1
|
Kiss-Bodolay D, Hautmann X, Lee KS, Rohde V, Schaller K. Intracranial Epidermoid Cyst: A Volumetric Study of a Surgically Challenging Benign Lesion. World Neurosurg 2024; 185:e1129-e1135. [PMID: 38493891 DOI: 10.1016/j.wneu.2024.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Intracranial epidermoid cysts are rare, benign tumors. Nevertheless, the microsurgical removal of these cysts is challenging. This is due to their capacity to adhere to the neurovascular tissue, as well as the associated difficulties in microsurgically peeling off their capsular wall hidden in dead angles. To better understand the rate of recurrence after surgical intervention, we have performed preoperative and postoperative volumetric analysis of epidermoid cysts, allowing the estimation of their growth rate after resection. METHODS Imaging data from 22 patients diagnosed and surgically treated for an intracranial epidermoid cyst between 2000 and 2022 were retrospectively collected from 2 European neurosurgical centers with microsurgical expertise. Volumetric analysis was performed on magnetic resonance imaging data. RESULTS Average cyst volume at diagnosis, before any surgery, measured in 12 patients was 28,877.6 ± 10,250.4 mm3 (standard error of the mean [SEM]). Estimated growth rate of incompletely resected epidermoids after surgery was 1,630.05 mm3 ± 729.95 (SEM). Assuming linear growth dynamics and normalizing to postoperative residual volume, the average postoperative growth rate corresponded to 61.5% ± 34.3% (SEM) of the postoperative residual volume per year. We observed signs of recurrence during a radiologic follow-up period of 6.0 ± 2.8 years (standard deviation) in more than 50% of our patients. CONCLUSIONS Due to their slow-growing nature, epidermoid cysts can often reach a complex multicompartmental size before resection, even in young patients, thus requiring complex approaches with challenging capsular resection, which implies a high risk of nerve and vascular injury per se. Tumor recurrence may be predicted on the basis of postoperative volumetry.
Collapse
Affiliation(s)
- Daniel Kiss-Bodolay
- Department of Neurosurgery, Geneva University Hospital, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Xenia Hautmann
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Kok Sin Lee
- Department of Basic Neurosciences and the Center for Neuroscience, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Karl Schaller
- Department of Neurosurgery, Geneva University Hospital, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| |
Collapse
|
2
|
Zhang H, Wang J, Liu J, Cao Z, Liu X, Jin H, Liu W, Xue Z, Yang N, Li C, Wang X. Fully neuroendoscopic resection of cerebellopontine angle tumors through a retrosigmoid approach: a retrospective single-center study. Neurosurg Rev 2023; 47:14. [PMID: 38102367 DOI: 10.1007/s10143-023-02244-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 11/01/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023]
Abstract
The objective of this study is to preliminarily investigate the surgical safety, efficacy, techniques, and clinical value of fully neuroendoscopic surgery for the resection of cerebellopontine angle (CPA) tumors via a retrosigmoid approach. The clinical data of 47 cerebellopontine angle area (CPA) tumors that were treated by full neuroendoscopic surgery from June 2014 to June 2023 were retrospectively analyzed. The efficacy and advantages of the surgical techniques were evaluated based on indicators such as duration of the surgery, neuroendoscopic techniques, intraoperative integrity of nerves and blood vessels, extent of tumor resection, outcomes or postoperative symptoms, and incidence of complications. The 47 cases of cerebellopontine angle tumors include 34 cases of epidermoid cysts, 7 cases of vestibular schwannomas, and 6 cases of meningiomas. All patients underwent fully neuroendoscopic surgery. Twenty tumors were removed using the one-surgeon two-hands technique, and 27 tumors were removed using the two-surgeons four-hands technique. The anatomical integrity of the affected cranial nerves was preserved in all 47 cases. None of the patients suffered a postoperative hemorrhage, cerebrospinal fluid leak, and aseptic or septic meningitis, or died. The rate of total tumor resection was 72.3% (34/47), and the symptom improvement rate was 89.4% (42/47). All patients were followed up for 2 to 12 months, and none died nor showed any signs of tumor recurrence. By analyzing 47 fully neuroendoscopic resections of CPA tumors using the posterior sigmoid sinus approach in our center, we believe that such method allows complete, safe, and effective resection of CPA tumors and is thereby worthy of clinical promotion.
Collapse
Affiliation(s)
- Hengrui Zhang
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Jiwei Wang
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Junzhi Liu
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Zexin Cao
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Xuchen Liu
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Haoyong Jin
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Wenyu Liu
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Zhiwei Xue
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Ning Yang
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Chao Li
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China.
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China.
| | - Xinyu Wang
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China.
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China.
| |
Collapse
|
3
|
Yufeng Z, Xiaoqing J, Lulu X, Pei H, Shengwu L, Zhongsheng L. Giant epidermoid cyst penetrating the skull: a case report and literature review. Br J Neurosurg 2023; 37:1693-1698. [PMID: 34320894 DOI: 10.1080/02688697.2021.1950635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Abstract
Intracranial epidermoid cyst is a rare pseudotumor of the nervous system, accounting for 0.2%-1.8% of all intracranial tumors. It is usually located in the cerebellopontine Angle or parasellar area, with insipid onset, slow growth and usually less than 2 cm in diameter. Giant epidermoid cysts that invade the bone have rarely been reported in the literature. Herein, we report a case of giant ECs extradural to the parietal bone, penetrating the skull and continuing to expand outward. In addition, a systematic search of four authoritative databases was conducted to collect the relevant reports of giant epidermoid cyst with diameter > 5cm for the first time, and to discuss the clinical and radiographic features of patients with giant epidermoid cyst and the influence of treatment options.
Collapse
Affiliation(s)
- Zhu Yufeng
- Department of Graduate School, Qinghai University, Xining, China
| | - Jin Xiaoqing
- Department of neurosurgery, Qinghai Provincial People's Hospital, Xining, China
| | - Xu Lulu
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Han Pei
- Department of neurosurgery, Qinghai Provincial People's Hospital, Xining, China
| | - Lin Shengwu
- Department of Graduate School, Qinghai University, Xining, China
| | - Lu Zhongsheng
- Department of neurosurgery, Qinghai Provincial People's Hospital, Xining, China
| |
Collapse
|
4
|
Tammam M, Khayat RE, Khallaf M, Hassan HM. The endoscopic-assisted approach versus the microscopic only approach in resection of cerebellopontine angle epidermoids: a 5-year retrospective study. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2022. [DOI: 10.1186/s41983-022-00536-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The endoscopic-assisted technique has been utilized with various intracranial lesions with many approaches. In the cerebellopontine angle (CPA), the technique has been used to combine the benefits of the operating microscope and the endoscope. In this study, we highlight the use of the endoscopic-assisted technique in resection of CPA epidermoid tumors to ensure a total resection, decrease complications and protect the neurovascular tangles.
Results
In the endoscopic-assisted group, only 18.8% of the patients had post-operative residual in the post-operative MRI. However, in the microscopic only group 56.3% of the patients had post-operative residual. Consequently, there is a statistically significant difference regarding the post-operative residual between the two groups.
Conclusions
The endoscopic-assisted approach is superior to the microscopic only approach in the excision of CPA epidermoids and minimizing the post-operative residual and the recurrence.
