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El Marrakchi M, Haddi M, Zian N, Bellihi Y, Ghannane H, Benali SA. Isolated thoracic intradural extramedullary epidermoid cyst: A technical note. Surg Neurol Int 2024; 15:170. [PMID: 38840622 PMCID: PMC11152523 DOI: 10.25259/sni_280_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 04/20/2024] [Indexed: 06/07/2024] Open
Abstract
Background Congenital, acquired, and iatrogenic spinal epidermoid cysts (EC) are very rare. Methods A 62-year-old female patient presented with a 5-month history of progressive paraparesis leading to paraplegia secondary to a posterior compressive intradural extramedullary lesion at the T7 level. The patient underwent a laminectomy/durotomy for gross total tumor excision. Results Histopathology confirmed the lesion was an epidermoid cyst. Although her spasticity improved within 5 weeks, she only regained partial lower extremity motion (i.e., 3/5 motor function). Conclusion Patients presenting with the acute/subacute onset of paraparesis secondary to spinal EC should undergo timely gross total cyst resections to optimize neurological outcomes.
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Affiliation(s)
- Malak El Marrakchi
- Department of Neurosurgery, Arrazi Hospital, Mohammed VI University Hospital Center of Marrakesh, Cadi Ayyad University, Faculty of Medicine, Marrakesh, Morocco
| | - Mostafa Haddi
- Department of Neurosurgery, Ibn Zohr Hospital, Marrakesh, Morocco
| | - Nahla Zian
- Department of Neurosurgery, Arrazi Hospital, Mohammed VI University Hospital Center of Marrakesh, Cadi Ayyad University, Faculty of Medicine, Marrakesh, Morocco
| | - Younes Bellihi
- Department of Neurosurgery, Arrazi Hospital, Mohammed VI University Hospital Center of Marrakesh, Cadi Ayyad University, Faculty of Medicine, Marrakesh, Morocco
| | - Houssine Ghannane
- Department of Neurosurgery, Arrazi Hospital, Mohammed VI University Hospital Center of Marrakesh, Cadi Ayyad University, Faculty of Medicine, Marrakesh, Morocco
| | - Said Ait Benali
- Department of Neurosurgery, Arrazi Hospital, Mohammed VI University Hospital Center of Marrakesh, Cadi Ayyad University, Faculty of Medicine, Marrakesh, Morocco
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Hussen E, Aboye S, Leake M, Nuredin Abrar F. Intramedullary Epidermoid Cyst of the Conus Medullaris: A Case Report and Literature Review. Int Med Case Rep J 2023; 16:521-527. [PMID: 37720363 PMCID: PMC10505022 DOI: 10.2147/imcrj.s430853] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/05/2023] [Indexed: 09/19/2023] Open
Abstract
Background Central nervous system tumors are usually located in the brain, and spinal cord tumors account for approximately 20% of central nervous system tumors. Epidermoid cysts constitute <1% of all intraspinal tumors. It consists of squamous epithelial-lined cysts containing keratin, cholesterol, and cellular granules. Epidermoid cysts can be classified as congenital, acquired, extradural, extramedullary, or intramedullary according to etiology and location. The intradural intramedullary type is uncommon. Case Presentation An 11-year-old female patient had back pain with radiation to both lower extremities but worsened on the left side for 5 years. On neurological examination, motor strength was 3/5 for hip flexion and knee extension bilaterally and 5/5 for other key muscle groups. Contrast-enhanced lumbosacral magnetic resonance imaging (MRI) revealed T1 hypointense and T2 hyperintense lesions in the L2-L4 intramedullary conus and cauda equina. Laminectomy and near total resection were done, and histopathological examination revealed an epidermoid cyst. On the third postoperative day, the patient was discharged with completely resolved back pain and an improvement in lower extremity motor power. At monthly follow-up visits for a further 6 months, her back pain and weakness completely resolved, and she had no neurologic deficits. A postoperative lumbosacral MRI was done and confirmed near total excision of the tumor. Conclusion Intramedullary conus epidermoid cysts are rare but not unknown to neurosurgeons. MRI with diffusion-weighted images (DWI) is an imaging modality of choice. Asymptomatic patients can be conservatively treated. Once the patient has progressive symptoms and signs of compression, surgical excision is recommended. Meticulous electrocauterization may help decrease tumor regrowth in the remnant capsule, which is recommended. Avoiding leakage of cyst fluid into the subarachnoid space helps to avoid postoperative chemical meningitis. Radiotherapy is an option for the management of multiple recurrences.
