Neurenteric cysts: risk factors and management of recurrence

A ventral brainstem neurenteric cyst - A case report and review of the pre-brainstem location

Background

Neurenteric cysts are uncommon, benign endoderm-derived lesions that result from aberrant embryologic development of the notochord. They are typically located in the intradural extramedullary spinal cord and rarely located intracranially. Contrary to spinal-located cysts, intracranial cysts are rarer in the pediatric population. Clinically, they may present with symptoms of mass effect, or they can be incidentally discovered.

Case Description

A 10-year-old healthy female child presented with recurrent headaches. The physical and neurological examination was unremarkable. Brain magnetic resonance imaging (MRI) showed a well-demarcated lesion anterior to the pontomedullary junction with striking T1 and T2/T2 fluid-attenuated inversion recovery high-signal intensity and a small rounded nodule within of low signal on T1, T2, and T2*. On initial conservative strategy with serial brain MRI, there was a progressive enlargement of the lesion with significant mass effect on the brainstem. The patient underwent a right retrosigmoid craniotomy, and the cyst wall was fenestrated and drained. Part of the cyst wall and the solid nodule were adherent to the brainstem and basilar artery and were not removed. The histologic findings were consistent with the diagnosis of a benign endodermal cyst. The postoperative period was uneventful.

Conclusion

We report a successful surgical treatment of this rare congenital cyst located in the ventral brainstem. We present pre-and post-operative imaging findings, intraoperative microscopic images of the procedure, and a brief review of relevant clinical literature on the topic.

Supratentorial Neurenteric Cysts: Systematic Literature Review and Case Report

BACKGROUND

Neurenteric cysts (NC) are uncommon, congenital lesions with histopathologic properties derived from the gastrointestinal or respiratory tract. They are typically located in the intradural extramedullary compartment but rarely seen in the supratentorial region. The occurrence of supratentorial NCs (S-NC) presents an interesting quandary regarding their embryopathogenesis.

METHODS

We present a case report and systematic literature review on S-NCs following PRISMA guidelines.

RESULTS

A 57-year-old woman presented with a seizure and paresthesias of the face, hands, and feet. MRI revealed a right temporo-occipital cystic lesion, which was managed with surgical resection. Histologically the cyst was Type A. The patient is without recurrence at 10 months. Including this case, 88 S-NCs are reported in the literature. Common presenting symptoms are headaches and seizures. They were mostly treated with craniotomy, preferably with gross total resection (GTR), although sub-total resection (STR) may be necessary due to adhesions. Resection usually led to symptom improvement (61%). Malignant transformation was seen in 3%. Recurrence was seen in 17%, with a mean time to recurrence of 4.2 years, and was significantly more common after STR than GTR.

CONCLUSIONS

If surgically resected, the cyst wall specimen should be sent for pathology review, because of the potential risk for malignancy. If conservatively managed, serial imaging is warranted to track for changes that may indicate transformation. The embryopathogenesis of these rare congenital lesions remains incompletely understood, but the most comprehensive theory involves enteric cell migration to the neuroectoderm during embryogenesis.

Supratentorial Intraparenchymal Neurenteric Cyst Treated by Neuroendoscopic Fenestration: A Case Report and Review of Literature

Neurenteric cysts (NCs) are rare benign congenital neoplasms in the central nervous system that originate from endodermal elements. NCs are more commonly located in the spine than in the brain. Although almost all intracranial NCs are found in the posterior fossa, some have reported supratentorial NCs. The complete excision of the cyst wall is suggested as a curative treatment; however, endoscopic treatment is less discussed. We present a supratentorial intraparenchymal NC in the frontal lobe treated by neuroendoscopic fenestration and review the literature regarding supratentorial NCs. A 43-year-old woman presenting with right hemiparesis and gait disturbance who was found to have a huge cystic lesion with calcification in her left frontal lobe underwent endoscopic fenestration to the ipsilateral lateral ventricle and biopsy. The histopathological diagnosis was consistent with NC. Postoperatively, her right hemiparesis and gait disturbance disappeared. Postoperative MRI showed shrinkage of the cyst. She was discharged without neurological deficits and no recurrence was seen 1 year after surgery. To the best of our knowledge, there have been no reports of a supratentorial intraparenchymal NC treated by neuroendoscopic fenestration. Minimally invasive treatments, such as neuroendoscopic cyst fenestration, can be considered depending on the location of the cyst.