Collapse
|
5
|
Singh S, Das KK, Kumar K, Rangari K, Dikshit P, Bhaisora KS, Sardhara J, Mehrotra A, Srivastava AK, Jaiswal AK, Behari S. Cerebellopontine Angle Epidermoids: Comparative Results of Microscopic and Endoscopic Excision Using the Retromastoid Approach”. Skull Base Surg 2022; 83:e60-e68. [DOI: 10.1055/s-0040-1722713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Background Densely packed neurovascular structures, often times inseparable capsular adhesions and sometimes a multicompartmental tumor extension, make surgical excision of cerebellopontine angle epidermoids (CPEs) a challenging task. A simultaneous or an exclusive endoscopic visualization has added a new dimension to the classical microscopic approaches to these tumors recently.
Methods Eighty-six patients (age: 31.6 ± 11.7 years, M:F = 1:1) were included. Nineteen patients (22.1%) had a multicompartmental tumor. Tumor extension was classified into five subtypes. Sixty-two patients underwent a pure microscopic approach (72%) out of which 10 patients (16%) underwent an endoscope-assisted surgery (11.6%) and 24 patients (28%) underwent an endoscope-controlled excision. Surgical outcomes were retrospectively analyzed.
Results Headache (53.4%), hearing loss (46.5%), and trigeminal neuralgia (41.8%) were the leading symptoms. Interestingly, 21% of the patients had at least one preexisting cranial nerve deficit. Endoscopic assistance helped in removing an unseen tumor lobule in 3 of 10 patients (30%). Pure endoscopic approach significantly reduced the hospital stay from 9.2 to 7.3 days (p = 0.012), and had a statistically insignificant yet a clearly noticeable lesser incidence of subtotal tumor excision (0 vs. 10%, p = 0.18) with comparable cranial nerve deficits but with a higher postoperative cerebrospinal fluid (CSF) leak rate (29% vs. 4.8%, p = 0.004).
Conclusion Endoscope assistance in CPE surgery is a useful addition to conventional microscopic retromastoid approach. Pure endoscopic excision in CPE is feasible, associated with a lesser duration of hospital stay, better extent of excision in selected cases, and it has a comparable cranial nerve morbidity profile albeit with a higher rate of CSF leak.
Collapse
Affiliation(s)
- Suyash Singh
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kuntal Kanti Das
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Krishna Kumar
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kamlesh Rangari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Priyadarshi Dikshit
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kamlesh Singh Bhaisora
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jayesh Sardhara
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arun Kumar Srivastava
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Awadhesh Kumar Jaiswal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| |
Collapse
|
6
|
Della Pepa GM, Stifano V, D'Alessandris QG, Menna G, Burattini B, Di Domenico M, Izzo A, D'Ercole M, Lauretti L, Olivi A, Montano N. Intraoperative Corticobulbar Motor Evoked Potential in Cerebellopontine Angle Surgery: A Clinically Meaningful Tool to Predict Early and Late Facial Nerve Recovery. Neurosurgery 2022; 91:406-413. [PMID: 35612564 DOI: 10.1227/neu.0000000000002039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/03/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intraoperative neuromonitoring is crucial for facial nerve preservation in cerebellopontine angle (CPA) surgery. Among the available techniques, the role of intraoperative corticobulbar facial motor evoked potentials (FMEPs) is unclear. OBJECTIVE To evaluate the significance of intraoperative FMEPs as indicators for early and late postoperative facial nerve function (FNF) in CPA tumor resection and the feasibility of their integration with standard monitoring techniques. METHODS An institutional series of 83 patients who underwent surgery under intraoperative monitoring for CPA extra-axial tumor resection was reported. A pair of needle electrodes was used to record FMEP from orbicularis oculi (OOc) and orbicularis oris (OOr) muscles at baseline, at the end of surgery and minimum values recorded. From FMEP amplitudes, minimum-to-baseline amplitude ratio (MBR), final-to-baseline amplitude ratio (FBR), and recovery value, intended as FBR minus MBR, were calculated. These indices were correlated with early and late postoperative FNF. RESULTS Our analysis demonstrated that higher FBR (both from OOc and OOr) and MBR (from OOr only) were associated with a good early and late FNF; a higher MBR from OOc was significantly associated with a good late FNF. The most accurate index in predicting early FNF was FBR measured from OOr with a cutoff of 35.56%, whereas the most accurate index in predicting late FNF was FBR as measured from OOc with a cutoff of 14.29%. CONCLUSION Our study confirmed that FMEPs are reliable predictors of early and late postoperative FNF in CPA surgery and could be easily integrated with standard intraoperative neuromonitoring techniques.
Collapse
Affiliation(s)
- Giuseppe Maria Della Pepa
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vito Stifano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Quintino Giorgio D'Alessandris
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Grazia Menna
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Benedetta Burattini
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michele Di Domenico
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Izzo
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Manuela D'Ercole
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Liverana Lauretti
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicola Montano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
7
|
Hellinger RL, Wolf AL, Amendola B, Coy S. Gamma knife radiosurgery of epidermoid tumors: an analysis of treatment results of eight patients. Rep Pract Oncol Radiother 2021; 26:683-687. [PMID: 34760304 DOI: 10.5603/rpor.a2021.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 05/06/2021] [Indexed: 11/25/2022] Open
Abstract
Background Epidermoid tumors (ETs) of the central nervous system (CNS) are rare tumors that typically occur in the 4th decade. They typically grow around vital neurovascular structures which makes surgical treatment difficult. The objective of this paper is to report on the effectiveness and safety in the management of epidermoid tumors with gamma knife surgery (GKS). Materials and methods This is a retrospective study of the medical records of 8 patients treated with GKS for epidermoid tumors between July 2010 to June 2019. The median prescription dose was 11 Gy, ranging from 10 to 12 Gy, 5 patients received the total dose target to the 50% line and 3 to the 55% isodose line. The mean tumor volume was 12.4 cc ranging from 4.4 to 24.8cc. The median follow-up time was 33.7 months and ranged from 0.9 to 58.8 months. At follow-up, patients were evaluated for neurological signs and symptoms and radiographic evidence of progression of disease. Two patients were treated after failure of linac stereotactic radiosurgery. One patient underwent stereotactic radiosurgery prior to GKS, and the other had failed surgical resection prior to GKS. Results The median age was 33 years old. There were two males and six females. The most common presenting manifestation was headaches followed by vision and hearing problems. Symptoms were resolved in all cases, except for one who had partial control of trigeminal neuralgia. All patients were locally controlled by imaging and neurological examination at first follow-up. Conclusion Gamma knife surgery is a safe and effective alternative treatment in patients with CNS epidermoid tumors and should be included in the initial recommendation.
Collapse
Affiliation(s)
- Ryan L Hellinger
- Innovative Cancer Institute, South Miami, Florida, United States, Miami Neuroscience Center, South Miami, Florida, United States
| | - Aizik L Wolf
- Innovative Cancer Institute, South Miami, Florida, United States, Miami Neuroscience Center, South Miami, Florida, United States
| | - Beatriz Amendola
- Innovative Cancer Institute, South Miami, Florida, United States, Miami Neuroscience Center, South Miami, Florida, United States
| | - Sammie Coy
- Innovative Cancer Institute, South Miami, Florida, United States, Miami Neuroscience Center, South Miami, Florida, United States
| |
Collapse
|
8
|
Curnes JM. A Pilot With Electrical Pain in the Face. Fed Pract 2021; 38:337-339. [PMID: 34733085 DOI: 10.12788/fp.0149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
An intracranial epidermoid cyst is an unusual but treatable cause of trigeminal neuralgia.
