A glioependymal cyst of the cerebellopontine angle. Immunohistochemical and ultrastructural studies

Giant supra and retrosellar glioependymal cyst presenting with only precocious puberty. Clinical study and review of the literature

INTRODUCTION AND IMPORTANCE

Intracranial glioependymal cysts are an uncommon type of neuroepithelial cyst and are encountered much less frequently than arachnoid cysts. These cysts primarily manifest within the parenchyma of the brain, although exceedingly rare instances have been reported in the lateral ventricles.

CASE PRESENTATION

We present a highly unusual case of a glioependymal cyst in a 7-year-old girl. The glioependymal cyst was located in the midline in the suprasellar region and extended to the upper clivus region. Its only manifestation was precocious puberty. We performed endoscopic fenestration of the cyst, leading to a return of hormonal levels to normal and a slight reduction in cyst size.

CLINICAL DISCUSSION

A comprehensive search of the Medline database revealed only a few documented cases of glioependymal cysts (fewer than 30 cases). Remarkably, the majority (if not all) were located laterally rather than in the midline of the brain. Endoscopic fenestration and biopsy are effective and confirm the diagnosis.

CONCLUSION

This instance of a rare glioependymal cyst located in the midline, spanning the suprasellar and retrosellar regions, is an uncommon occurrence. Its sole presentation was precocious puberty. The successful management of this condition was achieved through an endoscopic approach, leading to the normalization of endocrine abnormalities.

An Unusual Presentation of Glioependymal Cyst Encroaching Neuronal Parenchyma in an Elderly Female: A Case Report

A glioependymal cyst (GEC) is a rare type of cyst that occurs within the brain and spinal cord. A 42-year-old male patient with a cystic lesion in the right frontal lobe was admitted to the hospital to have his headache, vertigo, and body spasms evaluated. MRI scans showed a mass in the right side of the frontal lobe which caused a mass effect over the lateral ventricle and corpus callosum. The patient became symptom-free after the craniotomy, followed by fenestration of cortices and cyst wall removal.

Cerebellar Glioependymal Cyst

Glioependymal cyst (GEC) is an uncommonly observed clinical entity in the posterior cranial fossa. A 36-year-old female with cystic lesion in the right cerebellum was hospitalized for evaluating headache and dizziness. Brain images showed a well-defined, ovoid mass adjacent to the fourth ventricle. After drainage and excision of the cyst, the patient became symptom free. Pathology examination disclosed low cuboidal epithelium and glial cells in the cyst wall. The radiological features, neurological manifestations, and the operations for GECs of the present localization are described in this short communication.

Nerve-Sheath-Risen Neuroglial Cyst: A Case Report and Review of the Literature

BACKGROUND

Neuroglial cysts are rare intracranial lesions that are believed to originate from the sequestration of neural tube lining during embryogenesis. They can present anywhere within the neuraxis; however, their most common location is the frontal lobe. Cerebellopontine angle (CPA) neuroglial cysts are extremely rare and to the best of authors' knowledge, there are no previous reports of a neuroglial cyst arising from cranial nerves.

CASE DESCRIPTION

The current study presented a male adolescent with the reoccurrence of an intracranial cyst with symptoms of diplopia and facial numbness primarily treated as CPA arachnoid cyst with fenestration of the cyst 12 months prior to admission to our center. Different magnetic resonance imaging (MRI) sequences showed a thin-walled extra-axial cyst at the right CPA without gadolinium (Gd)-enhancement. Direct visualization of the lesion revealed a cyst arising from the 5th cranial nerve sheath compressing the surrounding structures. The cyst was fenestrated and a biopsy was taken from the cyst wall. The pathological analysis along with specified histological markers indicated the neuroglial nature of the cyst.

CONCLUSION

The rising of a neuroglial cyst from the nerve sheath is a finding that brings other possible origins of neuroglial cysts into consideration.

An ependymal cyst in cerebello-pontine angle presenting with syncope

Intracranial ependymal cysts are rare, congenital, benign lesions. These commonly occur in the supratentorial regions and usually generate no symptoms. The cerebellopontine angle (CPA) is an extremely rare site for ependymal cysts. Furthermore, there are no previous reports of CPA ependymal cysts related to syncope. We report a case of ependymal cyst in the left CPA with syncope. The patient underwent a cardiologic evaluation for syncope after admission, but there were no definite cardiologic abnormal findings. He underwent fenestration into the subarachnoid space, and the pathologic diagnosis revealed an ependymal cyst. We analyzed this case with review of other literatures.