Combined endoscopic endonasal transtubercular and transclival approaches for large neurenteric cyst in posterior cranial fossa: A case report and literature review

Background:

Intracranial neurenteric cysts (NCs) are extremely rare tumors that more commonly involve the posterior fossa than any other cranial part. While transcranial skull base surgery has been the mainstay of treatment, the utility of endoscopic transnasal surgery (ETS) remains to be established.

Case Description:

We report a case of a large posterior fossa NC extensively involving the suprasellar region, cerebellopontine angle, and prepontine cistern, which we successfully resected with ETS through a combination of transtubercular and transclival routes. Before surgery, the patient presented with abducens nerve and pseudobulbar palsies, which resolved within 2 weeks postoperatively. The patient remained free from recurrence for 3 years postoperatively.

Conclusion:

Extended ETS may offer a minimally invasive option for the posterior fossa NC, extensively occupying the ventral space of the brainstem.

Pediatric intracranial neurenteric cyst of the oculomotor nerve: a case-based review

BACKGROUND

Neurenteric cysts (NECs) of the central nervous system (CNS) are uncommon congenital entities arising from embryonal elements. Intracranial NECs in the pediatric population are rare.

METHODS

The authors describe the presentation, radiographic imaging, and pathologic findings of an 11-year-old boy with a right oculomotor nerve NEC. A literature review was performed to identify additional cases of pediatric intracranial NECs published in the English language, over the past 30 years (1990-2020). The authors discuss the presentation, investigations, management, and prognosis of this interesting entity.

RESULTS

We describe an 11-year-old boy who presented to neurosurgical attention with disconjugate gaze, anisocoria, and ptosis. Magnetic resonance imaging (MRI) demonstrated a lobulated, cystic, and peripherally enhancing mass involving the right oculomotor nerve. The patient underwent pterional craniotomy for drainage of the cyst and subtotal resection of the cyst wall. The tan-colored mass was displacing the basilar artery, compressing the cerebral peduncle, and adherent to the inferior surface of the tentorium. The lesion was within the oculomotor nerve and splitting the fibers, and the cystic contents were thick and mucinous. Histopathological examination of the specimen demonstrated a thin fibrous cyst wall with scattered inflammatory cells and lined by simple columnar epithelium containing mucin. The lining cells were immunoreactive with epithelial membrane antigen (EMA) and pan-keratin AE1/AE3. The diagnosis of a NEC was rendered. A comprehensive literature review of pediatric intracranial NECs yielded 46 additional lesions published in the literature, involving the skull base, posterior fossa, cerebral convexity, and cranial nerves. NECs present with local mass effect and less commonly, with aseptic meningitis or intracystic hemorrhage. Maximal safe GTR remains the mainstay management, although cyst drainage and marsupialization, cyst shunting, and fenestration of cystic contents into the ventricle or basal cisterns have been reported with variable success.

CONCLUSION

CNS NECs are rare congenital entities; although they occur less frequently in the intracranial components compared to the spine, their diagnosis and management should be considered for intracranial cystic lesions. Maximal safe GTR is the mainstay treatment and frequently yields favorable outcomes.

Predictors for complete surgical resection of posterior fossa neurenteric cysts: A case report and meta-analysis

Background

Incomplete resection of neurenteric cysts (NCs) has been associated with increased recurrence rates in patients compared to complete resection (CR) and information on intracranial NCs appearance on diagnostic imaging is scarce. We sought to identify factors associated with CR and provide the largest up-to-date review of NCs appearances on various diagnostic images.

Methods

Data from Medline, EMBASE, and Web of Science were extracted. Univariate and multivariate logistic regression models were used to analyze factors associated with CR.