Collapse
Affiliation(s)
- John M Curnes
- is the Senior Naval Flight Surgeon at Training Air Wing Four at Naval Air Station Corpus Christi in Texas
| |
Collapse
|
9
|
Hasegawa H, Vakharia K, Carlstrom LP, Van Gompel JJ, Driscoll CLW, Carlson ML, Meyer FB, Link MJ. Long-term surgical outcomes of intracranial epidermoid tumors: impact of extent of resection on recurrence and functional outcomes in 63 patients. J Neurosurg 2021:1-9. [PMID: 34653989 DOI: 10.3171/2021.5.jns21650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/27/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' objective was to reevaluate the role of microsurgery for epidermoid tumors by examining the associations between extent of resection (EOR), tumor control, and clinical outcomes. METHODS This was a retrospective study of patients with microsurgically treated intracranial epidermoid tumors. The recurrence-free and intervention-free rates were calculated using the Kaplan-Meier method. EOR was graded as gross-total resection (GTR) (total resection without residual on MRI), near-total resection (NTR) (a cyst lining was left in place), subtotal resection (STR) (> 90% resection), and partial resection (PR) (any other suboptimal resection) and used to stratify outcomes. RESULTS Sixty-three patients with mean clinical and radiological follow-up periods of 87.3 and 81.8 months, respectively, were included. Sixteen patients underwent second resections, and 5 underwent third resections. The rates of GTR/NTR, STR, and PR were 43%, 35%, and 22%, respectively, for the initial resections; 44%, 13%, and 44% for the second resections; and 40%, 0%, and 60% for the third resections (p < 0.001). The 5- and 10-year cumulative recurrence-free rates after initial resection were 64% and 32%, respectively. When stratified according to EOR, the 10-year recurrence-free rate after GTR/NTR was marginally better than that after STR (61% vs 35%, p = 0.130) and significantly better than that after PR (61% vs 0%, p < 0.001). The recurrence-free rates after initial microsurgery were marginally better than those after second surgery (p = 0.102) and third surgery (p = 0.065). The 5- and 10-year cumulative intervention-free rates after initial resection were 91% and 58%, respectively. When stratified according to EOR, the 10-year intervention-free rate after GTR/NTR was significantly better than that after STR (100% vs 51%, p = 0.022) and PR (100% vs 27%, p < 0.001). The 5-year intervention-free rate after initial surgery was marginally better than that after second surgery (52%, p = 0.088) and significantly better than that after third surgery (0%, p = 0.004). After initial, second, and third resections, permanent neurological complications were observed in 6 (10%), 1 (6%), and 1 (20%) patients, respectively. At the last follow-up visit, 82%, 23%, and 7% of patients were free from radiological recurrence after GTR/NTR, STR, and PR as the initial surgical procedure, respectively. CONCLUSIONS GTR/NTR seems to contribute to better disease control without significantly impairing functional status. Initial resection offers the best chance to achieve better EOR, leading to better disease control.
Collapse
Affiliation(s)
- Hirotaka Hasegawa
- Departments of1Neurologic Surgery and.,3Department of Neurosurgery, The University of Tokyo, Bunkyo, Tokyo, Japan
| | | | | | - Jamie J Van Gompel
- Departments of1Neurologic Surgery and.,2Otolaryngology (ENT)/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota; and
| | - Colin L W Driscoll
- Departments of1Neurologic Surgery and.,2Otolaryngology (ENT)/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota; and
| | - Matthew L Carlson
- Departments of1Neurologic Surgery and.,2Otolaryngology (ENT)/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota; and
| | | | - Michael J Link
- Departments of1Neurologic Surgery and.,2Otolaryngology (ENT)/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota; and
| |
Collapse
|
10
|
Verma PK, Singh A, Dikshit P, Das KK, Mehrotra A, Jaiswal S, Behari S, Jaiswal AK. Endoscopic Keyhole Approach for Intracranial Epidermoid. J Neurosci Rural Pract 2021; 12:614-622. [PMID: 34737493 PMCID: PMC8559065 DOI: 10.1055/s-0041-1735283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective In contemporary neurosurgical practice, keyhole endoscopic approach has established its role in various neurosurgical pathologies. Intracranial epidermoid is an ideal pathology for endoscopic keyhole approach as epidermoid is well encapsulated, extra-axial, avascular, and easily suckable. The objective of this study is to share our experience of endoscopic keyhole approach for intracranial epidermoids at various locations as a new minimally invasive neurosurgical approach to deal with these lesions. Materials and Methods We conducted a retrospective study on 26 patients who underwent keyhole pure endoscopic excision of intracranial epidermoid between July 2015 and December 2019. Patient's demographics, clinical features, radiological imaging, and postoperative complications were noted. Follow-up outcome of preoperative symptoms and postoperative complications were also analyzed. Results The mean age of the study population was 30.5 years with a mean follow-up of 30 months. The common presenting features were headache, hearing loss, and trigeminal neuralgic pain. Gross total resection was achieved in 73.1% cases, while near total resection and subtotal resection were achieved in 19.2 and 7.7% cases, respectively. In the follow-up, maximal improvement was seen in trigeminal neuralgic pain (83%) and headache (66.7%). Major postoperative complications were facial nerve paresis, lower cranial nerve paresis, and transient facial hypoesthesia, most of which improved over time. None of the patients required resurgery till date. Statistical Analysis Patients' data were analyzed using SPSS software version 23 (Statistical Package for Social Sciences, IBM, Chicago, United States). Conclusion This study demonstrates that with careful patient selection, endoscopic keyhole excision of epidermoid is a good alternative to conventional microsurgical excision with comparable surgical and functional outcomes.
Collapse
Affiliation(s)
- Pawan K. Verma
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amanjot Singh
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Priyadarshi Dikshit
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kuntal Kanti Das
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sushila Jaiswal
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Awadhesh K. Jaiswal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| |
Collapse
|
11
|
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. Acta Neurochir (Wien) 2021; 163:2465-2474. [PMID: 33942190 DOI: 10.1007/s00701-021-04840-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
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.
Collapse
|
12
|
Jha VC, Shrivastava A, Jha N, Rewatkar S, Singh SK. Analysis of Giant Intraventricular and Extraventricular Epidermoids, Defining Risk Factors for Recurrence, an Institutional Experience. Asian J Neurosurg 2021; 16:326-334. [PMID: 34268160 PMCID: PMC8244699 DOI: 10.4103/ajns.ajns_488_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/11/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Multicompartmental intraventricular epidermoids behave differently from multicompartmental extraventricular lesions and localized lesions during its management. Few studies are available which have analyzed risk factors separately in these groups of cases for recurrence of these lesions and time to recur. Materials and Methods: In this retrospective observational study, 72 cases of intracranial epidermoid were treated over a span of 7 years. Cases were categorized into three groups. Group 1 comprised 15% (11/72) of cases with intraventricular multicompartmental, Group 2 with 22% (16/72) extraventricular giant tumors with multicompartmental involvement and size >4.5 cm, and Group 3 comprised 63% (45/72) of patients with lesions <4.5 cm and localized. Data pertaining to demography, clinical and radiological features, surgery performed, postoperative complication, histology, and follow-up were obtained from medical records available in the institute. Results: The average duration to treat was 1.86 ± 0.52 (standard deviation [SD]) years, with headache as a major complaint in all the groups. Combined endoscope-assisted microsurgery was performed in 38.8% (28/72), microsurgery in 54.1% (39/72), and endoscopic excision in 6.9% (5/72) of cases. Tumor calcification was found in 23.6% (17/72) and preoperative capsular enhancement was seen in 19.4% (14/72) which persisted in 79% (11/14) of cases postoperatively on subsequent follow-up suggesting recurrence. On stepwise logistic regression analysis, preoperative capsular enhancement was a strong predictor of recurrence of tumor (P = 0.001). The average follow-up was 46 ± 14.92 (SD) months in Group 1, 52.34 ± 11.45 (SD) months in Group 2, and 63.36 ± 18.42 (SD) months in Group 3. Conclusion: Although the intracranial epidermoid is known to recur after long interval, tumor with specific characteristics can recur in short span of 5–6 years. Tumor characteristics such as preoperative capsular enhancement, multicompartmental distribution in vertebrobasilar territory, large size, and presence of calcification are strong predictors for recurrence. Performing endoscope-assisted microsurgery can decrease the postoperative morbidities but does not reduce the recurrence risk.