[Intramedullary neuroglial cyst: a case report]

BACKGROUND AND PURPOSE

Neuroglial cysts are uncommon congenital lesion with own wall, which can be confined into or outside the central nervous system. In the central nervous system the cyst is located commonly in the brain. Spinal intramedullary neuroglial cyst are exceptional. Our objective is to present a case of intramedullary neuroglial cyst, to discuss the differentiels diagnosis and to show difficulties of its medical taking care.

CASE REPORT

A 60 year-old man, without past history, was admitted to the hospital with a compression of conus medullaris since one year. The clinical examination revealed paraparesis and genito-sphincterian disorders. MRI of the spine revealed intramedullary cyst at T12-L1 level. The patient underwent cystic evacuation, a large marsupialization of the cavity and a wall biopsy. Histopathological examination confirmed the diagnosis of neuroglial cyst. The postoperative outcome was favourable with a partial improvement of motor weakness. Postoperative MRI showed a persistent residual cavity.

CONCLUSION

Neuroglial intramedullary cyst is uncommon. It is a benign lesion. Complete surgical resection is very difficult seen the absence of defined plan cleavage.

Supratentorial Arachnoid Cyst Located in the Brain Parenchyma: Case Report

BACKGROUND AND IMPORTANCE:

Arachnoid cysts have not been reported to be located within the brain parenchyma. We present a case of an arachnoid cyst that was contained entirely within the right frontal lobe devoid of communication with the subarachnoid space and ventricle.

CLINICAL PRESENTATION:

A 65-year-old woman presented with a 1-year history of progressive headache and nausea. Computed tomographic and magnetic resonance imagining scans showed a well-defined, nonenhancing mass measuring 5 × 5 × 3.5 cm in the right frontal lobe. The mass appeared to be contained entirely within the brain parenchyma. The patient underwent a right frontal craniotomy, at which time the cystic mass was identified in the brain parenchyma without any communication with the arachnoid space. The cyst contained a clear fluid, and its wall was excised. The fluid contents demonstrated a composition similar to that of normal cerebrospinal fluid. Histological and immunohistochemical examinations of the cyst wall were compatible with the diagnosis of an arachnoid cyst. Postoperatively, the symptoms of the patient resolved, and no recurrence was observed up to 6 months after removal.

CONCLUSION:

The present case showed an intraparenchymal arachnoid cyst arising in the frontal lobe. Although the etiology is not known, an arachnoid cyst should be included in the differential diagnosis of primary intracerebral cysts.

Ependymal cyst with hemorrhage in the cerebellopontine angle

Ependymal cysts are rare intracranial neoplasms. These lesions occur in the cerebral parenchyma, subarachnoid space, and juxtaventricular, intraspinal, and intramedullary regions. They occur extremely rarely in the cerebellopontine angle (CPA). There are no prior reports of CPA ependymal cyst with hemorrhage. We report a 79-year-old woman who experienced sudden onset of dizziness and vomiting. A CT scan and MRI revealed a cystic lesion with internal hemorrhage in the left CPA. Surgical resection via a left retrosigmoid approach was performed. Pathological examination revealed that the lesion was an ependymal cyst. To our knowledge, this is the sixth reported case of an ependymal cyst located in the CPA; however, our case had the unique presenting feature of hemorrhage. We review the clinical manifestation, pathogenesis, and management of these cysts.

