Neurosurgical management of intracranial epidermoid tumors in children. Clinical article

Spontaneous regression of an epidermoid cyst in a pediatric patient-Case report and review of the literature

Epidermoid cysts are infrequent, benign, slow-growing, space-occupying lesions that account for 0.5-1.8% of primary intracranial tumors. We report the case of a 17-month-old child who presented in 2015 for one episode of pallor associated with hypotonia. Epilepsy was excluded and MRI was recommended. The MRI was performed and there were no focal parenchymal lesions, but it showed an extra-axial ovoid lesion with imaging characteristics consistent with epidermoid cyst. Follow-up MRI at one year was performed and it showed minimal increased in dimensions of the cyst, without changes into the signal of the lesion. Another MRI was performed 7 years after and it showed complete resolution of the cyst. Six months afterwards, another MRI was performed and it confirmed the complete regression of the cyst, without any extra-axial masses reported. The patient did not present any neurological anomalies. No follow-up MRI was recommended afterwards. Spontaneous regression of epidermoid cyst in pediatric population is an extremely rare event, but it should be taken into account when the patient shows no symptoms. This is the third case of spontaneous regression of an epidermoid cyst reported in pediatric patients, and the first one in the temporal region. Careful follow-up and watchful waiting could be an option to surgical treatment in epidermoid cysts.

Epidermoid cyst of central nervous system: A case series and review of literature

INTRODUCTION

Epidermoid cysts, originating from ectodermal cell remnants during embryogenesis, are rare, slow-growing tumours commonly found in the cerebellopontine angle, fourth ventricle, and sellar/parasellar regions. This retrospective study explores clinicopathological features, demographics, and radiological details of fifteen central nervous system epidermoid cyst cases over three years.

MATERIALS AND METHODS

Histologically confirmed cases undergoing surgical excision from July 2020 to July 2023 were retrospectively evaluated. Patient age, clinical presentations, radiological features, and histopathological findings were analyzed using descriptive statistics and aligned with the PROCESS criteria.

RESULTS

Fifteen cases, spanning various age groups and clinical presentations, were included. There were four cases each in the posterior fossa and cerebellopontine angle, three in temporal region, two in intraspinal region, and one each in the retromastoid intra-diploic and third intra-ventricular region. Lesions exhibited diverse distribution, gross findings, and microscopic features. Radiological imaging exhibited well-defined hypo-attenuated masses on computed tomography and contributed to the preoperative diagnosis in eight cases. Despite challenges in complete excision due to adherence, 13 cases underwent successful resection. Chemical meningitis, a common postoperative complication, underscores the importance of meticulous surgery.

CONCLUSION

This study highlights clinicopathological characteristics, challenges in surgical management, and postoperative complications of central nervous system epidermoid cysts. Comparative analysis with existing literature emphasizes the uniqueness of epidermoid cysts, differentiating them from craniopharyngiomas and dermoid cysts. Despite the retrospective design, valuable insights are provided, emphasizing the need for prospective studies. Effective management involves complete excision, ensuring long-term remission and emphasizing the distinctive nature of these intriguing intracranial lesions.

The Endoscopic Resection of Sellar and Suprasellar Epidermoid Cyst in a Pediatric Patient: A Case Report and Review of the Literature

Epidermoid cysts are benign congenital tumors that originate from the ectodermal tissue. The sellar/suprasellar region is an infrequent location for epidermoid cysts and such cases are rarely reported in pediatric patients, as these become symptomatic only when they reach 30 years of age. Surgical intervention is considered the ideal treatment option in patients with suprasellar epidermoid cysts, either via open or endonasal approach. We discuss a case of a 12-year-old male who presented with left visual impairment and was treated with successful resection through an endoscopic endonasal approach (EEA). We also engage in a literature review of the use of EEA in the management of sellar/suprasellar epidermoid cysts in the pediatric age group.

Neurosurgical Management of Skull Base Epidermoid Tumors in Children

Epidermoid tumors (ET) are congenital and benign tumors that develop from de ectoderm during neurogenesis. In the skull base, these lesions can insinuate themselves into several intracranial compartments by filling the subarachnoid space, and possibly affecting some important structures, like the brainstem, cerebellopontine angle, the pituitary in the middle fossa, and others. In the pediatrics skull base tumors, the ET represents 7-9%, being very rare. The surgical perspective of these cases is dependent on the extension of the resection. We presented two cases of total and near-total resection of ETs in the pediatric skull base, with successful outcomes.

