Intraspinal cervicothoracic junction chondrosarcoma: illustrative case

BACKGROUND

Chondrosarcoma is an uncommon spinal tumor that can present as an extraskeletal mass. Rarely, these tumors present as dumbbell tumors through the neural foramina, mimicking schwannomas or neurofibromas.

OBSERVATIONS

A 46-year-old female presented with 2 years of worsening right-arm radiculopathy. Magnetic resonance imaging of the thoracic spine revealed a peripherally enhancing extramedullary mass through the right T1 foramen and compressing the spinal cord. Computed tomography showed the mass to be partially calcified. She underwent C7-T2 laminectomy and C6-T3 posterior instrumented fusion with gross-total resection of an extradural mass. Pathology revealed a grade I chondrosarcoma. Her symptoms improved postoperatively, with some residual right-arm radicular pain.

LESSONS

Intraspinal extradural dumbbell conventional chondrosarcoma is rare, with only 9 cases, including ours, reported. Patient ages range from 16 to 72 years old, and male sex is more common in these cases. The most common location is the thoracic spine, and our case is the only reported one in the cervicothoracic junction. These tumors often mimic schwannomas on imaging, but chondrosarcoma should remain in the differential diagnosis, because management of these tumors differs. Chondrosarcoma may benefit from more aggressive resection, including en bloc resection, and may require adjuvant radiotherapy.

A comparison of intra and postoperative analgesic effects of sacrococcygeal and lumbosacral epidural levobupivacaine in cats undergoing ovariohysterectomy

The aim of this study was to compare the intra and postoperative analgesic effects of sacrococcygeal epidural levobupivacaine with those of lumbosacral levobupivacaine in feline ovariohysterectomy. Thirty-six cats were premedicated with intramuscular acepromazine (0.05 mg/kg) and meperidine (6 mg/kg). Anesthesia was induced with intravenous propofol and maintained with isoflurane in oxygen. The cats were randomly assigned one of the three treatments receiving 0.33% levobupivacaine (0.3 mL/kg) into the sacrococcygeal (S-C group, n=12) or lumbosacral (L-S group, n=12) epidural space, or the same volume of 0.9% saline solution into one of the epidural approaches (Control group, n=12). Intraoperatively, cardiorespiratory variables, end-tidal isoflurane concentration (FE´ISO), and fentanyl requirements were recorded. Postoperative pain was assessed by the UNESP (Universidade Estadual Paulista)-Botucatu multidimensional composite pain scale and the Glasgow feline composite measure pain scale up to 8 hr post-extubation. Morphine was administered as rescue analgesia. Overall FE´ISO and fentanyl requirements were lower in the L-S and S-C compared to the Control (P=0.002-0.048, respectively). There was no significant difference in the cardiorespiratory variables during anesthesia, postoperative pain and rescue analgesia among groups. The time to standing after anesthesia was prolonged in the L-S and S-C groups than in the Control (P<0.001). Lumbosacral and sacrococcygeal epidural levobupivacaine resulted in similar decreases in isoflurane requirements and intraoperative fentanyl supplementation in the cats, with no postoperative benefits.

Metastatic extradural melanoma of the lumbar spine in a cat

A 7-year-old neutered male Domestic shorthair cat, with a 1.5-year history of left eye enucleation secondary to a diffuse iris malignant melanoma, was evaluated for progressive onset of pelvic limb paresis and ataxia with severe thoracolumbar hyperaesthesia and dysorexia. Neurological examination localised a lesion to the T3-L3 spinal cord segments. Magnetic resonance imaging of the thoracolumbar spine showed a well-defined extradural T1-weighted hyperintense non-contrast-enhancing mass, initially suggesting a potential haemorrhagic component. Exploratory surgery revealed a brownish extradural lumbar mass. Histologic examination concluded to a melanoma, most probably metastatic given the animal's previous medical history. This report highlights the importance of collecting a complete medical history, which can help in obtaining a preliminary differential diagnosis in cats with clinical signs of myelopathy. Although the location of this metastasis is particularly unusual both in human and veterinary medicine, making optimal treatment challenging for neurosurgeon, our increased understanding of immune and tumour cell biology during the past decade is likely to improve the future treatments of feline melanoma and its metastases.