Cerebellar Ependymal Cyst in a Dog

An 11-week-old, male, Staffordshire Bull Terrier had a history of generalized ataxia and falling since birth. The neurologic findings suggested a localization in the cerebellum. Magnetic resonance imaging of the brain was performed. In all sequences the area of the cerebellum was almost replaced by fluid isointense to cerebrospinal fluid. A complete necropsy was performed after euthanasia. Histologically, the lesion was characterized by extensive loss of cerebellar tissue in both hemispheres and vermis. Toward the surface of the cerebellar defect, the cavity was confined by ruptured and folded membranes consisting of a layer of glial fibrillary acidic (GFAP)-positive glial cells covered multifocally by epithelial cells. Some of these cells bore apical cilia and were cytokeratin and GFAP negative, supporting their ependymal origin. The histopathologic features of our case are consistent with the diagnosis of an ependymal cyst. Its glial and ependymal nature as demonstrated by histopathologic and immunohistochemical examination differs from arachnoid cysts, which have also been reported in dogs. The origin of these cysts remains controversial, but it has been suggested that they develop during embryogenesis subsequent to sequestration of developing neuroectoderm. We speculate that the cyst could have been the result of a pre- or perinatal, possibly traumatic, insult because hemorrhage, and tissue destruction had occurred. To our knowledge, this is the first description of an ependymal cyst in the veterinary literature.

Giant Supratentorial Enterogenous Cyst: Report of a Case, Literature Review, and Discussion of Pathogenesis

OBJECTIVE AND IMPORTANCE

To describe a histologically well-documented adult case of a giant supratentorial enterogenous cyst (EC). Fewer than 15 cases of supratentorial ECs are on record: 8 associated with the brain hemispheres or the overlying meninges, 4 with the sellar region, and 2 with the optic nerve.

CLINICAL PRESENTATION

A 31-year-old woman complained of long-standing mild left brachial and crural motor deficit precipitated by headache and signs of intracranial hypertension. Magnetic resonance imaging revealed a huge cyst overlying the frontoparietal brain.

INTERVENTION

Symptoms were relieved by evacuation of the cyst content by means of a Rickam's reservoir, and the lesion was subsequently removed in toto. Histological and immunohistochemical examination of the cyst wall clearly established the enterogenous nature of its epithelium. Follow-up for up to 2 years after intervention showed no sign of recurrence, and symptoms, including treatment-resistant seizures in the postoperative period, have entirely subsided.

CONCLUSION

Supratentorial ECs, distinctly rare in adult patients, may in some cases present as giant lesions. Total removal seems to be curative once careful examination has eliminated the possibility of a metastasis from an unknown primary. A correct histological diagnosis is important because, in contrast to other benign cysts of similar location and size, ECs may be prone to intraoperative dissemination.

Neuroepithelial cysts of the middle ear

Neuroepithelial cysts are lesions of the central nervous system that have previously been reported in cerebral parenchyma, in the spinal cord, and within the ventricles in association with the choroid plexus. We describe 2 cases of neuroepithelial cysts of the middle ear. One was diagnosed after surgery for a retraction pocket and chronic otitis media complicated by an intraoperative cerebrospinal fluid (CSF) leak. The other produced bilateral spontaneous CSF otorrhea and mimicked the presentation of arachnoid granulations. Both cases were verified with immunohistochemical stains. Neuroepithelial cysts, although rare, should be considered in the differential diagnosis of spontaneous CSF otorrhea or an epitympanic mass.

Hemifacial spasm associated with an ependymal cyst in the cerebellopontine angle. Case report

No previous case of hemifacial spasm associated with an ependymal cyst has been reported in the literature. In this article the authors report the first case in which hemifacial spasm accompanied an ipsilateral cerebellopontine angle ependymal cyst in a 27-year-old woman. Cyst fenestration and arterial decompression of the facial nerve at the root exit zone resulted in complete resolution of the patient's symptoms. A histopathological study including immunohistochemical methods identified an ependymal cyst.

Symptomatic ependymal cysts of the perimesencephalic and cerebello-pontine angle cisterns

Primary intracranial ependymal cysts are extremely rare. These are congenital, benign ependyma lined, commonly intraparenchymal and uncommonly extraparenchymal cysts in leptomeningeal location of variable size seen in the adult life. The authors report two cases of symptomatic ependymal cysts: one in the perimesencephalic cistern in a 10-month-old infant presenting with delayed mile stones and another in the cerebello-pontine cistern in a morbidly obese 35-year-old woman with known benign intracranial hypertension now presenting with hemifacial spasm. Neurosurgical intervention was curative in both cases. Interesting clinical, radiological and histological features are presented and discussed.

Supratentorial ectopic ependymoma

BACKGROUND

Ependymomas usually arise from the ventricular surface.