Collapse
Affiliation(s)
- Vikas Chandra Jha
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Adesh Shrivastava
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Neeraj Jha
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Sudhanshu Rewatkar
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Saraj Kumar Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India
| |
Collapse
|
13
|
Vernon V, Naik H, Guha A. Surgical management of cerebellopontine angle epidermoid cysts: an institutional experience of 10 years. Br J Neurosurg 2021; 36:203-212. [PMID: 33410366 DOI: 10.1080/02688697.2020.1867058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- Velho Vernon
- Department of Neurosurgery, J. J. Group of Hospitals and Grant Medical College, Mumbai, India
| | - Harish Naik
- Department of Neurosurgery, J. J. Group of Hospitals and Grant Medical College, Mumbai, India
| | - Amrita Guha
- Department of Radiology, Tata Memorial Centre, Mumbai, India
| |
Collapse
|
14
|
Refaat MI, Abdallah OY. Cerebellopontine Angle Epidermoid Cysts: Surgical Treatment Outcome. INDIAN JOURNAL OF NEUROSURGERY 2020. [DOI: 10.1055/s-0040-1713545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Abstract
Background Epidermoid cysts (ECs)are an uncommon slowly growing congenital lesions. The cerebellopontine angle (CPA) is the most common site. Surgical management for these lesions remains challenging due to the high-adherence of the cyst capsule to the surrounding structures and its tendency to present with invasion of multiple cisterns.
Objective The aim of this study was to evaluate the clinical and radiological outcome of surgically treated ECs in the CPA region.
Materials and Methods This is a retrospective study conducted on patients presenting with symptomatic CPA ECs. Clinical outcome was assessed in terms of improving or worsening of the presenting symptoms. Radiological outcome was assessed by comparing the tumor size, brainstem, and cerebellar compression in the preoperative and postoperative images.
Results In this study, 18 patients were included. All cases were operated upon by microsurgical evacuation of the cyst contents and excision of the nonadherent parts of the capsule. On admission, cranial nerve symptoms predominated. Improvement or resolution of preoperative deficits was seen in 15 patients. Preoperative symptoms worsened in two and new postoperative symptoms occurred in one patient. Seven patients needed additional ventriculoperitoneal (VP) shunt in the same setting due to the presence of hydrocephalus. During the follow-up period, symptomatic recurrence occurred in one patient, while asymptomatic recurrence occurred in one patient.
Conclusion Surgical management of CPA ECs, leaving remnants of the capsule on cranial nerves and brain stem can be considered as a relatively safe surgical procedure with a good clinical outcome and low-recurrence risks.
Collapse
Affiliation(s)
- Mohamed I. Refaat
- Department of Neurosurgery, School of Medicine, Cairo University, Egypt
| | - Omar Y. Abdallah
- Department of Neurosurgery, School of Medicine, Cairo University, Egypt
| |
Collapse
|
15
|
Ţica O, Ţica OA, Roşca E, Sabău M, Brihan I, Huniadi CA, Mohan AG, Muţiu G, Zdrîncă MM, Buhaş CL, Pantea-Roşan LR, Venter AC. Intradiploic epidermoid cysts - a series of three cases and our experience with literature data. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY = REVUE ROUMAINE DE MORPHOLOGIE ET EMBRYOLOGIE 2020; 61:889-894. [PMID: 33817730 PMCID: PMC8112750 DOI: 10.47162/rjme.61.3.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 03/29/2021] [Indexed: 11/05/2022]
Abstract
Intracranial epidermoid cysts are rare, representing almost 1% of all primary tumors and when are located in the diploe result from entrapped ectodermal embryonic remnants. Because of frequent complications, imaging studies are mandatory for highlighting erosions of both outer and inner table of the calvaria and treatment preparation. We enlisted three female patients within our study, comparing imaging with histopathology aspects. Even though the bone destruction was evident, no atypia or malignant signs were highlighted in serial sections. The interesting fact that we present is that our patients are all females, opposed to what is written in literature. Although the positive diagnosis can be made by imaging, histopathological examination of these cysts is mandatory for identifying malignant behavior.
Collapse
Affiliation(s)
- Ovidiu Ţica
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, Romania;
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Arrighi-Allisan AE, Delman BN, Rutland JW, Yao A, Alper J, Huang KH, Balchandani P, Shrivastava RK. Neuroanatomical Determinants of Secondary Trigeminal Neuralgia: Application of 7T Ultra-High-Field Multimodal Magnetic Resonance Imaging. World Neurosurg 2019; 137:e34-e42. [PMID: 31790844 DOI: 10.1016/j.wneu.2019.11.130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Seven-Tesla (7T) magnetic resonance imaging (MRI) has demonstrated value for evaluating a variety of intracranial diseases. However, its utility in trigeminal neuralgia has received limited attention. The authors of the present study applied ultra-high field multimodal MRI to two representative patients with secondary trigeminal neuralgia due to epidermoid tumors to illustrate the possible clinical and surgical advantages of 7T compared with standard clinical strength imaging. Techniques included co-registration of multiple 7T sequences to optimize the detection of potential concurrent neurovascular and neoplasm-derived compression. METHODS 7T MRI studies were performed using a whole body scanner. Two- and three-dimensional renderings of potential neurovascular conflict were created by co-registering time-of-flight angiography and T2-weighted turbo spin echo images in MATLAB and GE software. Detailed comparisons of the various field strength images were provided by a collaborating neuroradiologist (B.D.). RESULTS 7T MRI clearly illustrated minute tumor-adjacent vasculature. In contrast, conventional, low-field imaging did not consistently provide adequate details to distinguish cerebrospinal fluid pulsatility from vessels. The tumor margins, although distinct from the trigeminal nerve fibers at 7T, blended with those of the surrounding structures at 3T. Two- and three-dimensional co-registration of time-of-flight angiography with T2-weighted MRI suggested that delicate, intervening vasculature may have contributed to these illustrative patients' symptomatology. CONCLUSIONS 7T provided superior visualization of vital landmarks and subtle nerve and vessel features. Co-registration of various advanced 7T modalities may help to resolve complex disease etiologies. Future studies should explore the extent to which this dual etiology might persist across tumor types and utilize diffusion-based techniques to quantify what microstructural differences might exist between patients with trigeminal neuralgia from varying etiologies.