Intracranial Empyema in Children: A Single-center Retrospective Case Series

We conducted a retrospective, observational study of 42 children with intracranial empyema admitted to a pediatric neurosurgical center over a 9-year period. Intracranial empyema is rare, but causes significant morbidity and mortality. Twenty-eight cases had neurosurgical source control, more commonly for subdural collections. Streptococcus anginosus group bacteria are important pathogens in subdural empyema, whose isolation predicts more complicated postoperative courses.

Drop metastasis from the extradural to the intradural space in spinal Ewing's sarcoma - a novel case report

Spinal Ewing's Sarcoma is a rare tumour predominantly affecting children and adolescents. We describe the case of an 18-year-old male patient who first presented with a primary extradural cervical Ewing's sarcoma tumour, and 5 years later had a recurrence with thoracolumbar and lumbosacral intradural extramedullary Ewing's sarcoma tumours. Both presentations were successfully treated by surgical resection and adjuvant chemo- and radiotherapy, and he remains disease-free at 12 months follow-up. This is the first reported case of seeding of tumour from an extradural primary Ewing's sarcoma to intradural metastases. Total surgical resection of his initial cervical tumour, performed at another centre, was complicated by a dural tear and CSF leak. Thus, we propose that isolated drop metastasis via CSF fistula is the most likely mechanism for tumour spread in this case. Thus, clinicians may wish to counsel patients on the possibility of such spread if a CSF leak is encountered, and potentially increase the frequency of imaging surveillance of the whole spine in this context.

A Rare Case Report of Simultaneous Occurrence of Chronic Subdural Hematoma and Acute Extradural Hematoma in a Patient after Multiple Ventriculoperitoneal Shunt Surgeries

Ventriculoperitoneal (VP) shunt surgeries are common neurosurgical procedure for hydrocephalus. Subdural hematoma (SDH) and extradural hematoma (EDH) are rare but potentially life-threatening complications following VP shunt surgeries. We are describing probably the first case in which a 12-year-old boy presented to the emergency room in altered sensorium and gradual onset quadriparesis following multiple shunt revision procedures done in an outside hospital. Computed tomography head showed chronic right-sided frontotemporoparietal chronic SDH and parietal dominant EDH simultaneously with multiple shunt systems in ventricles. Patient was taken for surgery in emergency and emergent evacuation of hematoma was done. Patient improved in the postoperative period. In this case report we will make an attempt to describe a rare complication of VP shunt surgery and possible mechanisms responsible for it.

A Rare Diagnosis of Paraesthesia in the Pediatric Age Group: Unmasking the Male Factor

Spinal extradural arachnoid cysts are an uncommon condition and their exact causative triggers are still unclear. They appear to be extradural arachnoid outpouchings that connect to the intraspinal subarachnoid region via a little dura defect. These cysts are most commonly seen in the thoracic spine, followed by the lumbosacral junction. Compression of the spinal cord or nerve roots leads to the development of the symptoms. The most morbid symptom associated with these compressing extradural cysts is paresthesia. Numerous theories have been proposed about their origins, and the related conditions include spinal trauma, spina bifida, and the lymphedema-distichiasis syndrome. Their position in the spine influences the symptoms manifested. The diagnosis is made via MRI. Surgery is only performed on individuals with neurological impairment, and treatment is based on the clinical presentation. The preferred course of therapy is total surgical excision. We present a case that involves the successful surgical removal of an extradural spinal arachnoid cyst in a 10-year-old girl. Given the rarity of this pathology, its wide array of presenting symptoms, and the successful therapeutic protocol that was followed in this particular case, we believe this article shall prove beneficial to the medical fraternity.