METHODS

We report an 11-year-old female who presented with a supratentorial ectopic ependymoma.

RESULTS

The patient presented with a two-month-history of progressive headache, nausea and vomiting. Examination revealed papilledema, horizontal nystagmus, diplopia on upward gaze, and right pronator drift. CT scan showed an enhancing left precentral subcortical lesion measuring 3 cm in diameter with associated edema and mass effect. Its medial border was located 3 cm from the ependymal surface of the ventricle. A firm tumour was dissected from the centrum semiovale white matter, and removed in toto as confirmed on MRI. Pathological examination revealed histological, immuno-histochemical and electron microscopic features consistent with an ependymoma. Spine MRI and bone marrow aspirate, as well as lumbar puncture of cytology failed to show any dissemination.

CONCLUSION

From the literature review, this represents an exceptional ependymoma located at the distance from the ventricular system or cisterns. Different pathogenic alternatives are discussed.

Glioependymal cyst of the cerebellopontine angle

Images

Large ependymal cyst of the cerebello-pontine angle in a child

Most ependymal cysts occur intracerebrally, with a few cases situated in the subarachnoid space. The cerebellopontine angle is a common site for arachnoid cysts, but a very rare site for ependymal cysts. A case is described here of a large ependymal cyst in the cerebellopontine angle. A 12-year-old girl with left hearing disturbance was admitted. CT and MRI revealed a cystic tumor in the left cerebellopontine angle. At operation, we obtained a discrete thin-walled cyst which had arisen from a continuation of the choroid plexus of the lateral foramen of Luschka, which had no connection with the arachnoid. The cyst proved to be an ependymal cyst.

Colloid cysts of the third ventricle: ultrastructural features are compatible with endodermal derivation

The histogenesis of colloid cyst of the third ventricle remains unsettled. Ultrastructural and immunohistochemical analyses have suggested the following possible origins: (a) neuroepithelium, including paraphysis, ependyma, choroid plexus and tela chorioidea; and (b) endoderm, including respiratory and enteric epithelium. This report describes the ultrastructural features of the lining epithelium in four cases of colloid cyst. Six distinct cell types were recognized: (1) ciliated cells with occasional abnormal cilia; (2) non-ciliated cells with microvilli coated with granulofibrillary material; (3) goblet cells showing discharge of secretory granules; (4) basal cells with prominent tonofilaments and desmosomes; (5) basal-located cells with elongated electron-lucent cytoplasm and scattered membrane-bound dense-core granules (150-350 nm); and (6) small undifferentiated cells with scanty organelles. Junctional complexes were present in the former four cell types but absent in the latter two. The types of epithelial cells and their topographic distribution within the epithelium are both very similar to those of normal respiratory epithelium and to the lining epithelium of intraspinal bronchogenic cyst. The observations made in the present study are compatible with the hypothesis that colloid cysts of the third ventricle originate from the endoderm, most likely the respiratory epithelium.

Posterior fossa cysts: clinical, neuroradiological and surgical features

Various types of neuroimaging investigations were performed in 26 patients with posterior fossa cysts. The results were retrospectively analyzed to facilitate differential diagnosis and clarify indications for surgery. Four major findings were obtained in this study. First, posterior fossa intra-arachnoid cysts were encountered more frequently than expected and were found to be surgically treatable. Second, although IV ventricular cysts were categorized as Dandy-Walker malformation, Dandy-Walker variant, and persistent Blake's pouch in this study, the distinctions of neuroimaging findings between these three types are uncertain. Third, the diagnostic criteria for mega cisterna magna were established, and it was found to be a surgically untreatable condition. Finally, in cases with the following neuroimaging findings, surgery appears to be indicated: (1) occipital bossing or petrosal scalloping with distortion or obliteration of cerebrospinal fluid (CSF) cisterns of the posterior fossa; (2) compression and deformity of the brain surrounding the cyst; (3) radioisotope and/or computed tomography cisternographic findings suggestive of disturbance of intracystic CSF circulation; (4) a non-communicating cyst.

