Supratentorial Neurenteric Cysts: Case Series and Review of Pathology, Imaging, and Clinical Management

Surgical Experience and Management of Intracranial Neurenteric Cysts: Single-Center Experience and Review of the Literature

Introduction  Neurenteric cysts (NECs) are rare, congenital lesions lined by endodermal cell-derived columnar or cuboidal epithelium. Based on previous studies, gross total removal of the capsule has been presumed to be the ideal surgical goal. Objective  This series was undertaken to further understand the risk of recurrence based on the extent of capsule resection. Methods  Records were retrospectively reviewed for all patients with radiographic or pathological evidence of intracranial NEC from 1996 to 2021. Results  A total of eight patients were identified; four of eight (50%) presented with headache, and four had signs of one or more cranial nerve syndromes. One patient (13%) presented with third nerve palsy, one (13%) had sixth nerve palsy, and two (25%) with hemifacial spasm. One patient (13%) presented with signs of obstructive hydrocephalus. Magnetic resonance imaging demonstrated T2 hyper- or isointense lesions. Diffusion-weighted imaging was negative in all patients (100%) and T1 contrast-enhanced imaging demonstrated minimal rim enhancement in two patients (25%). In three of eight (38%), a gross total resection (GTR) was achieved, while in four (50%), a near-total resection, and in one (13%), a decompression was performed. Recurrences occurred in two (25%) patients, one with decompression and another with near-total resection, among these 1/2 required repeat surgery after a mean follow-up of 77 months. Conclusion  In this series, none from GTR group demonstrated recurrence, while 40% of those receiving less than GTR recurred, underpinning the importance of maximally safe resection in these patients. Overall patients did well without major morbidity from surgery.

Calcifying pseudoneoplasm of the neuraxis (CAPNON) associated with neurenteric cyst. An autopsy case showing unusual fatal outcome

A 53-year-old man with a history of an untreated brain mass was taken to Toyama Prefectural Central Hospital by emergency transport. Computed tomography revealed an intracranial hypo-attenuated lesion exhibiting mass effect. Several calcified foci were observed around the lesion. His radiographical diagnosis was meningioma with calcification and edema. He suddenly showed tonic seizure after admission; therefore an emergency craniotomy was performed. However, he unfortunately died due to advanced cerebral edema. Microscopic findings of the surgically obtained materials were consistent with neurenteric cyst (NC). Intracranial hard masses were found adjacent to NCs, and the masses were composed of fibrous cartilage-like matrix with extensive linear calcification and the presence of surrounding round-to-oval epithelioid cells. Thus, calcifying pseudoneoplasm of the neuraxis (CAPNON) associated with NC was considered the most appropriate diagnosis of the present case. To the best of our knowledge, this is the first report of such a case. The present case suggests that delay of treatment might cause a poor outcome, at least in CAPNON associated with NC. Careful investigations, including the underlying pathology, may be essential when considering the etiology of CAPNON and its treatment strategies.

Understanding the Pathogenesis of Lateral Supratentorial Neurenteric Cysts in Close Proximity to Other Vascular Pathologies: A Case Report and Review of Embryology

Several theories have been postulated to explain the embryogenesis of central nervous system (CNS) neurenteric cysts (NCs), but the exact mechanism remains poorly understood. Of those, the neurenteric canal migration hypothesis suggesting endodermal cell migration through the neurenteric canal and settling among ectodermal cells prior to neural tube closure might be the most robust as it explains, in contrast to other hypotheses, the existence of lateral supratentorial lesions, which are extremely rare, compared to their infratentorial counterparts. This mechanism might be supported by past medical history or the coexistence of CNS epidermoid cysts, which are thought to arise due to improper neural tube closure potentially increasing the probability of endodermal migration and subsequent NC development, yet there are no reported cases in the literature. We present a case of a patient with a history of a previously resected intracranial epidermoid cyst, representing three simultaneous pathologies including a laterally based right frontal NC along with a right corona radiata cavernous malformation lesion, and right middle cerebral artery bifurcation aneurysm. The three lesions were treated microsurgically in one operative session without complications. We discuss the case and review the relevant pathoembryology of laterally based supratentorial NC.

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.