Results

A total of 120 publications reporting 162 original cases on posterior fossa NCs met the inclusion criteria for analysis. Eighty-nine (55.6%) of the patients were female, the mean (SD) age of the patients' during operation was 34.3 (16.9) years, and CR was achieved in 98 (60%) of patients. Univariate analysis identified male sex as a statistically significant predictor for complete reaction (OR 2.13, 95% Cl 1.10-4.11, P = 0.02). The retrosigmoid approach (OR 1.89, 95% Cl 0.98-3.63, P = 0.06), far lateral approach (OR 0.46, 95% Cl 0.21-1.02, P = 0.06), and pediatric patient (OR 2.45, 95% Cl 0.94-6.56, P = 0.07) may be possible predictors for CR, however, they were not statistically significant. NCs are mainly hypodense on CT (32 [61.5%]), varied greatly in intensity on T1WI, hyperintense on T2WI magnetic resonance imaging (98 [67.1%]), and hyperintense on fluid-attenuated inversion recovery (17 [63.0%]).

Conclusion

We recommend utilizing various diagnostic imaging tests to help reduce misdiagnoses when identifying intracranial NCs. For patient safety, CR should be achieved when possible, to reduce risk of additional operations due to recurrence.

Endodermal Cysts of the Central Nervous System: Review of the Literature and a Case Report

Context

Endodermal cysts are rare benign developmental cysts lined by mucin-secreting and/or ciliated, cuboidal, or columnar epithelium of probably endodermal origin.

Aims

Endodermal cysts are rarely intracranial, frequently located in the posterior fossa. Supratentorial location is the most infrequent and only few cases are reported in the literature, included our case.

Settings and Design

The authors report a case of intracranial supratentorial endodermal cyst with a review of the literature.

Subjects and Methods

A 40-year-old woman was admitted to our department because of progressive gait disorder for 3 months due to right brachial and crural motor deficit associated to right crural sensory disorder (tactile hypesthesia) and right Babinski response at neurological examination due to an endodermal cyst located in the left frontoparietal convexity.

Discussion

Total resection of endodermal cysts is recommended, despite their location and adhesion to the surrounding structures, due to its high risk of recurrence. Fenestration of the cystic content into the subarachnoid cistern may cause obstructive hydrocephalus or chemical meningism.

Results

Although rare, surgeons should be aware that these lesions must be differentiated clinically, radiologically, and histologically from other supratentorial cystic lesions.

Intracranial neurenteric cyst: A case report and differential diagnosis of intracranial cystic lesions

Neurenteric cysts are uncommon, benign lesions that are rarely located intracranially. These cysts are likely due to aberrant embryologic development of the notochord. Clinically, neurenteric cysts may present with symptoms of mass effect, or they can be asymptomatic and incidentally discovered. Imaging features of neurenteric cysts have significant overlap with other intracranial cystic lesions, which can make diagnosis difficult. We present a case of a 35-year-old female with a histopathologically confirmed neurenteric cyst in the premedullary and left cerebellomedullary cistern, with associated symptoms of headache, dizziness, tinnitus, and dysphagia. The patient underwent surgical resection, with improvement in symptoms. We present a review of literature, and a discussion of typical features of multiple intracranial cystic lesions. We hope to promote accurate preoperative diagnosis, to allow for appropriate surgical technique to reduce the risk of recurrence.

Therapeutic Strategies and Prognostic Factors Based on 121 Spinal Neurenteric Cysts

BACKGROUND

Limited data existed to guide the management of intraspinal neurenteric cysts (ISNECs).

OBJECTIVE

To evaluate the risk factors for progression-free survival (PFS), elucidate the radiological features of ISNECs, and propose a treatment protocol.

METHODS

From 2003 to 2015, 121 patients with pathologically confirmed ISNECs treated at our institute were included in this study. Pertinent risk factors were evaluated.