Clinicoradiological Features and Treatment Outcome of Supratentorial Intraparenchymal Epidermoid Cyst: A Report of Five Cases and Literature Review

Objectives  Intraparenchymal epidermoid cysts (IECs) are rare lesions. They represent less than 1% of the intracranial epidermoid cysts. The supratentorial IEC is a clinically and prognostically distinct subset. Given the rarity, most of the articles are case reports. We present a series of five cases of supratentorial IEC to characterize their clinical presentation and outcome, with emphasis on the surgical features.

Materials and Methods  We searched our database for all cases of intracranial epidermoid cysts operated between January 2005 and January 2020. Five patients were identified having IEC from the hospital information system and the neurosurgical operation record book. Standard craniotomy and decompression of the lesion were performed in all these patients. Standard postoperative care includes computed tomography scan of head on the day of surgery and magnetic resonance imaging of brain after 6 weeks to look for the residual lesion, if any. Subsequent follow-up visits in outpatient department to look for resolution of the presurgical symptoms.

Results  The mean age of the patients in our series was 28.8 years (range: 28–40 years.). All the five patients were male. Four patients had IEC involving frontal lobe and one in parietal lobe with a small occipital lobe extension. Seizure was the most common presenting complaint followed by headache. Complete excision was achieved in all the cases. All the three patients with seizure attained seizure freedom postlesionectomy. Focal neurological deficits resolved gradually in postoperative period. There was no recurrence of lesion during follow-up.

Conclusion  Supratentorial IEC most commonly affects young males, involve frontal lobe and present clinically with seizure. Complete surgical excision offers best outcome in the form of remission of seizure disorder.

Pituitary infundibular epidermoid cyst: a rare cause of hypopituitarism

A 53-year-old man presented with 6 months history of weight loss associated with nausea, fatigue, dizziness and headache. On arrival he was in adrenal crisis. Biochemistry revealed anterior hypopituitarism with low cortisol, thyroxine, testosterone and a slightly raised prolactin. He was commenced on steroids, thyroxine and testosterone. MRI pituitary gland was reported to have a 9.4 mm microadenoma. Cabergoline was started for a possible microprolactinoma. Follow-up MRI showed increase in the size of complex cystic lesion causing chiasmal compression raising a possibility of craniopharyngioma. Visual fields assessment was normal. In view of the rapid enlargement, to protect vision and obtain a tissue diagnosis he underwent endoscopic trans-sphenoidal surgery. A cystic lesion was noted intraoperatively originating from pituitary stalk with intrasellar and suprasellar extension. It was filled with white caseous material and fluid. Histology revealed epidermoid cyst. His headache resolved postoperatively.

Recurrence of ruptured intracranial epidermoid cyst - A rare case report and presentation

INTRODUCTION

Intracranial epidermoid cysts are congenital tumors that develop from ectodermal remnants during neuroembryogenesis between the third and fifth weeks of gestation. These tumors are benign and usually present with local mass effect. Here, we present a rare case of ruptured intracranial epidermoid cyst with recurrence.

PRESENTATION OF CASE

A 55 years old male patient was brought to emergency with a history of headache and loss of consciousness for 1 h. Radiological imaging showed the features suggestive of ruptured intracranial epidermoid cyst which was operated. Two years later the patient re-presented with headache for 4-5 days where repeat MRI revealed recurrence of the tumor.

DISCUSSION

Epidermoid cysts are very slow growing tumor at a linear rate due progressive accumulation of normally dividing epidermal cells. These tumors often reach a large size before the onset of symptoms. At times, the tumor capsule may show infiltration to the brain parenchyma and tight adherence to neurovascular structures which leads to the incomplete removal of the tumor capsule leading to recurrence of tumor.

CONCLUSION

Rupture of intracranial epidermoid cyst is a rare phenomenon and recurrence of this tumor in patients is even infrequent.