Frontal Base Endodermal Cyst: A Case Report and Review of Literature

Background: Endodermal cyst (EC) is a rare congenital cyst of endodermal origin, but the pathogenesis of this entity remains uncertain. Supratentorial EC is particularly uncommon, but some cases have been reported. Here, we report a case of supratentorial EC that developed at the frontal base which indicates posttraumatic development rather than a congenital origin. Case Description: A 65-year-old man who had a history of orbital bone fracture without rhinorrhea sustained in a traffic accident presented with gradually enlarging frontal-base cystic lesions. Multiple cystic lesions were removed via left frontal craniotomy. The cysts showed no communication with the frontal sinus. Histological examination identified EC. Postoperative course was uneventful and no recurrences have been identified as of 2 years later. Conclusions: According to reported cases, unlike ECs in other intracranial locations, frontal base ECs tend to present at advanced ages. The present case also presented with EC enlargement at an advanced age and two lesions located at the bone hiatus in the frontal base that were presumably caused by trauma. It is possible that sinus communication was repaired as the bone fracture was remodeled, and the remnant sinus epithelial tissues developed into ECs over time. This situation makes it reasonable to presume a posttraumatic rather than a congenital origin. In conclusion, as for frontal base ECs, contrary to the traditional theory, the developmental mechanisms may not necessarily be congenital.

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.

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.

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.

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.

Supratentorial Neurenteric Cyst: A Rare Differential for a Frontal Cyst

Supratentorial neurenteric cyst is a rare entity. They are usually isointense to slightly hyperintense on T1W images and hyperintense on T2-weighted/fluid attenuated inversion recovery images. There was a diagnostic dilemma in this case due to the cerebrospinal fluid intensity of the cyst on magnetic resonance imaging. Postoperative residual lesion predisposes to hemorrhage and seizures.

Intracranial endodermal cyst presenting with nonobstructive hydrocephalus: A case report

RATIONALE

Endodermal cysts are rare benign lesions in the central nervous system. Their common symptoms include headache and neck pain caused by mass effect or inflammatory reaction. We report the case of an elderly woman with intracranial endodermal cyst who presented with nonobstructive hydrocephalus.

PATIENT CONCERNS

A 78-year-old woman presented with acute deterioration of consciousness caused by acute hydrocephalus. She subsequently underwent ventriculoperitoneal shunt placement. Eighteen months after this operation, she developed numbness of extremities and gait and progressive cognitive disturbances.

DIAGNOSIS

Initially, the endodermal cyst could not be recognized, but it became clinically evident in the craniocervical junction after ventriculoperitoneal shunt placement. MRI revealed multiple cystic lesions in the pontomedullary cistern. Postoperative pathology confirmed the diagnosis of endodermal cyst.

INTERVENTIONS

Subtotal resection of the cystic lesion was performed. Intra-operatively, multiple cysts containing a milky white fluid were noted and the medullary surface including the median and lateral apertures of the fourth ventricle were covered by thick, cloudy arachnoid membrane.

OUTCOMES

Although the numbness of extremities improved after the surgery, she remained bedridden due to deterioration in cognitive function and generalized muscle weakness. The patient developed recurrence 2 months after the surgery; however, no additional surgery was performed owing to her poor general condition.

LESSONS

Endodermal cysts rarely present with nonobstructive hydrocephalus caused by recurrent meningitis. In such cases, the lesions are often invisible on initial diagnostic imaging, and complete resection of the lesions is typically difficult because of strong adhesion between the cyst walls and contiguous vital structures.

Multiple Neurenteric Cysts along the Spinal Axis of an Infant: A Rare Entity

A spinal neurenteric cyst is a rare entity. It commonly presents already at 5 weeks of age up to the 6th decade of life. The most common location is the cervical region followed by thoracic and lumbosacral regions. We report a 9-month-old male infant with sudden onset of weakness in both lower limbs. MRI revealed 2 cystic lesions at cervical and thoracic level with spinal cord compression. He underwent laminectomy and excision of the cervical lesion. The child improved significantly. The postoperative MRI shows complete excision of a dorsal lesion and presence of a cervical lesion. Later, he underwent cervical laminotomy and partial wall excision followed by shunt placement. The histopathological report revealed a neurenteric cyst. Two neurenteric cysts presented in the neuroaxis of the same patient: one was located ventral (thoracic) and the other dorsal (cervical). At the 2-year follow-up, the child was active and walking without support. Multiple cystic lesions in the neuroaxis can be neurenteric cysts.

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.

Suprasellar keratinous cyst: A case report and review on its radiological features and treatment outcome

BACKGROUND

Keratinous or epidermoid cysts (ECs) are encapsulated lesions lined by squamous cell epithelium. They comprise approximately 1% of intracranial lesions. Contrary to dermoid cysts, they lack dermal elements such as sebaceous or apocrine glands and hair follicles. The sellar region is the second most common intracranial site following the cerebellopontine angle. Here, we report a case of EC in a patient who complained of endocrine disturbances. We also performed a systematic review on previously published cases to analyze clinical and radiological characteristics and report the treatment outcomes of suprasellar ECs.