RESULTS

Gross total resection (GTR) was achieved in 55 (44.6%) patients; 106 (87.6%), 12 (9.9%), and 3 (2.5%) ISNECs were classified as Wilkins A, B, and C, respectively. After a median follow-up duration of 64.2 mo, recurrence occurred in 25 (22.7%) patients, with a median PFS time of 43.1 mo. The actuarial PFS rates at 5 and 10 yr were 73.2% and 66.2%, respectively. The actuarial overall survival rates at 5 and 10 yr were 100% and 97.6%, respectively. Non-GTR (hazard ratio [HR], 5.836; 95% confidence interval [CI], 1.698-20.058; P = .005), Wilkins B/C (HR, 3.129; 95% CI, 1.009-9.702; P = .048), and a history of surgical resection (HR, 3.690; 95% CI, 1.536-8.864; P = .004) were adverse factors.

CONCLUSION

GTR and Wilkins A were favorable factors for PFS. If tolerable, GTR alone was advocated as an optimal treatment. Because of the benign nature and favorable prognosis, non-GTR was an alternative if GTR failed. Close follow-up was needed because of the recurrent tendency of ISNEC. Future study with a large cohort is necessary to verify our findings.

Endodermal Cyst with a Non-enhancing Nodule in the Quadrigeminal Cistern Developed in an Octogenarian

BACKGROUND

Intracranial endodermal cysts are congenital lesions that generally develop in the cerebellopontine angle and ventral brainstem of the posterior fossa, whereas endodermal cysts in the quadrigeminal cistern are very rare. We report a rare case of an endodermal cyst in the quadrigeminal cistern with a non-enhancing nodule that developed in patient over 80 years of age.

CASE DESCRIPTION

An 85-year-old man presented to our hospital with progressing gait disturbance and urinary incontinence. Preoperative images showed a cystic mass lesion with a nodule in the quadrigeminal cistern and hydrocephalus. There was no enhanced portion in the lesion, and the intensity of the cyst on magnetic resonance imaging revealed a high protein concentration. Subtotal resection was performed due to the adhesion of the cyst to the brainstem. It was diagnosed as an endodermal cyst. The postoperative course was uneventful, and hydrocephalus improved.

CONCLUSIONS

This is a rare case of an intracranial endodermal cyst in terms of location and age of onset compared with previous reports. This case demonstrates that endodermal cysts should be considered as a differential diagnosis for lesions in the quadrigeminal cistern with high protein concentration in the cyst and nodule representing chronic inflammation, regardless of enhancing effects.

Endodermal Cyst Arising from the Oculomotor Nerve: A Case Report Outlining the Novel Insertion of Cysto-subarachnoid Shunt for Refractory Disease

BACKGROUND

Endodermal cysts of the oculomotor nerve are rare presentations. Only case reports are available to help guide clinicians with managing this rare entity.

CASE DESCRIPTION

A 3-year-old boy presented with an acute on chronic left oculomotor nerve palsy due to a left interpeduncular cistern cyst found on magnetic resonance imaging. He underwent a left pterional craniotomy and fenestration of the histologically proven endodermal cyst and had initial improvement at the 2-month review. He subsequently developed clinical and radiologic evidence of recurrence and was treated surgically with a refenestration and insertion of a cysto-subarachnoid shunt through a trans-sylvian approach. At 6-month follow-up, there was complete resolution of the oculomotor nerve palsy with interval development of oculomotor synkinesis.

CONCLUSIONS

Magnetic resonance imaging is an essential modality in the follow-up of these patients postoperatively in the setting of unchanged or deteriorated neurology. Fenestration of the cyst is appropriate first-line surgical management; however, a cysto-subarachnoid shunt is a safe consideration in recurrent, symptomatic cysts and provides sustained symptom resolution.

Bronchogenic Cyst: Skull Base Lesions with Extracranial Extension

BACKGROUND

Intracranial bronchogenic cysts (BCs) are extremely rare. To our knowledge, this is the first report of a BC in which lesions involve the middle and posterior cranial fossa, as well as the infratemporal fossa.

CASE DESCRIPTION

We present the case of a 38-year-old woman who suffered from a cranial nerve dysfunction for 2 years. Magnetic resonance imaging showed that there were skull base communication lesions across the middle and posterior fossa. The patient was operated on through an infratemporal fossa approach. The final diagnosis was BC after histopathologic examination and immunohistochemical verification. The patient's neurologic dysfunction was partially ameliorated at the half-year follow-up.