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Affiliation(s)
- Endris Hussen
- Department of Neurosurgery, St. Paul’s Millennium Medical College, Addis Ababa, Ethiopia
| | - Samson Aboye
- Department of Neurosurgery, St. Paul’s Millennium Medical College, Addis Ababa, Ethiopia
| | - Merhawi Leake
- Minilik II Comprehensive Specialized Hospital, Addis Ababa, Ethiopia
| | - Fadil Nuredin Abrar
- Addis Ababa University College of Medicine and Health Sciences Hospital, Addis Ababa, Ethiopia
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Sarhan FM, Daqour AM, Abu-Harb ZH, Al-Darawish A, Ganaim FZ. Recurrent lumbar intraspinal epidermoid cyst presenting as lower back pain, a case report. Int J Surg Case Rep 2022; 97:107420. [PMID: 35853283 PMCID: PMC9403204 DOI: 10.1016/j.ijscr.2022.107420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Intraspinal Epidermoid Cyst (IEC) is a very-rare, yet one of the most benign tumors of the Central Nervous System (CNS). Very few cases of IEC were reported world-wide. Presentations depend on the location of the tumor with pain being the most common presenting symptom. CASE PRESENTATION A-35-year-old patient presented to the neurosurgical department for a regular follow up. Her history dates back to four years ago, when she first presented with back pain, which was later accompanied with fecal and urinary incontinence. Magnetic Resonance Imaging (MRI) showed a tumor at the level of L4-L5 which was surgically removed. Three years later, the patient presented to the clinic with similar symptoms. A repeat MRI showed a mass at L4-L5, which was surgically removed. Histological findings of both surgeries showed findings consistent with IEC. Currently the patient has no complaints. CLINICAL DISCUSSION IEC has various presentations. Our case presented with back pain, and urinary and fecal incontinence. Diagnosis depends on imaging and histology. MRI is the imaging modality of choice for those tumors in the CNS. Surgical removal is associated with high recurrence as a result of the suboptimal resection due to the strong adhesions between the capsule and the spinal cord. CONCLUSION Pain is the most common presenting symptom for IEC. Adjuvant radiotherapy, which should be implemented in the standard of care, is associated with a lesser degree of recurrence, in addition to regular follow-ups.
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Affiliation(s)
- Fajr M.A. Sarhan
- Al-Quds University-School of Medicine, Abu-Dis, East Jerusalem-West Bank, Palestine,Corresponding author.
| | | | - Zahra Hosam Abu-Harb
- Al-Quds University-School of Medicine, Abu-Dis, East Jerusalem-West Bank, Palestine
| | - Asaad Al-Darawish
- Al-Makassed Islamic Charitable Hospital, East-Jerusalem, West Bank, Palestine
| | - Fidaa Zakaria Ganaim
- Al-Quds University-School of Medicine, Abu-Dis, East Jerusalem-West Bank, Palestine
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Min SH, Lee JH, Kim JH, Jeong MJ, Kim SH, Kim JY, Kang MJ. [A Rare Case of Thoracic Intradural Epidermoid Cyst after Spinal Cord Stimulator Insertion: A Case Report]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2022; 83:938-944. [PMID: 36238904 PMCID: PMC9514589 DOI: 10.3348/jksr.2021.0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/21/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022]
Abstract
Spinal epidermoid cysts are extremely rare benign tumors and can be congenital or acquired. Acquired spinal epidermoid cysts are found in the lumbosacral region. To our knowledge, no case of epidermoid cyst related to spinal cord stimulator insertion has yet been reported. We report the MRI findings of a rare case of thoracic intradural epidermoid cyst acquired after spinal cord stimulator insertion in a 50-year-old female.
