Intrinsic brainstem epidermoid cyst. Case report and review of the literature

Intrinsic epidermoid cyst of the brainstem in children-review and case report

PURPOSE

The study aimed to summarize all published cases of intrinsic brainstem epidermoid cysts in a timeline to highlight the specific characteristics and individualize the disease, in addition to discussing the best treatment used.

METHODS

The scientific literature on pediatric cases of intrinsic epidermoid cysts of the brainstem was analyzed. We present the case of a 1.5-year-old male with incidental presentation, who was treated with gross total resection. We summarize all previously published cases to individualize the disease.

RESULTS

We identified 21 patients, including 10 boys and 11 girls, with a mean age of 4.85 (1-15) years at the time of surgery. The most frequent symptoms were cranial nerve palsy (71.4%), pyramidal tract deficit (57.14%), and headache (52.38%). Among the affected cranial nerves, VII was the most frequently reported in 10 patients.

CONCLUSION

Brainstem epidermoid cysts are extremely rare pathologies with relevant age involvement in young children. The treatment objective should be the maximum resection of the lesion through a careful approach and with the appropriate tools for the functional preservation of the patient.

Imaging Features of isolated hypoglossal nerve palsy

The hypoglossal nerve gives motor innervation to the intrinsic and extrinsic muscles of the tongue. Pathology of this nerve affects the balanced action of the genioglossus muscle causing tongue deviation toward the weak side. Clinically, hypoglossal nerve palsy manifests with difficulty chewing, swallowing and with dysarthric speech herein, we review the anatomy of the hypoglossal nerve as well as common and infrequent lesions that can affect this nerve along its course.

Surgical Management of Intracranial Giant Epidermoid Cysts in Adult: A Case-Based Update

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.

Intrinsic epidermoid of the brain stem: case report and review of the literature

PURPOSE

Purely cystic brain stem epidermoid is a rare diagnosis among all brainstem cystic lesions. Further, it is very rare in pediatric age group.

METHODS

Here, we are reporting a rare case of completely cystic brain stem epidermoid in a child. The patient presented with clinical features of brain stem involvement. MRI brain was suggestive of cystic brain stem lesion.

RESULTS

Patient went through surgical procedure. Final diagnosis of epidermoid cyst was confirmed on histopathological report.

CONCLUSION

With the help of various advanced sequences of MRI like diffusion and ADC, diagnosis of epidermoid cyst can be established at unusual intracranial site also. Surgical resection of epidermoid cyst at brain stem should be attempted judiciously utilizing all modern tools of neurosurgery.

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.

Mood Disorder as an Early Presentation of Epidermoid of Quadrigeminal Cistern

Intracranial epidermoids are space-occupying lesions of rare variant. Although cerebropontine angle and parasellar region are common sites of occurrence, it has been reported in various other parts of the intracranial cavity. Headache and features of increased intracranial tension are the common clinical manifestation. Report of psychiatric symptoms as the initial presentation of epidermoid is not known in literature except a single case report, which describes mutism to be the manifestation of intracranial epidermoid. We present here the case of a young male, who presented with long depressive episode persisting for 3 years with subsequent switch to mania, which persisted for more than 3 years. An episode of unconsciousness warranted neuroimaging, which revealed a large epidermoid of the quadrigeminal cistern. Surgical resection of the epidermoid was done. Persisting mood symptoms had responded to mood stabilizer and antipsychotic treatment.

Unusual Intraparenchymal Pontomedullary Epidermoid Cyst in a 2-Year-Old Child: A Case Report and Review of the Literature

BACKGROUND

Intrinsic brainstem epidermoid cysts are rare, benign, slow-growing lesions. Their eloquence precludes complete excision; however, subtotal resection often will result in prolonged or sometimes permanent relief of presenting symptoms and signs. We describe an unusual case and review the literature of this pathology in the pediatric population.

CASE DESCRIPTION

We report an intra-axial pontine epidermoid cyst in a 2-year-old girl who presented with developmental delay, multiple cranial nerve palsies, and pneumonia. Magnetic resonance imaging demonstrated an intrinsic pontine lesion with partial restricted diffusion and an enhancing plaque, the latter not typically seen in congenital lesions like epidermoid. However, gross surgical inspection and histopathology confirmed an epidermoid.

CONCLUSIONS

Our case, supported by the literature, shows that brain stem epidermoid cysts may have atypical radiologic characteristics and that near-total resection remains safe and can improve outcome.

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.

Epidermoid cyst in quadrigeminal cistern presenting with mutism

Epidermoid cyst of the quadrigeminal cistern is uncommon, and its presentation as mutism as the main clinical finding with no other neurological finding is very rare. We report a case where the epidermoid cyst presented with progressive symptoms of absolute mutism, which improved significantly following surgery. The possible causes and pathophysiological mechanism of mutism in the lesions of this region are discussed in this paper.