CONCLUSIONS

Intracranial BCs are rare. However, they should be considered in the differential diagnosis for cystic lesions with edge enhancement or extracranial extension.

Neurenteric cyst secondary to lumboperitoneal shunt

Background:

Neurenteric cysts are rare lesions that typically present in the upper thoracic and cervical spine and are occasionally found intracranially. The optimal treatment is gross total excision as subtotal/partial excisions are associated with high recurrence rates.

Case Description:

For the past 10 years, a patient with pseudotumor cerebri required repeated lumboperitoneal (LP) shunt revisions. This resulted in multiple neuroenterogenous cysts occurring around the proximal LP subarachnoid shunt catheter, a finding likely attributable to retrograde flow from the peritoneal cavity.

Conclusion:

Unlike ventriculoperitoneal (VP) shunts and LP shunts do not contain valves, making the retrograde passage of enterogenous cells possible when abdominal pressure exceeds lumbar subarachnoid pressure, especially in the morbidly obese patient.

A rare presentation of a pediatric neurenteric cyst as an intra-axial pontine lesion: A case report with a 5-year follow-up

Background

Intracranial neurenteric cysts are rare, benign, and slow-growing tumors. However, we encountered a pediatric case that the cyst expansion occurred in a short period of time resulting in rapid deterioration of the patient's symptoms.

Case Description

A previously healthy 7-year-old girl had a week history of dysarthric speech and diplopia along with headaches. Her magnetic resonance images (MRI) showed an abnormal cystic mass in her brainstem. Her symptoms were deteriorated for 1 month and her second MRI revealed an enlargement of the cystic lesion. The tumor biopsy and cyst drainage were carried out and histopathological examination of the cyst wall showed columnar epithelium containing ciliated cells. The final diagnosis of her tumor was neurenteric cyst.

Conclusion

We report a pediatric case of a neurenteric cyst in the brainstem, which expanded in a short period, and review this rare entity.

Diagnostic Dilemma in Discriminating Between Spinal Neurenteric Cysts and Simple Arachnoid Cysts Based on Embryogenesis and Surgical Correlation

BACKGROUND

Neurenteric cyst (NEC) is a rare intradural spinal tumor, but a correct preoperative diagnosis remains challenging. A misdiagnosis of arachnoid cyst (AC) often leads to conflicting surgical management and significantly higher recurrence.

CASE DESCRIPTION

We report the case of a 26-year-old woman who presented with progressive spastic quadriparesis with myelopathy below the C4 level, which was caused by a ventral intradural extramedullary cystic tumor at the C3-4 level. Magnetic resonance images showed the cystic content as identical to cerebrospinal fluid, which prompted the tentative diagnosis of spinal AC. Surgical fenestration was scheduled. However, intraoperative findings of a thick-walled cyst and severe adhesion to the neural structure without a history of trauma and inflammation were more compatible with the pathogenesis of an NEC. Because of the high recurrence rate after an incomplete resection of an NEC, we did a complete resection of the cyst with adhesive rootlets instead. Pathology analysis and immunohistochemical staining confirmed the diagnosis of an endodermal-derived NEC.

CONCLUSIONS

NECs must be differentiated from ACs because they are different diseases and require different surgical management. In cases with clear cystic content, however, the diagnosis is likely to be AC, but a thick cystic wall and structural adhesions should suggest the differential diagnosis of NEC. Gross total removal of NECs should be attempted to reduce NEC recurrence.

Supratentorial neuroenteric cyst in children: a case report and brief literature review

Neurenteric cysts are rare developmental lesions typically found outside the central nervous system but when they do, we most likely find them in a spinal (cervical or dorsal) intradural extramedular location, often associated with dysraphism. The more unusual intracranial cases have been published because of its rarity, occurring mostly as a posterior fossa extra-axial cyst, in adults. Supratentorial cases are distinctly infrequent, especially in children, resulting in few case reports and even fewer case reviews. We describe a case of a child with a supratentorial neurenteric cyst and present a brief review of the literature about these cysts in children, a noticeable gap in the literature.