Collapse
Affiliation(s)
- Annie E Arrighi-Allisan
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Bradley N Delman
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John W Rutland
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA; BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy Yao
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Judy Alper
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kuang-Han Huang
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Priti Balchandani
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
17
|
Sutiono AB, Sidabutar R, Pareira ES, Toda M, Yoshida K. Characteristics intracranial epidermoid cyst between two hospital from developed vs developing institution and literature review. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2019. [DOI: 10.1016/j.inat.2019.100500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
18
|
Abstract
OBJECTIVE To describe the clinical course and treatment outcomes for patients with petrous apex epidermoid with skull base erosion. STUDY DESIGN Retrospective case series. SETTING Tertiary-care academic center. PATIENTS Patients surgically managed for petrous apex epidermoids at a single-tertiary care institution from 2001 to 2017. INTERVENTIONS Surgical management of primary petrous apex epidermoids. MAIN OUTCOME MEASURES The presenting symptoms, imaging, pre- and postoperative clinical course, and complications were reviewed. RESULTS Seven patients were identified. The most common presenting symptoms included: sudden sensorineural hearing loss (n = 3), headaches (n = 1), vertigo (n = 2), and facial paralysis/paresis (n = 2). An epidermoid was discovered in two patients as an incidental finding after a head trauma and one patient after admission for altered mental status and meningitis. Two patients presented with complete facial paralysis (House-Brackmann 6/6). Preoperative normal hearing (pure-tone average < 25 db) was identified in three patients and serviceable hearing (pure-tone average 25-60 dB) in one patient. Three patients with nonserviceable hearing underwent a transcochlear or transotic approach. The remaining four patients underwent an attempted hearing preservation approach. Postoperatively, one patient developed delayed facial paralysis, improving within 3 months. Hearing was preserved in three patients. Two patients developed recurrence of disease within 4 and 7 years respectively. CONCLUSIONS Surgical management of aggressive petrous apex epidermoid is effective to preserve facial function and prevent recurrence. In our series different surgical approaches were used with variable outcomes.
Collapse
|
19
|
Luryi AL, Michaelides EM, Babu S, Bojrab DI, Kveton JF, Hong RS, Zappia J, Sargent EW, Schutt CA. Reliability of clinical diagnosis of masses of the cerebellopontine angle: A retrospective multi-institutional study. Am J Otolaryngol 2019; 40:133-136. [PMID: 30717992 DOI: 10.1016/j.amjoto.2019.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 01/18/2019] [Accepted: 01/28/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess the accuracy of pre-operative diagnosis of masses of the cerebellopontine angle (CPA) when compared to surgical pathology. DESIGN Retrospective chart review. PARTICIPANTS Patients who underwent surgery for CPA masses at two tertiary care institutions from 2007 to 2017. MAIN OUTCOME MEASURES Percent concordance between pre-operative and surgical pathologic diagnosis; sensitivity, specificity, positive predictive value, and negative predictive value for predicted diagnoses. RESULTS Concordance between pre-operative diagnosis and surgical pathology was 93.2% in 411 sampled patients. Concordance was 57.9% for masses other than vestibular schwannoma. Prediction of vestibular schwannoma and meningioma had high positive (0.95 and 0.97, respectively) and negative (0.76 and 0.99, respectively) predictive values. Prediction of facial neuroma had sensitivity of 0.13 and positive predictive value of 0.25. Headache (p = 0.001) and facial weakness (p = 0.003) were significantly associated with different pathologic profiles. Hearing loss was associated with differences in diagnostic prediction (p = 0.02) but not with differences in surgical pathology (p > 0.05). CONCLUSIONS Comparison between pre-operative predicted diagnosis and surgical pathology for cerebellopontine angle masses is presented. Vestibular schwannoma and meningioma were effectively identified while rarer CPA masses including facial neuroma were rarely identified correctly. Clinicians caring for patients with CPA masses should be mindful of diagnostic uncertainty which may lead to changes in treatment plan or prognosis.
Collapse
Affiliation(s)
- Alexander L Luryi
- Department of Surgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06511, United States
| | - Elias M Michaelides
- Department of Surgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06511, United States
| | - Seilesh Babu
- Department of Neurotology, Michigan Ear Institute, St. John Providence Hospital and Medical Centers, 30055 Northwestern Highway, Suite #101, Farmington Hills, MI 48334, United States
| | - Dennis I Bojrab
- Department of Neurotology, Michigan Ear Institute, St. John Providence Hospital and Medical Centers, 30055 Northwestern Highway, Suite #101, Farmington Hills, MI 48334, United States
| | - John F Kveton
- Department of Surgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06511, United States
| | - Robert S Hong
- Department of Neurotology, Michigan Ear Institute, St. John Providence Hospital and Medical Centers, 30055 Northwestern Highway, Suite #101, Farmington Hills, MI 48334, United States
| | - John Zappia
- Department of Neurotology, Michigan Ear Institute, St. John Providence Hospital and Medical Centers, 30055 Northwestern Highway, Suite #101, Farmington Hills, MI 48334, United States
| | - Eric W Sargent
- Department of Neurotology, Michigan Ear Institute, St. John Providence Hospital and Medical Centers, 30055 Northwestern Highway, Suite #101, Farmington Hills, MI 48334, United States
| | - Christopher A Schutt
- Department of Neurotology, Michigan Ear Institute, St. John Providence Hospital and Medical Centers, 30055 Northwestern Highway, Suite #101, Farmington Hills, MI 48334, United States.
| |
Collapse
|
20
|
Vaz-Guimaraes F, Koutourousiou M, de Almeida JR, Tyler-Kabara EC, Fernandez-Miranda JC, Wang EW, Snyderman CH, Gardner PA. Endoscopic endonasal surgery for epidermoid and dermoid cysts: a 10-year experience. J Neurosurg 2019; 130:368-378. [PMID: 29547084 DOI: 10.3171/2017.7.jns162783] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 07/24/2017] [Indexed: 11/06/2022]
Abstract
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.
Collapse
Affiliation(s)
- Francisco Vaz-Guimaraes
- 1Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- 2Department of Neurosurgery, Michael E. DeBakey VA Medical Center/Baylor College of Medicine, Houston, Texas
| | - Maria Koutourousiou
- 1Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John R de Almeida
- 3Otolaryngology and
- 4Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Ontario, Canada; and Departments of
| | | | | | | | | | - Paul A Gardner
- 1Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
21
|
Mangraviti A, Mazzucchi E, Izzo A, Sturdà C, Albanese A, Marchese E, Olivi A, Puca A, Sturiale CL. Surgical Management of Intracranial Giant Epidermoid Cysts in Adult: A Case-Based Update. Asian J Neurosurg 2018; 13:1288-1291. [PMID: 30459920 PMCID: PMC6208223 DOI: 10.4103/ajns.ajns_91_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Epidermoid cysts (ECs) are benign and slow-growing lesions that account for about 0.2%-2% of all intracranial tumors. Symptoms appear slowly and tumors may have already grown to giant proportions when patients receive their first diagnosis. The optimal treatment for ECs is surgical removal, which includes the total resection of the entire capsule of the lesion in order to minimize the risk of malignant transformation associated with partial removal. However, considering the giant size that the ECs can reach at the time of the diagnosis, and their adherence to the surrounding structures, the risks and benefits of total versus subtotal resections in the short- and long-term patients' outcome are still under debate. Here, we report a case of an extensive giant EC and offer a discussion of its characteristics, surgical management, and postoperative outcome, taking a cue to argue about the recent literature based in the latest case studies.