Thoracic spinal extradural arachnoid cyst causing Brown-Sequard-like syndrome: a rare case report and review of literature

Spinal extradural arachnoid cysts are rare benign lesions occurring along the cerebrospinal axis. They may be associated with pain or varying degrees of neurological compressive symptoms. Brown-Sequard syndrome is a rare sequalae, where there is ipsilateral upper motor neuron paralysis with loss of proprioception as well as contralateral loss of pain and temperature sensation below the lesion. We present a 33-year-old female with a 6-month history of worsening right lower limb weakness and a 2-month history of right lower limb pain. Motor examination revealed right lower limb weakness as well as exaggerated knee and ankle jerk reflexes. A magnetic resonance imaging (MRI) was done, which showed an eccentrically located T4-7 cystic extradural mass causing severe cord compression. She had T4-7 laminectomies with total excision of the cyst and disconnection of the fistulous tract between the cyst and the subarachnoid space. She made full neurologic recovery with no complications.

Intracranial Interdural and Extradural Cerebellar Convexity Dermoid Cyst: A Case Report of Rare Tumor at the Rarest Location

Intracranial dermoid cysts are rare dysembryonic tumors of benign nature. These are uncommon in adults. If present, they are usually located in the midline or along the lines of embryonic fusion. The posterior fossa region is an infrequent site. Extradural or interdural locations are even more rare. In this case report, the authors report a laterally located large posterior fossa right cerebellar convexity interdural and extradural dermoid cyst over the sigmoid sinus. It was managed by totally extradural maximum possible safe decompression with microneurosurgical technique. The authors share their experience of addressing this rare pathology at the rarest location with unusual imaging findings.

Extradural lumbar arteriovenous fistula imitating a synovial cyst: illustrative case

BACKGROUND

Spinal dural arteriovenous fistula is the most common spinal vascular malformation. It usually presents with neurological deficits due to venous congestive myelopathy. Sometimes, however, the symptoms are radicular and can imitate those of a disc hernia or synovial cyst.

OBSERVATIONS

In this illustrated case, a 34-year-old male patient presented with radicular pain due to nerve root compression. In the magnetic resonance imaging (MRI) examination of the spine, a synovial cyst was suspected, so the patient underwent no further examination before surgery. Intraoperatively, the authors were surprised to see a vascular malformation, which was shown to be an extradural arteriovenous fistula according to the histopathological examination.

LESSONS

In atypical MRI findings of the spine, vascular malformations should be considered. In cases with a spinal dural arteriovenous fistula, the thrombosis risk can be high and lead to a need for prolonged anticoagulation.

Time to evacuation of acute subdural and extradural haematoma: prospective study before and after implementation of a major trauma centre

Purpose: Patients with Extradural (EDH) and Acute Subdural Haematomas (ASDH) represent a subgroup of head-injured patients that gain the most from timely treatment. While treatment times for head injury overall improved since the introduction of Major Trauma Centres (MTCs), no data exists describing how the time to treatment of EDH and ASDH has changed. We, therefore, compared the evacuation of ASDH and EDH before and after the implementation of a major trauma network.Methods: Data was collected prospectively between 1 May 2006 to 31 May 2007 and 1 March 2014 to 31 March 2016. The study was carried out at University Hospital Southampton, designated MTC in 2012. Patients over 18 with ASDH or EDH requiring emergency surgery were included.Results: The median time (IQR) for decompression was 4.8h (3.9-6.6) in 2006-7 and 4.4h (3.4-5.9) in 2014-16, p = 0.386. The proportion treated within 4 hours was 32% in 2006-7, and 33% in 2014-16 (p = 1.000). Analysis showed a decrease in time for CT scan (p = 0.01) and acceptance by neurosurgery (p < 0.001). There were increases in time for transferring to hospital (p = 0.005), awaiting operating theatre (p = 0.005), and operative time (p = 0.018).Conclusions: Since the introduction of MTCs, there has been no significant reduction in time to treat this select group of patients despite reductions in time to treatment of most other trauma and head-injured patients. This may be because parts of the pathway have improved, but others haven't. It is also possible that while previously head injury was poorly served, resources were prioritised to this group so finding further gains is difficult.