Intracranial neurenteric cyst arising at the suprasellar cistern with extension to middle cranial fossa

INTRODUCTION

Intracranial neurenteric cysts are rare and are not often found in the supratentorial space. We present a case of an intracranial neurenteric cyst that arose at the suprasellar cistern with extension to the middle cranial fossa.

HISTORY

A 3-year-old girl presented with seizure. Neuroimaging showed a huge extra-axial cyst involving the suprasellar cistern and left middle cranial fossa. Under the impression of an arachnoid cyst, she underwent fenestration of the cyst with basal cisterns and ventricle. The pathologic diagnosis was neurenteric cyst. Four years after the surgery, MRI showed no recurrence but did show poorly developed myelination of the left temporal white matter. Three years after surgery, seizures recurred. We consider epilepsy surgery in case of uncontrolled seizure.

DISCUSSION

We discuss the unique case of supratentorially located neurenteric cyst that is just treated by fenestration. A close follow-up is needed for children with intracranial neurenteric cysts to surveil not only recurrence of lesion but also normal brain development.

Intradural spinal tumors in adults-update on management and outcome

Among spinal tumors that occur intradurally, meningiomas, nerve sheath tumors, ependymomas, and astrocytomas are the most common. While a spinal MRI is the state of the art to diagnose intradural spinal tumors, in some cases CT scans, angiography, CSF analyses, and neurophysiological examination can be valuable. The management of these lesions depends not only on the histopathological diagnosis but also on the clinical presentation and the anatomical location, allowing either radical resection as with most extramedullary lesions or less invasive strategies as with intramedullary lesions. Although intramedullary lesions are rare and sometimes difficult to manage, well-planned treatment can achieve excellent outcome without treatment-related deficits. Technical advances in imaging, neuromonitoring, minimally invasive approaches, and radiotherapy have improved the outcome of intradural spinal tumors. However, the outcome in malignant intramedullary tumors remains poor. While surgery is the mainstay treatment for many of these lesions, radiation and chemotherapy are of growing importance in recurrent and multilocular disease. We reviewed the literature on this topic to provide an overview of spinal cord tumors, treatment strategies, and outcomes. Typical cases of extra- and intramedullary tumors are presented to illustrate management options and outcomes.

Neurenteric Cyst or Neuroendodermal Cyst? Immunohistochemical Study and Pathogenesis

BACKGROUND

Neurenteric cysts are rare central nervous system lesions derived from an endodermal origin. There is no consensus concerning pathogenesis because of the paucity of occurrences. We report an immunohistochemical study of 10 cases with neurenteric cysts and postulate its pathogenesis.

METHODS

Ten patients underwent surgical treatment for neurenteric cysts from 1995 to 2015. We retrospectively reviewed clinical, radiologic, operative, and pathologic findings for these patients. Immunohistochemical stains were completed in all cases to distinguish cell type and origin.

RESULTS

Three cell types were identified: pseudostratified-ciliated, goblet-columnar, and simple cuboidal cells. All cases were positive for cytokeratin 7, and negative for cytokeratin 20, caudal-type homeobox 2, mucin 2, thyroid transcription factor 1, human chorionic gonadotropin, placental alkaline phosphatase, and cluster of differentiation 31. Four of them had positive staining for mucin 5AC, with expression only in goblet-columnar cells. According to the immunohistochemical results, the cells resembled the respiratory tract (pseudostratified-ciliated), stomach (goblet-columnar), and respiratory bronchioles (simple cuboidal). Seventy-five percent of cases with recurrence had a goblet-columnar component, emphasizing the importance of total resection of the cyst and complete pathologic examination.

CONCLUSIONS

We postulate that the cystic tumor was derived from multipotent endodermal cells that migrated and traveled along the neuroectoderm, with incomplete differentiation into various cell types as a result of an unsuitable microenvironment. Because the neurenteric canal was only the channel of migration rather than a component of the cysts, the term neuroendodermal cysts is more precise in presenting the embryopathogenesis.