Atypical Moyamoya disease associated with brain tumor

Laser interstitial thermal therapy is effective and safe for the treatment of brain tumors in NF1 patients after cerebral revascularization for moyamoya angiopathy: a report on two cases

Background

The co-occurrence of moyamoya vasculopathy and extra-optic pathway tumors is rare in neurofibromatosis type 1 (NF1), with only four cases described in the literature. Brain surgery in these patients may be challenging because of the risk of brain infarction after skin and dural incision. Given its percutaneous and minimally invasive nature, laser interstitial thermal therapy (LITT) is an ideal option for the treatment of brain tumors in these patients. Here, we report on two patients with NF1 and moyamoya syndrome (MMS) treated for a brain glioma with LITT, after cerebral revascularization.

Cases

The first patient, with familial NF1, underwent bilateral indirect revascularization with multiple burr holes (MBH) for symptomatic MMS. Two years later, she was diagnosed with a left temporal tumor, with evidence of radiologic progression over 10 months. The second patient, also with familial NF1, developed unilateral MMS when he was 6 years old and was treated with MBH. At the age of 15 years, MRI showed a right cingular lesion, growing on serial MRIs. Both patients underwent LITT with no perioperative complications; they are progression free at 10 and 12 months, respectively, and the tumors have decreased in volume.

Discussion

While the association of extra-optic neoplasm and moyamoya angiopathy is seldom reported in NF1, tumor treatment is challenging in terms of both avoiding stroke and achieving oncological control. Here, we show in 2 cases, that LITT could be a safe and effective option in these rare conditions.

Glioblastoma with concomitant moyamoya vasculopathy in neurofibromatosis type 1: illustrative case

BACKGROUND

In a case of concurrent glioblastoma and moyamoya vasculopathy, it is arduous to safely perform surgery because the brain is highly vulnerable and collaterals are sometimes well developed. In addition, radiotherapy carries a risk of aggravating moyamoya vasculopathy, and chemotherapeutic agents also have a risk of interfering with collateral development.

OBSERVATIONS

A 48-year-old woman with neurofibromatosis type 1 was admitted because of left hemiparesis and hemispatial neglect. Brain imaging studies revealed a large mass with peripheral enhancement in the right frontal lobe and occlusion of the bilateral middle cerebral arteries with an abnormal vascular network at the base of the brain. Total tumor resection was performed, and the pathological diagnosis was isocitrate dehydrogenase-mutant glioblastoma. Radiotherapy with a total dose of 60 Gy was delivered with concurrent temozolomide, and thereafter six cycles of adjuvant temozolomide were given. Progression of moyamoya vasculopathy without symptoms was observed after the completion of each of radiotherapy and adjuvant temozolomide.

LESSONS

The authors present the first adult case of glioblastoma with moyamoya vasculopathy. Careful consideration and attention should be given throughout treatment to avoiding moyamoya vasculopathy-related ischemic and hemorrhagic events. Although the patient did not exhibit neurological deterioration, progression of moyamoya vasculopathy occurred early after radiotherapy and continued thereafter.

Moyamoya Disease Associated with Tuberculum Sellae Meningioma and Cavernous Sinus Hemangioma

BACKGROUND

Primary moyamoya disease associated with skull base tumors has been reported only rarely in the literature. Surgical treatment can be complicated due to the compensatory collateral circulation through meningeal and leptomeningeal anastomosis. A standard frontotemporal craniotomy may interrupt critical transdural anastomoses.

CASE DESCRIPTION

We report a case of primary moyamoya disease coexisting with tuberculum sellae meningioma and left cavernous sinus hemangioma. Simultaneous management of tuberculum sellae meningioma and moyamoya disease was performed using a left modified pterional incision. Two separate bone windows were opened to protect the transdural anastomosis via the middle meningeal artery. The tuberculum sellae meningioma was successfully removed through a small frontal craniotomy, and encephaloduromyosynangiosis was used to treat moyamoya disease through a temporoparietal craniotomy. Finally, CyberKnife radiotherapy was used to treat the left cavernous sinus hemangioma at 6 weeks after the initial operation. The patient recovered well without complications. This is the first report of moyamoya disease associated with tuberculum sellae meningioma and cavernous sinus hemangioma.

CONCLUSIONS

With careful bone flap design, moyamoya disease and skull base tumors can be treated simultaneously. Care should be taken to avoid interruption of critical dural-pial collaterals and injury to fragile moyamoya vessels.

Moyamoya syndrome associated with Basal meningioma successfully treated by the modified transsphenoidal approach: case report

Objective Moyamoya vasculopathy associated with skull base tumors has been rarely reported except for partially removed pituitary adenoma and craniopharyngioma. Only a single case of meningioma resulted in vast cerebral infarction. Surgical treatment carries a high risk of damage to the compensatory collateral circulation through leptomeningeal anastomosis leading to a devastating outcome.