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Duong HD, Pham AH, Chu HT, Le TD, Pham DT, Van Dong H. Microsurgery for intradural epidermoid cyst at cauda equina level in a 9-year-old child: A case report. Int J Surg Case Rep 2021; 82:105932. [PMID: 33957405 PMCID: PMC8113878 DOI: 10.1016/j.ijscr.2021.105932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction and importance Epidermoid cysts are rare benign tumors. Here, we present a case of spontaneous intradural epidermoid cyst at cauda equina level in a 9-year-old patient, which we believed the first case to be reported in Vietnam. Case presentation A 9-year-old boy presented with 4 months of spontaneous left lower extremity muscle weakness and paresthesia. The MRI images suggested the diagnosis of intradural epidermoid cyst at cauda equina level. The patient underwent L5–S1 laminectomy and durotomy for tumor resection. The histology confirmed the diagnosis of epidermoid cyst. Post-operative images demonstrated total cyst removal. Clinical discussion The epidermiology, presentation and diagnosis and strategy of treatments as well as their outcomes were discussed. Conclusion Diagnosis of spinal epidermoid cyst is often delayed for its obscure presentation. Microsurgical dissection along with intra-operative mobile C-Arms enable total tumor resection while preserving spinal stability and neurological function. Follow-up with post-operative magnetic resonance imaging and tumor marker are helpful. Diagnosis of spinal epidermoid cyst is often delayed for its obscure presentation. Microsurgical dissection and mobile C-Arm enables total tumor resection while preserving stability and neurological function Magnetic resonance imaging and tumor marker are helpful in follow-up.
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Affiliation(s)
- Ha Dai Duong
- Department of Surgery, Hanoi Medical University, Hanoi, Viet Nam; Department of Neurosurgery I, Viet Duc University Hospital, Hanoi, Viet Nam.
| | - Anh Hoang Pham
- Department of Surgery, Hanoi Medical University, Hanoi, Viet Nam; Department of Neurosurgery I, Viet Duc University Hospital, Hanoi, Viet Nam
| | - Hung Thanh Chu
- Department of Surgery, Hanoi Medical University, Hanoi, Viet Nam.
| | - Tam Duc Le
- Department of Surgery, Hanoi Medical University, Hanoi, Viet Nam; Department of Neurosurgery and Spine Surgery, Hanoi Medical University Hospital, Hanoi, Viet Nam
| | - Dung Tuan Pham
- Department of Neurosurgery I, Viet Duc University Hospital, Hanoi, Viet Nam
| | - He Van Dong
- Department of Neurosurgery I, Viet Duc University Hospital, Hanoi, Viet Nam
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Ganko R, Rodriguez M, Magnussen J, Simons M, Myint E, Assaad N. Do prophylactic steroids prevent chemical meningitis in surgery for epidermoid cysts? Case report and literature review. Surg Neurol Int 2020; 11:472. [PMID: 33500810 PMCID: PMC7827574 DOI: 10.25259/sni_797_2020] [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: 11/07/2020] [Accepted: 12/10/2020] [Indexed: 11/09/2022] Open
Abstract
Background: Cranial and spinal epidermoid cysts (ECs) are rare and surgical resection can be complicated by chemical meningitis. Here, we treated a patient undergoing surgical resection of an intramedullary spinal EC with prophylactic steroids to help prevent postoperative chemical meningitis. Notably, we found a paucity of evidence regarding the efficacy of steroids used for this purpose. Case Description: A 44-year-old male presented with a rare intramedullary thoracic EC. He was given oral dexamethasone postoperatively and did not subsequently develop chemical meningitis. Here, we reviewed the current literature regarding the efficacy of steroid use for this purpose, utilizing multiple electronic databases (Ovid MEDLINE, Ovid EMBASE, and Scopus). We found only three studies (one case report, one case series, and a randomized controlled trial), that involved patients who received steroids. Of the 24 patients given prophylactic steroids, none developed fever or meningismus. One patient received 8 days of oral dexamethasone. Eleven patients received intraoperative hydrocortisone irrigation alone, while final 12 patients received intraoperative hydrocortisone irrigation plus a 3 week postoperative tapering course of oral steroids. Notably, all of the nine patients who did not receive any steroids developed postoperative fever, with 78% demonstrating meningismus. Conclusion: Here is level II evidence that establishes the efficacy of prophylactic steroids utilized in patients undergoing surgery for ECs to prevent postoperative chemical meningitis. Nevertheless, there is still no current consensus regarding either the type of steroid utilized, or the route of administration.