Spontaneous extradural hematoma in a Sickle cell Beta Thalassemia patient-A rare complication

Spontaneous extradural hematoma in Sickle cell disease is rare neurological complication with few cases reported in the English literature. We report a case of a 16-year-old male patient who was previously diagnosed with Sickle Cell Beta Thalassemia and presented with severe headache and vomiting for 3 days. An emergency CT scan of the head demonstrated right-sided acute parietal extradural hematoma with mass effect. Patient underwent emergent craniotomy with evacuation of the hematoma. Patient recovered completely. Although calvarial infarction has been associated with extradural hematoma, an absence of it makes our case distinct. A high index of suspicion should be made in SCD patients for possibility of EDH in progressive headache.

Intradural extramedullary spinal cord meningioma with a rare extradural foraminal extension: A case report

Background

Meningiomas are mostly benign and slow-growing neoplasms of the central nervous system. Spinal meningiomas account for up to 45% of all intradural spinal tumors in adults and up to 25%-45% of all spinal tumors. Spinal extradural meningiomas are rare and may be easily confused with malignant neoplasms.

Case description

A 24-year-old woman was presented to our hospital with paraplegia and loss of sensation in the T7 dermatome and lower body. MRI findings showed T6-T7 right-sided intradural extramedullary and extradural lesion, measuring 1.4 cm × 1.5 cm × 3 cm, extending to the right foramen, compressing the spinal cord, and displacing it to the left. Hyperintense lesion on T2 and hypointense lesion on T1 were observed. The patient reported improvement after surgery and during follow-up. We recommend maximizing the decompression during surgery to achieve better clinical outcome. Extradural meningiomas represent 5% of all meningiomas; therefore, having an intradural on top of extradural meningioma with extraforaminal extensions makes this a unique and rare case.

Conclusion

Meningiomas can be easily missed in diagnosis depending on imaging and the pathognomonic pattern it represents, which can mimic other pathologies, such as schwannomas. Therefore, surgeons should always suspect their patient having a meningioma even if the pattern is not typical. Moreover, preoperative preparation, such as navigation and defect closure, must be taken in case it turns out be a meningioma instead of the presumed pathology.

Diagnosis and successful management of an extradural compressive hematoma secondary to diphacinone poisoning in a dog

OBJECTIVE

To describe the successful case management of an extradural hematoma secondary to anticoagulant rodenticide toxicity causing spinal compression and paraplegia.

CASE SUMMARY

A 3-month-old, female intact, mixed breed dog was presented for a 12-hour history of paraplegia. CBC and biochemistry results were unremarkable, and a coagulation panel revealed prolonged prothrombin time with normal activated partial thromboplastin time. Magnetic resonance imaging revealed an extradural compressive lesion within the vertebral canal extending from T6 to T11, most consistent with an extradural hematoma. Further coagulation testing revealed a coagulopathy caused by vitamin K1 deficiency and confirmed exposure to the anticoagulant rodenticide, diphacinone. The dog was medically managed with fresh frozen plasma, aminocaproic acid, and oral vitamin K1 therapy. A right-sided T6 to T11 hemilaminectomy was later performed for removal of the extradural hematoma and spinal decompression. The dog's neurological status gradually improved postoperatively and, at the time of discharge, was nonambulatory paraparetic with voluntary micturition. Four weeks postoperatively, the dog had normal prothrombin and activated partial thromboplastin times and was nonambulatory paraparetic with strong motor function.

NEW OR UNIQUE INFORMATION PROVIDED

This is the first reported case of a dog with an extradural hematoma secondary to anticoagulant rodenticide causing spinal cord compression and neurological deficits. Surgical management of this case was successful and resulted in improvement of neurological signs. Extradural hematoma should be considered as a potential location of bleeding in rodenticide toxicity as well as a differential diagnosis in patients with neurological deficits.