CASE DESCRIPTION

A 42-year-old woman presented with a one-year history of amenorrhea, weight gain, severe headache, and visual disturbances for 6 months. Work-up identified an elevated prolactin level and a temporal field defect of the right eye. Magnetic resonance imaging (MRI) showed a cystic suprasellar lesion pushing on the optic chiasm. She underwent endoscopic trans-sphenoidal surgery, which confirmed a keratinous cyst on histology. Postoperatively, complete resection was confirmed on imaging. She did well although her hospital stay was prolonged due to diabetes insipidus and hypocortisolism.

CONCLUSION

Chronic endocrine disturbances can be the presenting complaints of a suprasellar EC, whose T1-weighted MRI appearance can be non-specific, mimicking other differential diagnoses, such as a Rathke's cleft cyst. However, the T2-weighted MRI appearances of ECs are generally hyper-intense and lesions show diffusion restriction. Treatment is surgical and yields good outcomes in most cases reported.

Neurosurgical management of a rare congenital supratentorial neurenteric cyst with associated nasal dermal sinus: case report

The authors describe the case of a patient with the classic clinical presentation and radiographic features of a nasal dermal sinus with an associated intracranial cyst; however, histopathology revealed that the intracranial cyst was neurenteric instead of the typical epidermoid or dermoid cyst. Preoperative assessment included CT and MRI, which revealed a direct communication between the patient's nasal polypoid lesion and the anterior skull base via the foramen cecum. At the hands of a multidisciplinary plastic surgery and neurosurgery team, the patient underwent concurrent gross-total resection of the nasal polypoid lesion, the intracranial intradural cystic lesion, and their interconnecting tract.

Intracranial Enterogenous Cysts Close to the Brainstem Treated Through the Nerve Endoscope

Enterogenous cysts (ECs) are rare, inborn lesions of central nervous system, which mostly occurred in the ventral side of the spinal cord as well as common in children; adult intracranial cysts are rare. Although the morbidity of intracranial ECs is quite low, we also can make a preliminary diagnosis of those patients with the help of imaging examination. In this article, we introduced 1 case of ECs ventral to the brainstem, which present images on magnetic resonance imaging as hypointense lesions on T1-weighted and high-intensity mass on T2-weighted image. In consideration of the difficulty of the surgical approach and the surgical visual field exposure, we use microscope and nerve endoscope to design personalized surgical approach to minimize the surgical injury. Pathologic examination showed that it was typical EC. Not only is the location extremely rare, but also the surgical method is uncommon in this disease. We not only study the intracranial ECs' manifestations, but also discuss the surgical approach and the application of nerve endoscope of our choice,which aims to provides a new surgical therapeutic approach for these lesions.

Intraparenchymal endodermal cyst with spontaneous intracystic hemorrhage in the temporal lobe of an adult

BACKGROUND

Endodermal cysts (EC) are rare but well-known congenial lesions of the central nervous system mainly located in the spinal subdural space. Intracranial ECs are rare and commonly encountered in the posterior cranial fossa as extra-axial lesions; an intraparenchymal location is exceedingly rare. A complete removal is the best surgical strategy and any residue can cause recurrence. It is necessary to exclude EC in patients with intracranial cystic lesions. We present a case of intraparenchymal EC with spontaneous intracystic hemorrhage in the temporal lobe of an adult.

METHODS

A 43-year-old man presented with headache and memory deterioration. Brain computed tomography and magnetic resonance imaging showed a slightly enhanced temporal lobe cystic lesion, which was homogenously hyperintense on T1-and T2-weighted images. There was a suspicion of brain abscess at admission. The lesion was totally removed with a left subtemporal craniotomy. Histological examination revealed an EC with intracystic hemorrhage.

RESULTS

The preoperative symptoms were relieved after surgery and 3-month follow-up magnetic resonance imaging found no cystic signs.

CONCLUSION

This case suggests that EC should be considered in the differential diagnosis of intracranial cystic lesions and a complete removal is the best strategy of choice.

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.

Supratentorial Neurenteric Cysts: Case Series and Review of Pathology, Imaging, and Clinical Management

BACKGROUND

Neurenteric cysts are rare congenital lesions along the neuroaxis, typically found in the spine, and rarely intracranially. Here, we present 3 patients who presented to our institution during a 6-year period with supratentorial intracranial neurenteric cysts and conduct a comprehensive review of the literature to describe the salient pathology, radiologic features, and clinical issues regarding these lesions.

CASE REPORTS

Three patients were treated surgically for supratentorial neurenteric cysts. One patient presented in extremis, whereas the others were treated electively. Each patient presented with significantly different signs and symptoms and unique radiologic findings. All patients were neurologically intact after surgery.

CONCLUSIONS

Neurenteric cysts present with a variety of signs and symptoms. Given the increased use of neuroimaging, supratentorial neurenteric cysts may be encountered more frequently and are important to include on the differential diagnosis and managed accordingly. Postoperative seizures occur in more than 20%, even in patients who had no preoperative seizures. Surgery can be performed safely with good neurologic outcomes.