An epithelial cyst in the cerebellopontine angle. Case report

A case of a benign epithelial cyst in the posterior cranial fossa is described. It had the unique histological feature of a double-layered cuboidal epithelial lining. Detailed immunohistochemical and electron microscopic studies supported an endodermal origin. The differential diagnosis and the histogenesis of epithelial cysts in the central nervous system are discussed.

Ventral brain-stem compression from a subarachnoid ependymal cyst

A case of ventral brain-stem compression by a congenital subarachnoid ependymal cyst in an infant is presented. Marsupialization of the cyst provided effective decompression and clinical improvement. Immunohistochemical staining demonstrated the glial nature of the epithelium. The fact that these cysts may be congenital, as demonstrated here, supports the hypothesis that they arise from glial elements that have been displaced during development.

Epithelial cyst in cerebellopontine angle with xanthogranulomatous changes simulating cholesterol granuloma

We describe the clinical, radiological, and pathological features of an epithelial lined cyst in the cerebellopontine angle of a 54-year-old man who presented with headaches, ataxia, and multiple cranial nerve dysfunction. The surgically excised lesion showed a cyst lined by ciliated columnar epithelium with copious mucin secretion similar to that seen in colloid cysts of the third ventricle and enterogenous cysts of the spinal canal. In addition the cyst contained brownish material with an exuberant xanthogranulomatous reaction and numerous cholesterol clefts. This lesion closely resembled a cholesterol granuloma by radiographic and pathologic studies. Although two examples of neuroepithelial lined cysts have been described in the cerebellopontine angle, to our knowledge a lesion similar to that in our patient has not been reported previously.

Intraparenchymal epithelial (enterogenous) cyst of the medulla oblongata

Intraparenchymal solitary cyst of the medulla oblongata was diagnosed on MRI examination in a 66-year-old woman with a nine year history of progressive brainstem dysfunction and three negative CT scan examinations. Craniotomy and drainage of the cyst to the IVth ventricle led to remarkable clinical recovery. Biopsy of the wall of the cyst revealed an epithelial lining with tonofilaments, desmosomes and surface coating on ultrastructural examination. Immunohistochemistry demonstrated positive reactions of epithelium for keratins, cytokeratins, epithelial membrane antigen and Ulex Europeus lectin, indicating endodermal origin of the cyst.

Intraspinal bronchogenic cyst: ultrastructural study of the lining epithelium

This report describes the ultrastructural characters of the lining epithelium of a symptomatic intraspinal bronchogenic cyst at the C5-T2 level of a 21-year-old female. Six distinct cell types were recognized: ciliated cells, non-ciliated cells, and goblet cells that reached the lumen, and basal cells, Kulchitsky cells and undifferentiated cells that were basally located and did not reach the lumen. The microvilli of non-ciliated cells were coated with granulofibrillary material. Discharge of granular contents from goblet cells was noted. Abnormal cilia, particularly compound cilia, were frequent. Complex interdigitations of cytoplasmic membrane with prominent desmosomes were present in the pseudostratified region. Kulchitsky cells contained characteristic membrane-bound dense-core neurosecretory granules. Intraepithelial unmyelinated axons were observed but none were closely associated with Kulchitsky cells. The types of cells forming the lining epithelium of the present cyst and their topographic distribution within the epithelium are very similar to those of the normal tracheobronchial epithelium.

Subarachnoid epithelial cyst of the cerebellum. Immunohistochemical and ultrastructural studies

This report describes the immunohistochemical and ultrastructural studies of a subarachnoid epithelial cyst of the cerebellum found incidentally at autopsy of a 76-year-old man. The cyst was composed of an inner epithelial layer, a middle connective tissue layer and an outer arachnoid membrane. The epithelial layer was strongly positive for cytokeratin, carcinoembryonic antigen and epithelial membrane antigen, but negative for glial fibrillary acidic protein, S-100 protein, neuron-specific enolase and vimentin. Ultrastructurally, the epithelial layer had four distinct types of cells: ciliated cells, non-ciliated cells with coated microvilli, basal cells with tonofilaments and desmosomes, and cells with dense-core secretory granules (Kulchitsky cells). The latter two types of cells have not been described previously in epithelial cysts of the CNS. The lining epithelium closely resembled the upper respiratory epithelium. The findings suggest that the cyst was of endodermal rather than neuroectodermal origin.