Collapse
Affiliation(s)
- Antonella Mangraviti
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli – IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Edoardo Mazzucchi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli – IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Izzo
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli – IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cosimo Sturdà
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli – IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessio Albanese
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli – IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Enrico Marchese
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli – IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli – IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfredo Puca
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli – IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carmelo Lucio Sturiale
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli – IRCCS, Rome, Italy
| |
Collapse
|
22
|
Grahnke K, Burkett D, Li D, Szujewski C, Leonetti JP, Anderson DE. Cranial Nerve Preservation Following Surgical Treatment for Epidermoid Cysts of the Posterior and Middle Fossae. J Neurol Surg B Skull Base 2018; 79:445-450. [PMID: 30210971 DOI: 10.1055/s-0037-1617431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/19/2017] [Indexed: 10/18/2022] Open
Abstract
Epidermoid cysts are rare lesions, accounting for 0.2 to 1.8% of all intracranial tumors. They most commonly occur in the cerebellopontine angle where they may cause a breadth of neurologic complications due to mass effect on the nearby cranial nerves (CN), vascular structures, and the brain stem. Treatment of epidermoid cysts is surgical, with the goal of complete resection using microsurgical technique and even more importantly preservation of the involved CNs, vasculature, and brain parenchyma. Successful surgery can result in total resolution of symptoms, but, in certain situations, may not be advisable due to adherence, scarring, or inflammation making dissection of CN fascicles difficult and possibly hazardous. We conducted a retrospective review from 1998 to 2016 and compiled a series of 28 skull base epidermoid cysts operated on at our institution. Cases were evaluated for presenting symptoms, history of prior resection, and postoperative results including CN function, extent of resection, residual tumor, and need for reoperations. The average tumor size (largest diameter) was 3.9 cm with a range of 1 to 7cm. Eighteen of twenty-eight (64%) patients underwent a gross total resection and ten underwent subtotal resection. No patients, whether presenting with CN deficits or not, experienced permanent worsening of CN function following surgery. Complete resection of epidermoid cysts should remain a high priority of therapy, but, in our opinion, preservation of CN function should be a primary goal, determining the extent of resection to provide patients with the highest quality of life possible following surgery.
Collapse
Affiliation(s)
- Kurt Grahnke
- Departments of Neurological Surgery and Otolaryngology, Head and Neck Surgery, and Stritch School of Medicine, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois, United States
| | - Daniel Burkett
- Department of Neurological Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, United States
| | - Daphne Li
- Departments of Neurological Surgery and Otolaryngology, Head and Neck Surgery, and Stritch School of Medicine, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois, United States
| | - Caroline Szujewski
- Departments of Neurological Surgery and Otolaryngology, Head and Neck Surgery, and Stritch School of Medicine, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois, United States
| | - John P Leonetti
- Departments of Neurological Surgery and Otolaryngology, Head and Neck Surgery, and Stritch School of Medicine, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois, United States
| | - Douglas E Anderson
- Departments of Neurological Surgery and Otolaryngology, Head and Neck Surgery, and Stritch School of Medicine, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois, United States
| |
Collapse
|
23
|
Singh I, Rohilla S, Kumar P, Krishana G. Combined microsurgical and endoscopic technique for removal of extensive intracranial epidermoids. Surg Neurol Int 2018. [PMID: 29527394 PMCID: PMC5838849 DOI: 10.4103/sni.sni_392_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Intracranial epidermoid tumors are challenging lesions because they grow along the subarachnoid spaces around delicate neurovascular structures and often extend from one compartment to another. The purpose of this study was to determine the usefulness of endoscopic assistance in the microsurgical resection of these lesions, in which total resection is therapy of choice. Methods A total of 48 cases of intracranial epidermoids were treated by combined microscopic and endoscopic techniques. Initially, the tumor was removed under the microscope and after ensuring maximum excision, the endoscope was used to find out and excise any residual tumor. Results Out of these 48 cases complete excision was achieved in 44 cases and subtotal excision in four patients. Postoperative complications were seen in 17 patients, but none of the complications was attributed to the use of endoscope. Overall use of endoscope benefited 79% of cases. Conclusion We recommend combined microsurgical and endoscopic approach to achieve complete/maximum resection of extensive intracranial epidermoid tumors.
Collapse
Affiliation(s)
- Ishwar Singh
- Department of Neurosurgery, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India
| | - Seema Rohilla
- Department of Radiodiagnosis, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India
| | - Prashant Kumar
- Department of Anaesthesiology and Critical Care, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India
| | - Gopal Krishana
- Department of Neurosurgery, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India
| |
Collapse
|
24
|
El-Shehaby AMN, Reda WA, Abdel Karim KM, Emad Eldin RM, Nabeel AM. Gamma knife radiosurgery for cerebellopontine angle epidermoid tumors. Surg Neurol Int 2017; 8:258. [PMID: 29184709 PMCID: PMC5680664 DOI: 10.4103/sni.sni_206_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/05/2017] [Indexed: 01/14/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Amr M N El-Shehaby
- Gamma Knife Center Cairo, Cairo, Egypt.,Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Wael A Reda
- Gamma Knife Center Cairo, Cairo, Egypt.,Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Khaled M Abdel Karim
- Gamma Knife Center Cairo, Cairo, Egypt.,Department of Clinical Oncology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Reem M Emad Eldin
- Gamma Knife Center Cairo, Cairo, Egypt.,Department of Radiation Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Cairo, Egypt.,Department of Neurosurgery, Faculty of Medicine, Benha University, Qalubya, Egypt
| |
Collapse
|
25
|
Farhoud A, Khedr W, Aboul-Enein H. Surgical Resection of Cerebellopontine Epidermoid Cysts: Limitations and Outcome. J Neurol Surg B Skull Base 2017; 79:167-172. [PMID: 29868322 DOI: 10.1055/s-0037-1606220] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 07/15/2017] [Indexed: 10/19/2022] Open
Abstract
Objective Epidermoid cysts are benign slowly growing tumors commonly involving the cerebellopontine angle (CPA). The aim of this study was to analyze the surgical limitations, surgical strategies, complications, and outcome of resection of these lesions. Material and Methods The clinical data and outcome of 32 cases operated for CPA epidermoid between 2007 and 2015 were retrospectively analyzed. The mean follow-up period was 42.6 months, and all patients were followed up at least for a whole year. Results There were 15 males and 17 females. The median age was 37.6 years. Headache and cranial nerves dysfunction were the most common presenting symptoms. Surgery was performed in all patients using the standard lateral suboccipital retrosigmoid approach. In three cases, microvascular decompression of an arterial loop was performed in addition to tumor excision. Total resection was accomplished in 19 out of 32 cases (59.4%), subtotal resection in 7 cases (21.9%), and only partial excision was achieved in 6 cases (18.7%). There was no recurrence or regrowth of residual tumor during the follow-up period. We had a single postoperative mortality due to postoperative pneumonia and septic shock. New cranial nerves deficits occurred in 15.6% of cases but were transient in most of them. Conclusion The favorable outcome of total resection of CPA epidermoids should always be weighed against the critical risks that accompany it especially in the presence of tight adhesions to vital neurovascular structures. The retrosigmoid approach is suitable for the resection of these tumors even if they were large in size.