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Affiliation(s)
- Renata Ganko
- Department of Neurosurgery, Macquarie University Hospital, Macquarie Park, New South Wales, Australia
| | - Michael Rodriguez
- Department of Anatomical Pathology, Douglas Hanly Moir Pathology (Sonic Healthcare), New South Wales, Australia
| | - John Magnussen
- Faculty of Medicine and Health Sciences, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Mary Simons
- Faculty of Medicine and Health Sciences, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Esther Myint
- Department of Anatomical Pathology, Douglas Hanly Moir Pathology (Sonic Healthcare), New South Wales, Australia
| | - Nazih Assaad
- Department of Neurosurgery, Macquarie University Hospital, Macquarie Park, New South Wales, Australia
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Hernandez JJC, Anokwute M, Martinez SJH, Olivas JR. Intradural iatrogenic epidermoid cyst at cauda equina: A case report. Surg Neurol Int 2020; 11:299. [PMID: 33093976 PMCID: PMC7568090 DOI: 10.25259/sni_417_2020] [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: 07/09/2020] [Accepted: 09/03/2020] [Indexed: 11/20/2022] Open
Abstract
Background: Spinal epidermoid accounts for <1% of all primary spinal cord tumors. They occur due to the invagination of epidermal elements into the neural tube during the embryonic period. Even more infrequent are spinal epidermoid cysts that occur without attendant spinal dysraphism (e.g., as occurs with the iatrogenic inoculation of epithelial cells in the subarachnoid space following a lumbar puncture). Case Description: A 38-year-old female with a history of epidural spinal blocks at L2-3 for two previous pregnancies presented with low back pain, right lower extremity weakness (4/5 level), hyporeflexia, and tingling/ numbness in the right L3-5 distribution. The lumbar MR demonstrated an intradural extramedullary lesion at the L2-L3 level that compressed the cauda equina/nerve roots. MR findings were compatible with an epidermoid cyst, this was histologically confirmed following a microsurgical L2-3 laminectomy for lesion resection. Pathologically, the lesion demonstrated a keratinized stratified squamous epithelium with keratin content without cutaneous attachments, thus confirming the diagnosis of an epidermoid cyst. Postoperatively, her sensory complains improved and her motor strength fully recovered to the 5/5 level. Conclusion: Patients with spinal epidermoid cysts typically present with underlying spinal dysraphism, but only rarely do iatrogenic cases arise. Here, we presented a patient who developed a spinal lumbar epidermoid cyst in a female patient after undergoing spinal epidural anesthesia during pregnancy. Notably, this was successfully treated a with decompressive laminectomy and microsurgical resection.
