Unlike true tumors, which grow in an exponential pattern, the dermoid cyst in the reported case exhibited a linear growth pattern. The increase in volume followed the classic appearance of a cuboid sequence, which is also consistent with linear growth in all 3 dimensions.

Surgical strategy for intracranial dermoid and epidermoid tumors: An experience with 33 Patients

Background:

The aim of this paper is to report on our surgical strategy and technique and to identify the best management for intracranial dermoids and epidermoids tumors (IDETs).

Methods:

We retrospectively reviewed 33 consecutive patients (14 males and 19 females; mean age at surgery, 37.9 years) with pathologically confirmed IDETs who underwent surgical resection, with mean follow-up of 7.2 years.

Results:

Gross total tumor removal was achieved in 24 cases (72.7%) with zero surgical mortality and a recurrence rate of 9%.

Conclusions:

The surgical strategies used in this group of patients enabled total removal of most tumors without surgical mortality and with low morbidity and recurrence rates, proving to be safe and effective.