Resection of an Isolated Pituitary Stalk Epidermoid Cyst Through a Pretemporal Approach: Case Report and Review of the Literature

BACKGROUND

Intracranial epidermoid cysts are congenital epidermal inclusion cysts derived from ectodermal origin with desquamated skin. The majority of these cysts occur in the cerebellopontine angle cistern. Epidermoid cyst of the pituitary stalk, however, is a rare location. To date, only 4 previous cases have been reported.

CASE DESCRIPTION

A 63-year-old male presented to our clinic with migraine headaches, dizziness, increased thirst, increased urinary frequency, and impotence. Magnetic resonance imaging of the brain demonstrated a rim-enhancing cystic mass with diffusion restriction on diffusion-weighted imaging located within the pituitary stalk. The patient underwent a pretemporal approach with gross total resection of the cyst. The patient's postoperative course was uneventful with no new deficits and/or endocrinopathies.

CONCLUSION

Epidermoid cyst of the pituitary stalk is an unusual and rare presentation. Four other cases treated via endoscopic approaches have been previously reported in the neurosurgical literature. To our knowledge this is the first case description of an infundibular epidermoid cyst pressing with isolated diabetes insipidus surgically treated via a transcranial pretemporal approach with gross total resection. The patient had a smooth and uneventful postoperative course with persistent diabetes insipidus.

Extent of resection of epidermoid tumors and risk of recurrence: case report and meta-analysis

OBJECTIVE

Intracranial epidermoid tumors are slow-growing, histologically benign tumors of epithelial cellular origin that can be symptomatic because of their size and mass effect. Neurosurgical resection, while the treatment of choice, can be quite challenging due to locations where these lesions commonly occur and their association with critical neurovascular structures. As such, subtotal resection (STR) rather than gross-total resection (GTR) can often be performed, rendering residual and recurrent tumor potentially problematic. The authors present a case of a 28-year-old man who underwent STR followed by aggressive repeat resection for regrowth, and they report the results of the largest meta-analysis to date of epidermoid tumors to compare recurrence rates for STR and GTR.

METHODS

The authors conducted a systemic review of PubMed, Web of Science, and the Cochrane Collaboration following the PRISMA guidelines. They then conducted a proportional meta-analysis to compare the pooled recurrence rates between STR and GTR in the included studies. The authors developed fixed- and mixed-effect models to estimate the pooled proportions of recurrence among patients undergoing STR or GTR. They also investigated the relationship between recurrence rate and follow-up time in the previous studies using linear regression and natural cubic spline models.

RESULTS

Overall, 27 studies with 691 patients met the inclusion criteria; of these, 293 (42%) underwent STR and 398 (58%) received GTR. The average recurrence rate for all procedures was 11%. The proportional meta-analysis showed that the pooled recurrence rate after STR (21%) was 7 times greater than the rate after GTR (3%). The average recurrence rate for studies with longer follow-up durations (≥ 4.4 years) (17.4%) was significantly higher than the average recurrence rate for studies with shorter follow-up durations (< 4.4 years) (5.7%). The cutoff point of 4.4 years was selected based on the significant relationship between the recurrence rate of both STR and GTR and follow-up durations in the included studies (p = 0.008).

CONCLUSIONS

STR is associated with a significantly higher rate of epidermoid tumor recurrence compared to GTR. Attempts at GTR should be made during the initial surgery with efforts to optimize success. Surgical expertise, as well as the use of adjuncts, such as intraoperative MRI and neuromonitoring, may increase the likelihood of completing a safe GTR and decreasing the long-term risk of recurrence. The most common surgical complications were transient cranial nerve palsies, occurring equally in STR and GTR cases when reported. In all postoperative epidermoid tumor cases, but particularly following STR, close follow-up with serial MRI, even years after surgery, is recommended.

Endoscopic endonasal surgery for epidermoid and dermoid cysts: a 10-year experience

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.

Suprasellar Epidermoid Cyst Originating from the Infundibulum: Case Report and Literature Review

Epidermoid cysts account for a small fraction of intracranial brain tumors, most commonly found in the cerebellopontine angle and parasellar cisterns. Here we present a rare case of an epidermoid cyst located in the suprasellar region, specifically originating from the infundibulum. Only one additional case with an epidermoid cyst originating within the pituitary stalk has been previously reported in the literature. The patient in this case presented with headaches, diplopia and blurred vision without any endocrinopathy. The patient's pre-operative evaluation was significant for pseudotumor cerebri, hyponatremia, obesity, and a history of smoking; post-operative course was significant for neurogenic diabetes insipidus.