Asymptomatic Intraosseous Meningioma of the Humerus: A Case Report and Review of the Literature

Meningiomas are the most common central nervous system tumor. They are typically benign neoplasms but may produce neurological symptoms due to mass effect. Meningiomas may also extend to extradural locations; however, these account for only a small percentage of all meningiomas. Most extradural meningiomas arise in intraosseous locations, usually within the cranial bones or vertebrae. However, this is a rare case of extradural extension of an asymptomatic intracranial meningioma to the proximal humerus in the absence of any musculoskeletal symptoms. To the best of our knowledge, this presentation of an extradural intraosseous meningioma has not previously been reported in the literature. We present a case of an incidental intraosseous meningioma in a 66-year-old man. This patient was initially being screened for metastasis of stage IA1 adenocarcinoma of the lung, and a positron emission tomography (PET) scan revealed a focus of activity in the proximal diaphysis of the right humerus suspicious for malignancy. The upper extremity magnetic resonance imaging (MRI) demonstrated an indeterminate lesion. Curettage of the humeral lesion revealed an intraosseous psammomatous meningioma without evidence of metastatic lung carcinoma. Our case report aims to illustrate the importance of considering alternative metastatic sources, such as intracranial meningioma, during the investigation of an indeterminate bony lesion. This is the first case to illustrate asymptomatic intraosseous meningioma in an appendicular skeletal location, highlighting the need for thorough source investigation.

Multiple Undifferentiated Pleomorphic Sarcoma (Malignant Fibrous Histiocytoma) with Extradural Involvement in a 7-Year-Old Labrador Retriever

A 7-year-old castrated male Labrador retriever was referred for evaluation of progressive hind limb paresis of 4 weeks' duration. On computed tomography and magnetic resonance imaging examination, masses were found in several regions including the lung, right kidney, and peritoneum. Additionally, an extradural mass at the region of T13-L1 was identified, which is assumed to related to the chief complaint, progressive hind limb paresis. With the consent of the owner, a dorsal laminectomy was performed to remove the mass and surrounding tissues for the palliation of the hind limb paresis. Hematoxylin and eosin staining and immunohistochemical examination revealed the mass to be consistent with an undifferentiated (high-grade) pleomorphic sarcoma. The patient presented with recurrence of the hind limb paresis, respiratory discomfort, and urinary incontinence. The owner declined treatment and the dog was euthanized. Systemic metastasis was confirmed on postmortem microscopic examination. To the authors' knowledge, this is the first report describing multiple undifferentiated high-grade pleomorphic sarcoma with extradural involvement developing into the vertebral canal through the intervertebral space, resulting in spinal damage, in a dog.

Epidural administration of combinations of ropivacaine, morphine and xylazine in bitches undergoing total unilateral mastectomy: a randomized clinical trial

OBJECTIVE

To investigate the epidural administration of combinations of ropivacaine, morphine and xylazine in bitches undergoing unilateral mastectomy.

STUDY DESIGN

Prospective, randomized, blinded, clinical study.

ANIMALS

A total of 22 bitches scheduled to undergo unilateral mastectomy for mammary tumor excision.

METHODS

Dogs were anesthetized with acepromazine (0.02 mg kg^-1) and morphine (0.3 mg kg^-1) intramuscularly, propofol intravenously (IV) and isoflurane. Prior to the beginning of surgery, dogs were randomly administered one of three epidural treatments: ropivacaine (0.75 mg kg^-1) with morphine (0.1 mg kg^-1) (group RM, n = 7); ropivacaine with xylazine (0.1 mg kg^-1) (group RX, n = 8); or ropivacaine with morphine and xylazine (group RMX, n = 7). Cardiopulmonary variables and the expired concentration of isoflurane (Fe'Iso) were recorded intraoperatively. Meloxicam (0.1 mg kg^-1) was administered IV during skin closure. Postoperative pain scores were evaluated with the Glasgow composite measure pain scale short form for 24 hours, and rescue analgesia with morphine (0.5 mg kg^-1) was administered intramuscularly when pain scores were ≥ 6/24.

RESULTS

Fe'Iso was significantly higher in group RM than in groups RX and RMX. Heart rate decreased significantly in groups RX and RMX, but blood pressure remained within acceptable values. The number of dogs administered rescue analgesia within 24 hours was significantly higher in group RX (seven dogs, 87.5%) than in groups RM (one dog, 14.3%; p = 0.01) and RMX (two dogs, 28.6%; p = 0.04). Time to standing was significantly longer in group RX than in group RM.