Case presentation A 46-year-old woman presented to our hospital with progressive visual disturbance. She had a history of medically treated moyamoya vasculopathy. Head magnetic resonance imaging revealed a well-demarcated skull base tumor extending from the planum sphenoidale to the diaphragm sellae. The patient had no cerebral ischemic symptoms, but iodine-123 N-isopropyl-p-iodoamphetamine single-photon emission computed tomography indicated bilateral hemodynamic compromise. Modified extended transsphenoidal surgery was performed, resulting in successful removal without complications including cerebral ischemia.

Conclusion The very low tolerance to cerebral ischemia associated with moyamoya disease manipulation in this location carries an extremely high risk of cerebral infarction. This is the first report of a basal meningioma associated with moyamoya syndrome that was successfully removed. The modified extended transsphenoidal approach is the first-line surgery for skull base meningioma located in the para-midline region.

Successful treatment of suprasellar tumors associated with poor brain blood perfusion by severe intracranial arterial stenosis: two case reports

Background

Treatment strategy to prevent perioperative cerebral infarction in patients with asymptomatic severe stenosis of the internal carotid artery is not fully established.

Case presentation

Two patients were treated for skull base tumor in the presence of severe stenosis of the internal carotid artery, unilateral in one patient and bilateral in the other patient. Both patients were asymptomatic but had reduced vascular reserve capacity. The extended transsphenoidal approach was planned avoiding the low perfusion pressure region, with only conventional methods of maintaining blood pressure and PaCO₂ rather than performing prophylactic vascular reconstruction surgery, and successful tumor removals were achieved without causing further neurological or radiological deficits.

Conclusion

If the surgical route is planned to avoid the distribution of stenotic vessels and low perfusion pressure, prophylactic vascular reconstruction surgery would be unnecessary. Although more experiences based on sub-classified etiology for internal carotid artery stenosis are required, various types of operations including intracranial-extracranial vascular surgery might be justified based on this principle.

Pleomorphic xanthoastrocytoma and moyamoya disease in a patient with neurofibromatosis type 1 - case report -

A 32-year-old man with familial neurofibromatosis type 1 presented with a rare case of coexisting pleomorphic xanthoastrocytoma (PXA) and moyamoya disease manifesting as progressive right hemiparesis. Magnetic resonance (MR) imaging with gadolinium showed an enhanced mass lesion in the left basal ganglia extending to the left parietal lobe. Preoperative angiography showed severe stenosis of the bilateral internal carotid arteries, and moyamoya vessels. The patient underwent open biopsy. Histological examination showed the characteristic findings of PXA. After radiation therapy and chemotherapy, MR imaging showed decreased size and enhancement of the tumor, but his clinical condition worsened with generalized convulsions and consciousness disturbance. He died 1 year and 6 months after the first presentation. Autopsy findings demonstrated necrosis in the main mass and tumor cell dissemination without anaplastic change. The rare combination of PXA and moyamoya disease in the basal ganglia limited treatment options. Injured moyamoya vessels and ischemic condition might have caused tumor progression and dissemination. Radiation therapy, in combination with moyamoya disease, induced decreased cerebral blood flow (CBF) in the left frontal lobe. Tumor dissemination, CBF decrease, and hydrocephalus led to the clinical deterioration of this patient.

De novo appearance of primitive neuroectodermal tumor in a patient with systemic lupus erythematosus and moyamoya disease

Primitive neuroectodermal tumor is a rare brain tumor composed of undifferentiated or poorly differentiated neuroepithelial cells with a high malignant potential that usually occurs in children, and which is only occasionally encountered in adults. A 19-year-old female with systemic lupus erythematosus presented with right hemiparesis and a headache of 10 days duration. Brain magnetic resonance imaging showed a large solid mass with necrotic portions in the left frontoparietal lobe. Primitive neuroectodermal tumor was confirmed by a neuronavigator-guided brain biopsy. This is the first case report of primitive neuroectodermal tumor associated with systemic lupus erythematosus and moyamoya disease. This case demonstrates that brain tumors, such as primitive neuroectodermal tumor, should be included in the differential diagnosis of neurological manifestations in children and adolescent patients with systemic lupus erythematosus.

Growth hormone-secreting pituitary adenoma associated with primary moyamoya disease--case report

A 40-year-old female presented with growth hormone (GH)-secreting pituitary adenoma associated with primary moyamoya disease manifesting as amenorrhea, acromegaly, and transient ischemic attack. Magnetic resonance (MR) imaging revealed a tumor mass extending from the sella turcica to the suprasellar cistern, and MR angiography demonstrated stenoses in the bilateral internal carotid arteries with basal moyamoya vessels. Her blood GH and insulin-like growth factor (IGF-1) levels were elevated to 78.94 and 923.0 ng/ml, respectively. The patient underwent removal of the pituitary adenoma because her ischemic symptoms disappeared after oral aspirin medication. Subtotal resection resulted in persistence of the high blood GH and IGF-1 levels. Postoperative MR angiography showed progression of the stenoses in the bilateral internal carotid arteries. Excess systemic GH and IGF-1 may participate in the progression of vascular disease and so could have caused the deterioration of the moyamoya disease.