Intraparenchymal epidermoid cyst: proper surgical management may lead to satisfactory outcome

Intraparenchymal epidermoid cysts (IECs) are rare lesions, thus the preoperative diagnosis and proper surgical management are still a challenge. We searched the database at our institution and performed a search of English literature in PubMed and Google Scholar. Keywords used were as follows: "intraparenchymal"; "intracerebral"; "intraaxial"; "epidermoid cyst"; "brainstem"; "cholesteatoma"; "pearly tumor". Only cases that were true intraparenchymally located and contained adequate clinical information were included. Six cases of IECs were recorded at our institution. Total removal was achieved in all the six patients with good outcomes. 29 cases meeting the above criteria were found in the literature. Including ours, a total of 35 patients were analyzed. Females were more frequently affected (F/M ratio, 1.9:1). Most of them were located in the brainstem (42.9%) and temporal lobe (22.9%). While in children, all were located in the brainstem. 45.2% showed subtle peripheral enhancement on Magnetic Resonance Imaging (MRI), and all appeared hyperintense on Diffusion Weighted Imaging (DWI). In the subgroup of cerebral lobes and cerebellums, total resection was achieved in 89.5%, and they all showed good outcomes. While in the subgroup of brainstem, 46.7% (seven cases) underwent total resection and 50% (three cases) of them died postoperatively. MRI with DWI is helpful in the preoperative diagnosis. Total resection should be achieved for the IECs located in cerebral lobes and cerebellums, while subtotal resection is a wise and safe strategy for the IECs located in the brainstem.

Cerebellar Vermian Epidermoid Tumor: A Report of 2 Cases

BACKGROUND

Epidermoid tumors are rare, benign slow-growing congenital tumors, most frequently located in the cerebellopontine angle of the intracranial cavity. They usually grow to a large size before patients become symptomatic. Although these tumors are amenable to surgery, their adherence to neurovascular structures poses a surgical challenge that results in subtotal resection, thus increasing the risk of recurrence.

CASE DESCRIPTION

We report 2 adult patients whose imaging studies revealed epidermoid tumors located in the cerebellar vermis, an uncommon site for such tumors. The patients presented with variable symptomatology. We highlight the imaging features and challenges of surgery. Both patients had good outcomes, with resolution of symptoms and neurologic deficits.

CONCLUSIONS

A safe complete excision of epidermoid tumor and its capsule is possible with a good understanding of their clinical and radiologic features and a high index of suspicion. To the best of our knowledge, this is the first report of cerebellar vermian epidermoid tumors from sub-Saharan Africa.

Gamma knife radiosurgery for cerebellopontine angle epidermoid tumors

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.

Malignant Transformation of an Intracranial Extradural Epidermoid Cyst into Squamous Cell Carcinoma Presented with Cerebrospinal Fluid Leakage

We report a case of malignant transformation of an intracranial extradural epidermoid cyst into squamous cell carcinoma (SCC), that presented with cerebrospinal fluid (CSF) leakage at the time of recurrence. Intracranial epidermoid cysts are histologically benign and slow-growing neoplasms. They are congenital lesions that develop from ectodermal remnants during neuroembryogenesis. Malignant transformation of epidermoid cysts into SCC is very rare. Various clinical presentations of these tumors after malignant transformation are mentioned in the literature. None of the previous cases, presented with CSF leakage as the recent case did. In cases of malignant transformation, surgical resection and then adjuvant radiation therapy are highly recommended.