CONCLUSIONS AND CLINICAL RELEVANCE

All epidural treatments provided adequate antinociception with minimal cardiovascular adverse effects during mastectomy. The inclusion of morphine (groups RM and RMX) provided the best postoperative analgesia. Owing to the undesirable effect of xylazine on ambulation, the combination ropivacaine-morphine appeared to provide greater benefits in bitches undergoing unilateral mastectomy.

Compressive vertebral hemangiomas with neurological deficits: diagnosis, surgical strategies and long term outcome

PURPOSE

Compressive vertebral hemangiomas with neurological deficits (CVHND) form a rare, unique subset of lesions comprising of differing clinico-imaging findings, pathologic behavior and treatment, when compared to the commoner and usually incidental intra-osseus vertebral hemangiomas (VH). Though various surgical strategies and a broad array of adjuncts have evolved and changed over the years, there is paucity of comprehensive data from sizeable series of such patients treated surgically with long term follow up. The purpose of this study is to device an optimum management strategy in CVHND based on our surgical experience.

MATERIALS AND METHODS

The data from electronic medical records of 26 consecutive patients operated in our department from 2009 to 2019 were retrospectively analyzed.

RESULTS

There were 11 males and 15 females with a mean age of 34.7 years. Neurological examination revealed paraparesis or paraplegia with myelopathy in all patients with Frankel score of B, C and D in 1 (3.9%), 11 (42.3%) and 14 (53.8%) patients respectively. Sixteen patients (61%) underwent laminectomy and gross total excision of extradural soft tissue component, 7 (27%) laminectomy with posterolateral fusion, three (12%) underwent additional anterior interbody support. The mean follow up was 72.4 months and at last follow-up 24 patients (92%) were Frankel E. Symptomatic recurrence was seen in two patients operated early in the series, they underwent re-surgery, gross total excision with posterolateral fusion, remaining neurologically intact at last follow up.

CONCLUSIONS

Pre-operative embolization, surgical excision of extradural component and intra-operative vertebroplasty form the mainstay of treatment for CVHND. Instrumented posterolateral fusion with optional anterior interbody support accomplished through the same approach is required only in a minority of cases. The long-term outcome following timely and appropriate treatment is excellent. Anterior or anterolateral approaches for intervertebral support and radical procedures like total en-bloc spondylectomy (TES) are not usually required.

Fourth ventricle roof angle as a measure of fourth ventricle bowing and a radiographic predictor of brainstem dysfunction in Chiari malformation type I

OBJECTIVE

Chiari malformation type I (CM-I) is a congenital and developmental abnormality that results in tonsillar descent 5 mm below the foramen magnum. However, this cutoff value has poor specificity as a predictor of clinical severity. Therefore, the authors sought to identify a novel radiographic marker predictive of clinical severity to assist in the management of patients with CM-I.

METHODS

The authors retrospectively reviewed 102 symptomatic CM-I (sCM-I) patients and compared them to 60 age-matched normal healthy controls and 30 asymptomatic CM-I (aCM-I) patients. The authors used the fourth ventricle roof angle (FVRA) to identify fourth ventricle "bowing," a configuration change suggestive of fourth ventricle outlet obstruction, and compared these results across all three cohorts. A receiver operating characteristic (ROC) curve was used to identify a predictive cutoff for brainstem dysfunction. Binary logistic regression was used to determine whether bowing of the fourth ventricle was more predictive of brainstem dysfunction than tonsillar descent, clival canal angle, or obex position in aCM-I and sCM-I patients.

RESULTS

The FVRA had excellent interrater reliability (intraclass correlation 0.930, 95% CI 0.905-0.949, Spearman r2 = 0.766, p < 0.0001). The FVRA was significantly greater in the sCM-I group than the aCM-I and healthy control groups (59.3° vs 41.8° vs 45.2°, p < 0.0001). No difference was observed between aCM-I patients and healthy controls (p = 0.347). ROC analysis indicated that an FVRA of 65° had a specificity of 93% and a sensitivity of 50%, with a positive predictive value of 76% for brainstem dysfunction. FVRA > 65° was more predictive of brainstem dysfunction (OR 5.058, 95% CI 1.845-13.865, p = 0.002) than tonsillar herniation > 10 mm (OR 2.564, 95% CI 1.050-6.258, p = 0.039), although increasing age was also associated with brainstem dysfunction (OR 1.045, 95% CI 1.011-1.080, p = 0.009). A clival canal angle < 140° (p = 0.793) and obex below the foramen magnum (p = 0.563) had no association with brainstem dysfunction.