Collapse
Affiliation(s)
- Ahmed Farhoud
- Department of Neurosurgery, Alexandria University, Alexandria, Egypt
| | - Wael Khedr
- Department of Neurosurgery, Alexandria University, Alexandria, Egypt
| | | |
Collapse
|
26
|
Czernicki T, Kunert P, Nowak A, Wojciechowski J, Marchel A. Epidermoid cysts of the cerebellopontine angle: Clinical features and treatment outcomes. Neurol Neurochir Pol 2015; 50:75-82. [PMID: 26969562 DOI: 10.1016/j.pjnns.2015.11.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/12/2015] [Accepted: 11/26/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To report clinical characteristics, treatment outcomes and risk of recurrence in patients with surgically treated cerebellopontine angle epidermoids. METHODS In 1994-2013, we operated 17 patients, including 7 with tumor limited to the cerebellopontine angle, 7 with cerebellopontine angle tumor penetrating supratentorially, and 3 with cerebellopontine angle tumor extending along skull base to contralateral cerebellopontine angle. All patients were followed-up for the mean duration of 126 months. RESULTS On admission cranial nerve symptoms predominated. Total tumor removal was achieved in 5 patients, and incomplete removal (with small tumor remnants left on vessels, nerves, or brainstem) in 12 patients. Postoperatively, preoperative deficits worsened in 2 and new postoperative deficits occurred in 10 patients. The extent of tumor expansion had no effect on postoperative morbidity and risk of recurrence. During long-term follow-up, improvement or resolution of preoperative deficits was seen in 11 of 17 patients, and new postoperative deficits in 8 of 10 patients. Symptomatic recurrences after an average of more than 9 years were noted in 5 patients, 3 of whom were reoperated. Recurrences occurred in some younger patients and always in area of primary tumor. No effect of extent of tumor removal on risk of recurrence was found. CONCLUSIONS The extent of tumor removal had no effect on the risk of recurrence, and thus it may be acceptable to leave tumor capsule fragments adhering closely to nerves, vessels, or brainstem. During long-term follow-up, resolution or improvement of present preoperatively and new postoperative neurological deficits may be expected in most patients.
Collapse
Affiliation(s)
- Tomasz Czernicki
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland.
| | - Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Arkadiusz Nowak
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | | | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|
27
|
Cerebellopontine angle epidermoid cysts: clinical presentations and surgical outcome. Neurosurg Rev 2015; 39:259-66; discussion 266-7. [PMID: 26566990 DOI: 10.1007/s10143-015-0684-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 06/30/2015] [Accepted: 08/09/2015] [Indexed: 10/22/2022]
Abstract
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.
Collapse
|
28
|
Abolfotoh M, Bi WL, Hong CK, Almefty KK, Boskovitz A, Dunn IF, Al-Mefty O. The combined microscopic-endoscopic technique for radical resection of cerebellopontine angle tumors. J Neurosurg 2015; 123:1301-11. [DOI: 10.3171/2014.10.jns141465] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The combined microscopic and endoscopic technique has shown significant advantages in the management of various lesions through different approaches. Endoscopic-assisted techniques have frequently been applied to cerebellopontine angle (CPA) surgery in the context of minimally invasive craniotomies. In this paper the authors report on the use of the endoscope in the CPA as a tool to increase the extent of resection, minimize complications, and preserve the function of the delicate CPA structures. They also describe a technique of the simultaneous use of the microscope and endoscope in the CPA and dissection of CPA tumors under tandem endoscopic and microscopic vision to overcome the shortcomings of introducing the endoscope alone in the CPA. The reliability of using the microscope alone in dissecting CPA tumors is evaluated, as is the effectiveness of the combined technique in increasing the resectability of various types of CPA tumors.
METHODS
The authors conducted a retrospective analysis of 50 patients who underwent combined microscopic-endoscopic resection of CPA tumors by the senior author over a period of 3 years (February 2011 to February 2014) at Brigham and Women's Hospital, Harvard Medical School. The reliability of the extent of microscopic removal was evaluated with endoscopic exploration. Additional resection was performed with both microscopic and the combined microscopic-endoscopic technique. Endoscopically verified total resection was validated by intraoperative or postoperative MRI. The function of the cranial nerves was evaluated to assess the impact of the combined technique on their function.
RESULTS
A tumor remnant was endoscopically identified in 69% of the 26 patients who were believed to have microscopic total resection. The utilization of the endoscopic visualization and dissection increased endoscopically verified total removal to 38 patients, and 82% of these patients had no sign of residual tumor on postoperative imaging. The technique was most effective with epidermoid tumors. There were a total of 17 new cranial nerve deficits in 10 patients. Preoperative fifth cranial nerve deficits improved in 52% and hearing improved in 29% of patients after surgery.
CONCLUSIONS
This method provides simultaneous microscopic and endoscopic visualization and dissection techniques through skull-base approaches to CPA tumors. It overcomes some of the shortcomings of endoscopic-assisted surgery, further extends the surgical field, and increases the radicality of tumor resection with good functional outcomes.
Collapse
Affiliation(s)
- Mohammad Abolfotoh
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
- 2Department of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Wenya Linda Bi
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Chang-Ki Hong
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
- 3Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University, College of Medicine, Seoul, Korea; and
| | - Kaith K. Almefty
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
- 4Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Abraham Boskovitz
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ian F. Dunn
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ossama Al-Mefty
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
29
|
Aboud E, Abolfotoh M, Pravdenkova S, Gokoglu A, Gokden M, Al-Mefty O. Giant intracranial epidermoids: is total removal feasible? J Neurosurg 2015; 122:743-56. [DOI: 10.3171/2014.11.jns1481] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
Collapse
Affiliation(s)
| | - Mohammad Abolfotoh
- 2Department of Neurosurgery, Brigham and Women's Hospital, Harvard University, School of Medicine, Boston, Massachusetts; and
- 4Department of Neurosurgery, Ain Shams University, Cairo, Egypt
| | | | - Abdulkerim Gokoglu
- 2Department of Neurosurgery, Brigham and Women's Hospital, Harvard University, School of Medicine, Boston, Massachusetts; and
| | - Murat Gokden
- 3Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ossama Al-Mefty
- 2Department of Neurosurgery, Brigham and Women's Hospital, Harvard University, School of Medicine, Boston, Massachusetts; and
| |
Collapse
|
30
|
Pure endoscopic removal of epidermoid tumors of the cerebellopontine angle. Childs Nerv Syst 2014; 30:1261-7. [PMID: 24481575 DOI: 10.1007/s00381-014-2357-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 01/02/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Epidermoid tumors located in the cerebellopontine angle (CPA) are challenging lesions because they tend to grow slowly in the subarachnoid cisterns around delicate neurovascular structures and often extend into surgical anatomic corners. The aim of this paper is to demonstrate the advantages and limitations of purely endoscopic removal of the CPA epidermoids. METHODS Six patients harboring an epidermoid tumor located in the CPA were treated using an endoscope-controlled microsurgical technique. A retrosigmoid suboccipital approach was used in all patients. The cerebellomedullary cistern and the cisterna magna were opened to allow cerebrospinal fluid drainage and cerebellar drop, thus yielding a wide and straight working channel to the CPA. Then, the tumor and its capsule were removed by the modified microsurgical instruments. RESULT The symptoms caused by mass effect of the lesion resolved after surgery. There were no deaths, but permanent deficits occurred in one patient whose cranial nerves VII/VIII complex was accidentally lesioned. Tumors and their capsules were totally removed in five cases. All patients were discharged 3-5 days after surgery. To date, no recurrences have been observed (follow-up range 14-50 months). CONCLUSION The endoscope-controlled microsurgical technique enables a safe tumor removal even when parts of the lesion are not visible in a straight line in CPA epidermoids. By angled endoscopic lenses, tumor extending into adjacent cranial compartments or surgical anatomic corners can be removed through a single small craniotomy without retracting neurovascular structures.