Brainstem epidermoid cyst: An update

The incidence of epidermoid tumors is between 1% and 2% of all intracranial tumors. The usual locations of epidermoid tumor are the parasellar region and cerebellopontine angle, and it is less commonly located in sylvian fissure, suprasellar region, cerebral and cerebellar hemispheres, and lateral and fourth ventricles. Epidermoid cysts located in the posterior fossa usually arise in the lateral subarachnoid cisterns, and those located in the brain stem are rare. These epidermoids contain cheesy and flaky white soft putty like contents. Epidermoid cysts are very slow growing tumors having a similar growth pattern of the epidermal cells of the skin and develop from remnants of epidermal elements during closure of the neural groove and disjunction of the surface ectoderm with neural ectoderm between the third and fifth weeks of embryonic life. We are presenting an interesting case of intrinsic brainstem epidermoid cyst containing milky white liquefied material with flakes in a 5-year-old girl. Diffusion-weighted imaging is definitive for the diagnosis. Ideal treatment of choice is removal of cystic components with complete resection of capsule. Although radical resection will prevent recurrence, in view of very thin firmly adherent capsule to brainstem, it is not always possible to do complete resection of capsule without any neurological deficits.

Cyst-cisternal shunting for cystic multirecurrent brainstem epidermoid: case report and literature review

BACKGROUND

Surgical treatment of recurrent, posterior cranial fossa epidermoids in multioperated patients carries significant morbidity, mainly due to tumor adhesion to cranial nerves and vessels, and brainstem involvement. Radical resection is often not feasible; therefore surgery should aim to restore cerebrospinal fluid circulation, release engulfed neurovascular structures, and relieve brainstem compression. Intra-axial epidermoids are extremely rare. We present an innovative surgical technique of a cyst-cisternal shunting to treat cystic recurrent, unresectable brainstem epidermoids.

METHODS

The surgical technique is stepwise described and a case illustration is reported. The pertinent literature has been reviewed.

RESULTS

Few cases of brain stem epidermoid tumors have been described to date. The surgical steps of this technique and related intraoperative images are provided. One case illustration regarding the resection of a large recurrent cystic intra-axial brainstem epidermoid is reported to demonstrate the application of the technique in a clinical setting. The patient was followed up for 14 years and did not experience any recurrence, showing a stable disease at the last follow-up control. A systematic review of the competent literature has been provided.

CONCLUSIONS

Cyst-cisternal shunting in case of recurrent, brainstem epidermoid is a safe and long-term effective technique to relieve mass effect into the brainstem.

Ruptured pediatric cerebellopontine angle epidermoid cyst: a case report detailing radiographic evolution and clinical course

Epidermoid cysts (ECs) are uncommon pediatric tumors that often occur in the cerebellopontine angle. Although cyst rupture is a recognized complication, the radiographic evolution of an EC following rupture and the resultant parenchymal brainstem edema have not been reported. The authors present the case of a 13-year-old female with a newly diagnosed cerebellopontine angle EC who presented with worsening headaches, photophobia, and emesis. Magnetic resonance imaging demonstrated significant pericystic brainstem edema and mass effect with effacement of the fourth ventricle. Refractory symptoms prompted repeat imaging, revealing cyst enlargement and dense rim enhancement. Resection of the EC resolved both her symptoms and the brainstem edema. This case documents the radiographic evolution of EC rupture and subsequent clinical course.

Giant intracranial epidermoids: is total removal feasible?

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.

Surgical strategy for intracranial dermoid and epidermoid tumors: An experience with 33 Patients

Background:

The aim of this paper is to report on our surgical strategy and technique and to identify the best management for intracranial dermoids and epidermoids tumors (IDETs).

Methods:

We retrospectively reviewed 33 consecutive patients (14 males and 19 females; mean age at surgery, 37.9 years) with pathologically confirmed IDETs who underwent surgical resection, with mean follow-up of 7.2 years.

Results:

Gross total tumor removal was achieved in 24 cases (72.7%) with zero surgical mortality and a recurrence rate of 9%.

Conclusions:

The surgical strategies used in this group of patients enabled total removal of most tumors without surgical mortality and with low morbidity and recurrence rates, proving to be safe and effective.

Pineal epidermoid cyst: case report and review of the literature

Intracranial epidermoid cysts are one of the rare tumors of all intracranial tumors. They represent 0,2 to 1% of intracranial tumors and 7% of tumors in the cerebellopontine angle. The pineal region is exceptionally subject to such kind of tumor. Cushing was the first to report the pineal localization of the epidermoid cyst in 1928. Up to now, 85 cases of pineal epidermoid cyst were cited in the literature. We report a clinical case concerning a 45 years old man who presented an intracranial hypertension during 18 months. The clinical examination found a hemiparesis with a facial hypoesthesis. The MRI showed a process of the pineal region. The patient underwent a surgery with a large resection. The histological examination confirms the epidermoid cyst. Many approaches were described in the literature. The outcome is related to this localization.