CONCLUSIONS

The authors identified a novel radiographic measure, the FVRA, that can be used to assess fourth ventricular bowing in CM-I and is more predictive of brainstem dysfunction than tonsillar herniation. The FVRA is easy to measure, has excellent interrater variability, and can be a reliable universal radiographic measure. The FVRA will be useful in further describing CM-I radiographically and clinically by identifying patients more likely to be symptomatic as a result of brainstem dysfunction.

Giant solitary extradural plasmacytoma of the skull: illustrative case

BACKGROUND

Solitary extradural plasmacytoma of the skull (SEPS) is an extremely rare entity with only 35 cases reported in the English-language literature. SEPS is a rare presentation of plasma cell dyscrasias, accounting for 4% of plasma cell tumors. The diagnosis of solitary plasmacytoma requires exclusion of multiple myeloma (MM) and prompt diagnosis and treatment.

OBSERVATIONS

The authors describe the case of a 52-year-old man with SEPS. He presented with a painless, progressive, soft swelling mass in the left parietal region. Magnetic resonance imaging revealed a left frontotemporal extra-axial lesion that involved the ipsilateral orbital apex and posterior ethmoidal cells. Biological studies did not reveal features suggestive of MM. A diagnosis of SEPS was based on microscopic examination and immunohistochemical analysis after surgery. The patient had an excellent recovery and was discharged the day after surgery without neurological deficit.

LESSONS

SEPS is a potentially curable disease, and total resection with or without radiotherapy is associated with a good prognosis and long-term recurrence-free survival. Distinction between SEPS and MM is of paramount importance because the prognosis and treatment differ.

Evaluation of electrical nerve stimulation to confirm sacrococcygeal epidural needle placement in dogs

OBJECTIVES

To evaluate the use of 0.7 mA as a fixed electrical current to indicate epidural needle placement and to confirm that 0.7 mA is greater than the upper limit of the minimal electrical threshold (MET) for sacrococcygeal epidural needle placement in dogs.

STUDY DESIGN

Prospective clinical study.

ANIMALS

A group of 20 client-owned dogs.

METHODS

During general anesthesia and with standard monitoring, the presence of the patellar reflex was confirmed in all dogs. An insulated needle was inserted through the sacrococcygeal intervertebral junction, and absence of tail movement was confirmed when a fixed electrical current of 0.7 mA was applied. Then, the needle was further advanced toward the epidural space until the expected motor response was obtained - the nerve stimulation test (NST). The NST was considered positive when a motor response of the muscles of the tail was elicited but not the perineal muscles, whereas it was considered negative when no movement of the tail was evoked. The electrical current was turned to 0 mA and then increased by 0.01 mA increments until tail movement was evoked; this was recorded as the MET. In the positive NST cases, 0.05 mL cm^-1 occipitococcygeal length of 2% lidocaine or 0.25-0.5% bupivacaine was administered. Epidural blockade was confirmed by the loss of patellar reflex. Descriptive statistics were used to present data.

RESULTS

Sacrococcygeal epidural needle placement, corroborated by loss of the patellar reflex, was correctly predicted in 89.5% (95% confidence interval, 68.6-97.1%) of the cases. The MET was 0.22 mA (0.11-0.36).

CONCLUSIONS AND CLINICAL RELEVANCE

A current of 0.7 mA is approximately twice the upper limit of the MET for epidural placement. Therefore, this study demonstrates, with a success rate of 89.5%, the adequacy of using 0.7 mA as the fixed electrical current to detect sacrococcygeal epidural needle placement in dogs.

Progressive compressive myelopathy induced by a rare primary isolated thoracic vertebral hydatid cyst: A case report

RATIONALE

Hydatid cyst is a disease caused by the larvae of Echinococcus spp. The larvae often reside in the liver, lungs, and brain. Occasionally, a primary isolated thoracic vertebral hydatid cyst is reported to cause severe complications. Various diseases may lead to the development of progressive compressive myelopathy. Herein, we report a rare case of a primary isolated thoracic vertebral hydatid cyst with compressive myelopathy.