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Affiliation(s)
| | - Miracle Anokwute
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | | | - Jose Ramon Olivas
- Departments of Neurosurgery, Northeast National Medical Center, Monterrey, Nuevo Leon, Mexico
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8
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Sîrbu OM, Chirteş AV, Mitricã M, Sîrbu CA. Spinal Intramedullary Epidermoid Cyst: Case Report and Updated Literature Review. World Neurosurg 2020; 139:39-50. [DOI: 10.1016/j.wneu.2020.03.207] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/27/2020] [Accepted: 03/29/2020] [Indexed: 11/17/2022]
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9
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Wu L, Tian Y, Wang L, Wang D, Xu Y. Subependymoma of the Conus Medullaris with Cystic Formation: Case Report and a Literature Review. World Neurosurg 2020; 137:235-238. [PMID: 32081826 DOI: 10.1016/j.wneu.2020.02.053] [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: 01/05/2020] [Revised: 02/07/2020] [Accepted: 02/08/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Subependymoma in the spinal cord is very rare and usually occurs in the cervical cord. We report an exceptional case of subependymoma that occurred at the conus medullaris with cystic formation. This article reviews the literature on subependymoma in the conus medullaris; discusses its clinical manifestations, imaging findings, and differential diagnoses; and offers an opinion about the cystic formation of the subependymoma. CASE DESCRIPTION A 69-year-old woman experienced progressive limb weakness with a somatosensory abnormality for 3 months. Preoperative magnetic resonance imaging showed a cystic intramedullary lesion at the conus medullaris with a well-defined margin. A preliminary diagnosis of epidermoid cyst was made based on the imaging findings. During the operation, cystic formation of the tumor was found, and the tumor was completely removed. Pathology showed an uneven proliferation of glial cells, consistent with subependymal morphology, and the tumor was confirmed as subependymoma. CONCLUSIONS We present an extremely rare case of cystic formation in subependymoma at the conus medullaris. Subependymoma should be included in the differential diagnosis of intramedullary cystic lesions. The breakdown of the blood-brain barrier and excessive extravasation may be potential mechanisms of cystic formation.
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Affiliation(s)
- Liang Wu
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Tian
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li'ao Wang
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dejiang Wang
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yulun Xu
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Rkhami M, Gader G, Loukil B, Badri M, Zammel I. Iatrogenic Epidermoid Cyst of the Cauda Equina: A Late Complication of Lumbar Disc Herniation Surgery. World Neurosurg 2020; 133:271-274. [DOI: 10.1016/j.wneu.2019.10.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 10/11/2019] [Accepted: 10/13/2019] [Indexed: 11/24/2022]
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Akgun B, Ergun AC, Ozercan IH, Kok S. Intradural Extramedullary Epidermoid Cyst at the Conus Medullaris Level with Thoracic Syringomyelia: A Case Report. ACTA MEDICA (HRADEC KRÁLOVÉ) 2019; 62:39-42. [PMID: 30931896 DOI: 10.14712/18059694.2019.45] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Spinal epidermoid cysts are benign tumors. Syringomyelia secondary to intramedullary tumors are frequently observed. However, the association between syringomyelia and spinal intradural extramedullary epidermoid cyst in the conus medullaris region is extremely rare. We present the case of a 3-year-old male who was admitted with paraparesis and urinary retention. Magnetic resonance imaging (MRI) of the spine demonstrated intradural extramedullary lesion, compatible with epidermoid cyst, that at the conus medullaris level and a large syringomyelia extending from T4 to L1 vertebrae. Total microsurgical excision of the cyst was performed. No additional drainage was carried out for the syringomyelic cavity. Histopathological examination verified the diagnosis of the epidermoid cyst. Total excision of the cyst and disappearance of the syringomyelia were observed on MRI at 15 days postoperatively. We have clarified the etiology, clinical, histopathological and radiological features, differential diagnosis, and treatment modalities of spinal epidermoid cysts. In addition, we have discussed the possible mechanisms of syringomyelia formation in spinal intradural lesions.
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Affiliation(s)
- Bekir Akgun
- Firat University Hospital, Departments of Neurosurgery Elazig, Turkey.
| | - Ahmet Cemil Ergun
- Firat University Hospital, Departments of Neurosurgery Elazig, Turkey
| | | | - Selman Kok
- Firat University Hospital, Departments of Neurosurgery Elazig, Turkey
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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.
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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
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