Spontaneous regression of an epidermoid cyst of the cavernous sinus

Epidermoid cysts are rare lesions in the pediatric population. The natural history of epidermoids is usually that of slow growth, although rupture and cases of malignant transformation have been reported. Spontaneous regression of an intracranial epidermoid cyst has not previously been described to our knowledge. We present a 3-year-old boy who presented with severe vertigo. MRI was performed which revealed a 2cm non-enhancing lesion in the right cavernous sinus. The lesion was T1-hypoinsense, T2-hyperintense, and with evidence of restricted diffusion, consistent with an epidermoid cyst. The patient was followed with annual MRI studies over the next 3years, demonstrating progressive reduction in the size of the lesion over time, with complete resolution after 3years. The child's symptoms also resolved during this period. Long-term follow-up imaging at 5years showed no evident lesion. To our knowledge, this is the first report documenting spontaneous regression of an intracranial epidermoid cyst. While isolated, this finding demonstrates the potential for involution of epidermoids and lends support to the clinical practice of careful observation of these lesions, especially when located in areas associated with high potential surgical morbidity. Importantly, the novelty of this observation suggests a need for further study to better elucidate the underlying mechanism of this regression.

Transpterygoid stent placement for management of a recurrent infratemporal fossa epidermoid cyst: a technical note

Epidermoid cysts (ECs) are benign congenital cysts that typically develop from misplaced stratified squamous epithelium during neural tube closure. They are most commonly encountered in the cerebellopontine angle, the fourth ventricle, and the region of the sella turcica. Recurrence of an EC or regrowth of residual components following surgery is known to occur, but the exact incidence is not defined. Repeat surgical removal is generally considered but may be complicated by significant morbidity. We present a novel endoscopic method by which to manage a recurrent EC of the infratemporal fossa using a silastic stent through a transpterygoid approach that permits periodic drainage of recurrent cyst material in the outpatient setting with minimal morbidity.

Combined pre- and subtemporal transtentorial approach for epidermoid cysts of the cerebellopontine angle

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.

Epidermoid cyst of the brainstem in children: case-based update

Epidermoid cysts are rare, slow growing, space-occupying lesions of early adulthood. Among the various locations, involvement of the brainstem is quite exceptional. In children, these tumors are extremely uncommon; only 4 purely intrinsic brainstem epidermoids are reported in the literature. The pathogenesis of true intraaxial brainstem epidermoid is unclear and is usually not considered in the preoperative differential diagnosis of brainstem tumors. We report 2 additional cases of brainstem epidermoid cysts occurring in children, underlining their clinical characteristics, the difficulties faced in the diagnostic work-up, and the surgical treatment adopted. These tumors pose a surgical challenge and attempts at aggressive removal of the cyst wall are fraught with increased risks of morbidity and mortality. On the other hand, cases treated more conservatively show good or excellent results with minimal complications. Neurosurgical judgment at the time of surgery is warranted to ensure maximum resection while minimizing postoperative neurologic deficits.

Epidermoid tumors of the temporal lobe as epileptogenic foci

Intracerebral epidermoid tumors of the temporal lobe are exceedingly rare. The vast majority of these slow-growing tumors remain clinically silent while only a select few are associated with overt symptomatology. We report two patients with epidermoid tumors whose unique location in the temporal lobe resulted in secondarily generalized seizures. Our first patient, a 19-year-old female, presented with a secondarily generalized tonic-clonic seizure and MRI revealed a superior temporal lobe lesion that was subsequently treated with an awake craniotomy and gross total resection. Our second patient was a 71-year-old male with a recent seizure history and known left temporal lobe lesion. The patient underwent craniotomy for gross total resection of the mass. In these two patients, we found that MRI proved diagnostic and surgical resection was curative. Our clinical experience and review of the literature indicate that gross total resection of these lesions confers control of localization-related epilepsy.