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

Endoscopic resection of sellar and suprasellar epidermoid cyst: report of two cases and review of literature

INTRODUCTION

Epidermoid cysts (EC) are lesions developing from neuroectodermal epithelial cells. They represent 1-2% of all intracranial tumors and are usually found in cerebellopontine angle and parasellar regions. To the best of our knowledge, only 27 cases have been reported of EC in sellar and suprasellar region. In 12 cases out of the 27, surgery was done by craniotomy means. The 7 most recent manuscripts (with 15 patients described) share in common the use of endoscopic endonasal approach (EEA) to perform surgical removal.

RESULTS

In this paper, we report the safe removal of epidermoid cysts arising from the pituitary using an EEA in two patients, which should be the sixth such description in literature. In both cases, resection and evolution was favourable.

DISCUSSION

Surgical resection is the treatment standard for epidermoid cysts, with total resection including the cyst wall to prevent recurrence when possible. The degree of resection obtained is limited by adherence to nearby neural and vascular structures. The advent of EEA approaches has allowed safe maximal resection especially in midline lesions nearby sellar and suprasellar compartiments.

Endoscopically operated 15 ventral skull-base dermoid and epidermoid cysts: Outcomes of a case series and technical note

BACKGROUND

Epidermoid and dermoid tumors in the sellar region are rare. These cystic lesions are a surgical challenge, as the thin capsule adheres firmly to nearby structures. A case series of 15 patients is presented.

METHODS

The patients were operated on in our clinic between April 2009 and November 2021. The endoscopic transnasal approach (ETA) was used. Lesions were located in the ventral skull base. In addition, the literature was reviewed to compare clinical features and outcomes of ventral skull-base epidermoid/dermoid tumors operated on via ETA.

RESULTS

In our series, removal of cystic contents and tumor capsule (gross total resection: GTR) was achieved in 3 patients (20%). GTR was not possible for the others, because of adhesions to vital structures. Near total resection (NTR) was achieved in 11 patients (73.4%), and subtotal resection (STR) in 1 (6.6%). At a mean follow-up of 55±26.27 months, there were no cases of recurrence requiring surgery.

CONCLUSION

Our series demonstrates that ETA is suitable for resection of epidermoid and dermoid cysts in the ventral skull base. GTR cannot always be the absolute clinical aim, because of inherent risks. In patients with expected long-term survival, the aggressiveness of surgery should be weighed on an individual risk/benefit basis.

Imaging of Sella and Parasellar Region

The sellar and parasellar region is complex, with a unique meningeal, neural, vascular, and bony anatomy. Understanding the imaging anatomy is critical for accurate imaging interpretation. resonance (MR) imaging is the primary modality for pituitary imaging, whereas computed tomography may be used when MR imaging is contraindicated, and provides complementary bony anatomic information. This article reviews embryology and anatomy of the sellar and parasellar region. Imaging appearances of pituitary adenomas, Rathke cleft cysts, meningiomas, craniopharyngiomas, arachnoid cysts, vascular disorders, infectious abnormalities, and pituitary apoplexy are discussed and illustrated.

Suprasellar epidermoid cyst in an adult female, presenting as amnesia and somnolence: A rare case report

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Suprasellar epidermoid cysts are rare benign congenital lesions.

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They are usually asymptomatic but, they may present with non-specific headache and visual disturbances.

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Our case presented with amnesia and somnolence which are unique for suprasellar epidermoid cysts.

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Endoscopic trans-nasal and trans-sphenoidal approaches can be the safe way for resection of these lesions.

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Attention needs to the possible postoperative complications and longtime imaging follow up.

Introduction

Intracranial epidermoid cysts (ECs) are rare benign congenital lesions and account for approximately 0.3 to 1.8% of all intracranial brain tumors. They frequently occur at the cerebellopontine angles and parasellar regions, insinuating between brain structures. The author reports here a case of pathologically proven suprasellar epidermoid cyst in an adult female, presented with amnesia and somnolence to increase awareness about this unusual presentation.

Case report

A 58-year-old female was presented to our hospital complaining of amnesia for one year, followed by weakness and somnolence for 2 months. Radiological imaging showed the features of the suprasellar epidermoid cyst which resected through the transsphenoidal endoscopic approach.

Discussion

Epidermoid cysts are slow-growing, benign lesions however, they may rarely undergo malignant transformation into a squamous cell carcinoma. The mean age at presentation of these lesions is 40 years. Suprasellar/sellar lesions usually present with non-specific headaches and visual disturbances. However, our case presented with amnesia and somnolence.

Conclusion

Surasellare epidermoid cysts (ECs) are rare benign congenital lesions. They often manifest with headache and visual field defects but, they may present with atypical symptoms as amnesia and somnolence. Endoscopic transnasal and trans-sphenoidal approaches can help to remove the lesion in most cases. Attention needs to the possible postoperative complications and longtime imaging follow-up because this lesion may recur after a few years.

Intraparenchymal Epidermoid Cyst Close to Broca Area-Awake Craniotomy and Gross Total Resection

BACKGROUND

Epidermoid tumors, or epidermoid cysts (ECs), are benign, slow-growing, congenital, and rare lesions that represent approximately 0.2%-1.8% of all intracranial tumors. Intraparenchymal ECs are very rare lesions that may account for 1.5% of all intracranial epidermoid tumors; frontal lobe involvement is found in 39.2% of intraparenchymal ECs. We present a case using awake craniotomy to achieve maximal safe gross total resection of a rare intraparenchymal EC close to Broca area in a bilingual patient.

CASE DESCRIPTION

A 45-year-old man presented with a generalized seizure episode. He was initially treated with levetiracetam, which led to renal failure. Imaging findings demonstrated an intraparenchymal left frontal EC with peripheral coarse calcifications at Broca area. As the patient was bilingual and had a normal neurologic examination, we performed a left frontal awake craniotomy under local anesthesia so as to map both languages, using the motor task and a test for language monitoring, alternating a naming task in Portuguese and English and a semantic task in Portuguese. A gross total resection was achieved with no neurologic deficits. Histopathologic examination confirmed the diagnosis of an epidermoid cyst. After 1 year, the patient is still seizure-free.

CONCLUSIONS

Awake surgery proved to be a useful tool for complete resection of the capsule even in a very eloquent language area. In multilingual patients with benign intra-axial lesions, intraoperative mapping should be performed for all the languages in which the patient is fluent to avoid postoperative neurologic deficits.