Collapse
|
31
|
Acioly MA, Liebsch M, de Aguiar PHP, Tatagiba M. Facial Nerve Monitoring During Cerebellopontine Angle and Skull Base Tumor Surgery: A Systematic Review from Description to Current Success on Function Prediction. World Neurosurg 2013; 80:e271-300. [DOI: 10.1016/j.wneu.2011.09.026] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Accepted: 09/06/2011] [Indexed: 11/17/2022]
|
32
|
Hearing preservation in management of epidermoids of the cerebellopontine angle: CPA epidermoids and hearing preservation. Otol Neurotol 2013; 33:1599-603. [PMID: 23032664 DOI: 10.1097/mao.0b013e31826bed8d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Surgical approaches for epidermoid cysts of the cerebellopontine angle (CPA) are dictated by tumor location. Previous reports have advocated the sacrifice of usable hearing to achieve maximal tumor resection in a single operation. The aim of the current study is to demonstrate the applicability of hearing preservation approaches in the neurotologic management of epidermoids of the CPA. STUDY DESIGN Retrospective chart review. METHODS A search of archived surgical cases at a single institution between January 1, 1997, and December 31, 2011, revealed 18 cases of epidermoid cysts involving the CPA. RESULTS Eighteen patients with a mean age 40.9 years underwent surgery. Average tumor size was 4.47 cm, and presenting symptoms included headache, vertigo, cranial neuropathies, and seizures. Thirteen patients underwent a retrosigmoid approach, 2 translabyrinthine, 2 pterional, and 1 retrolabyrinthine/presigmoid. Complications included CSF leak, pseudomeningocele, meningitis, cranial nerve dysfunction, and persistent imbalance. All but 5 patients had long-term follow-up imaging to chronicle tumor residua/recurrence, varying from 6 to 149 months postoperatively. The average length of follow-up was 71.4 months, and residual tumor was common, with most patients demonstrating a focal or small area of residual tumor on follow-up imaging. Two patients had undergone previous surgery for epidermoid excision elsewhere. Two patients required reoperation for epidermoid regrowth, and the times between surgeries were 44 and 78 months. Of the patients who underwent a retrosigmoid approach, 9 had postoperative audiograms. All of these patients maintained hearing at or near their preoperative level except for 2 patients whose hearing declined and one whose hearing significantly improved. CONCLUSION Hearing preservation approaches for epidermoids of the CPA is a feasible option for long-term control of these tumors. Resection from a retrosigmoid approach can provide years of useful hearing, and the majority of patients do not require reoperation.
Collapse
|
33
|
Endoscopic-assisted resection of intracranial epidermoid tumors. World Neurosurg 2013; 82:450-4. [PMID: 23548848 DOI: 10.1016/j.wneu.2013.03.073] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 03/26/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Intracranial epidermoid tumors are epithelially derived lesions that may present particular challenges to neurosurgeons, often encasing critical neurovascular structures and extending into multiple subarachnoid cisterns. We aimed to evaluate our recent experience with endoscopic assistance to craniotomy with microsurgical resection of these lesions. METHODS A retrospective review of patients undergoing endoscopic-assisted craniotomy for resection of an epidermoid tumor at the Keck School of Medicine of University of Southern California between 2009 and 2012 was conducted. In all patients, the surgical approach and tumor resection were first performed microscopically. This was followed by use of an angled endoscope to facilitate further inspection and additional resection of tumor using a two-surgeon technique. RESULTS Twelve patients undergoing 13 consecutive endoscopic-assisted craniotomies were included in the analysis. The mean patient age was 45 years. The mean maximal tumor diameter was 4.0 cm (range, 2.4-5.8 cm). Surgery was for recurrent epidermoid in 6 of 13 cases (46%). Epidermoid tumor location included the cerebellopontine angle (9 patients, 75%), fourth ventricle (2 patients, 17%), and third ventricle (1 patient, 8%). Surgical approaches included retrosigmoid craniotomy (8 patients), suboccipital craniotomy (1 patient), suboccipital craniotomy with supracerebellar approach (1 patient), extradural temporopolar approach (1 patient), and subtemporal approach (1 patient). In 11 of 13 cases (85%), additional tumor was identified upon inspection with an angled endoscope, facilitating additional tumor resection in each case. Gross or deliberate near total resection was achieved in 7 of 13 cases (54%). Four patients (31%) had improvement of cranial nerve function. Postoperative neurological deficits included transient abducens and oculomotor nerve paresis in one patient each. CONCLUSIONS The endoscope is a safe and effective adjunct to the microscope in facilitating additional inspection and further resection of epidermoid tumors. Endoscopic-assisted surgery is particularly useful for identifying and removing additional tumor located around surgical corners.
Collapse
|
34
|
Nagasawa DT, Choy W, Spasic M, Yew A, Trang A, Garcia HM, Yang I. An analysis of intracranial epidermoid tumors with malignant transformation: treatment and outcomes. Clin Neurol Neurosurg 2012; 115:1071-8. [PMID: 23219403 DOI: 10.1016/j.clineuro.2012.10.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 10/29/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVE While typically benign, epidermoid tumors upon rare occasion can undergo malignant transformation, which carries a poor prognosis. Here, we reviewed treatment strategies and analyzed outcomes for every case of malignant epidermoid tumor reported since its original description in 1912. METHODS A comprehensive literature review identified all reported cases of malignant transformation of intracranial epidermoid tumor. Treatments were categorized as follows: palliative management, stereotactic radiosurgery (SRS), chemotherapy, and surgery plus multiple (2+) adjuvant therapies. Survival data of these groups were compared to treatment outcomes for patients receiving only surgical resection, as reported in our previous study. RESULTS We identified 58 cases of intracranial epidermoid tumor with malignant degeneration. Average survival regardless of therapy was 11.8 months. Mean survival outcomes for groups treated with palliative management, chemotherapy, SRS, and multiple postoperative adjuvant therapies were 5.3 months, 25.7 months, 29.2 months, and 36.3 months, respectively. Outcomes for the groups including SRS, chemotherapy, and multiple post-operative adjuvant therapies were statistically significant compared to surgical resection alone. CONCLUSION While there remains a lack of consensus regarding the best approach to the management of patients with malignant epidermoid tumors, our systematic analysis characterizes and confirms the added benefit of SRS, chemotherapy, and multimodal adjuvant therapies.
Collapse
Affiliation(s)
- Daniel T Nagasawa
- UCLA Department of Neurological Surgery, University of California Los Angeles, Los Angeles, CA 90095-1761, USA
| | | | | | | | | | | | | |
Collapse
|
35
|
de Oliveira RS, Maia WS, Santos MV, Camara RLB. Combined pre- and subtemporal transtentorial approach for epidermoid cysts of the cerebellopontine angle. Childs Nerv Syst 2012; 28:2137-42. [PMID: 23089931 DOI: 10.1007/s00381-012-1904-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 08/25/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Epidermoid cysts of the cerebellopontine angle (CPA) can be a surgical challenge for the pediatric neurosurgeon. Ideally, total removal must be achieved; however, occasional adhesions of these tumors to vital neurovascular structures and extension far beyond the midline may preclude their total removal. The aims of this article are to present an alternative surgical approach to these lesions and to provide the rationale for this technique. MATERIAL AND METHODS A 16-year-old boy was admitted to our pediatric neurosurgery department with a 1-year history of nonspecific headaches. His neurological examination showed right-sided dysmetria and gait ataxia. Magnetic resonance scans showed a space-occupying lesion on the right CPA with low intensity on T(1)-weighted images and high intensity on T(2)-weighted images. RESULTS Craniotomy for tumor excision via pre- and subtemporal transtentorial approach was performed disclosing a 3.5 × 3 × 2.8-cm(3) well-encapsulated tumor, which was confirmed to be an epidermoid cyst. The postoperative course was uneventful. CONCLUSIONS A combined pre- and subtemporal approach utilizes a wide opening of the tentorium and the option of supratentorial retraction of the cerebellum to provide an excellent angle of approach to CPA lesions involving the anterolateral aspect of the brain stem in children.
Collapse
Affiliation(s)
- Ricardo Santos de Oliveira
- Division of Pediatric Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, 14049-900, Ribeirão Preto, Brazil.
| | | | | | | |
Collapse
|