PATIENT CONCERNS

A 57-year-old female had numbness and weakness in the lower limbs for a span of 3-months.

DIAGNOSIS

Thoracic magnetic resonance imaging (MRI) showed that an isolated mass was observed in the T5 vertebral body, which compressed the spinal cord. The diagnosis was confirmed after surgical excision, and Echinococcus granulosus was found to be the etiologic factor.

INTERVENTIONS

The patient underwent laminectomy with no complications.

OUTCOMES

After surgical decompression, the patient made slow and measurable progress. While relatively rare in the non-pastoral area, the primary isolated thoracic vertebral column hydatid cyst may be considered as a possible etiology of atypical extradural spinal compression.

LESSONS

This case illustrates the complexity of spinal echinococcosis manifestations and the necessity of an interdisciplinary approach.

Foramen magnum meningioma with excessive calcification and no dura tail sign: A case report

RATIONALE

Foramen magnum meningiomas are very rare lesions. They frequently originate from the arachnoid cells at the dura matter of the craniocervical junction. Foramen magnum meningiomas are challenging for neurosurgeons because of the complex anatomy of foramen magnum. We present a rare case of FMM with excessive calcification and without the dura tail sign which made the lesion mimic a teratoma.

PATIENTS CONCERNS

A 63 years old woman presented with progressive numbness and hyperesthesia of the shoulders and upper limbs for 2 and half years. She also experienced occasional headaches and dizziness with no nausea, vomiting or fever.

DIAGNOSES

Computed tomography scan, and magnetic resonance imaging revealed a calcified mass at occipital cistern. The lesion did not show the usual "dura tail sign" which made it mimic a teratoma on magnetic resonance imaging. Histopathology established meningioma.

INTERVENTION

The tumor was completely resected via suboccipital approach.

OUTCOMES

Two years follow-up revealed no recurrence of the lesion and no neurological deficits.

LESSONS

We advocate the use of electromyographic and auditory brainstem responses to monitor the inferior cranial nerves because the tumor often adheres to these nerves.

Report of a spinal extradural arteriovenous fistula with double radiculomedullary venous drainage: therapeutic implications and role of intraoperative spinal angiography

Low-flow spinal extradural arteriovenous fistulas (SEAVFs) are frequently misdiagnosed as spinal dural arteriovenous fistulas (SDAVFs), and their true prevalence is unknown. The principal feature distinguishing low-flow SEAVFs from SDAVFs is the location of the shunt, which involves a pouch of epidural plexus in SEAVFs and a radiculomedullary vein (RMV) in SDAVFs. A venous hypertensive myelopathy comparable to the one observed with SDAVFs develops when the arterialized venous pouch of an SEAVF is connected to an RMV. Depending on the size of the epidural pouch, a low-flow SEAVF may uncommonly drain into multiple RMVs. The authors present an observation of a low-flow SEAVF whose double radiculomedullary drainage was revealed only after intraoperative digital subtraction angiography, and they discuss the surgical implications of this anatomical configuration.

Primary Spinal Melanoma With Intra- and Extradural Extensions: A Rare Case

Primary spinal melanoma (PSM) is a rare primary central nervous system melanoma with limited literature. A 30-year-old male presented with one year of progressive bilateral leg weakness and back pain. Physical examination revealed slightly decreased power and deep tendon reflexes of the lower extremities, decreased sensation at the level of T10, and normal anal sphincter and plantar reflexes. Magnetic resonance imaging (MRI) scan of the thoracolumbar spine revealed a hypointense lesion on T2-weighted and a hyperintense lesion on T1-weighted imaging at the level of T10 with mild extensions. The lesion was causing a mass effect on the spinal cord. The patient underwent laminectomy and near-total excision which showed a black, firm-to-hard, scarcely vascular extradural tumor extending from T10 to T11 that adhered to nerve roots. Histopathological examination and immunostaining with S-100 and Melan-A stains confirmed the diagnosis of malignant melanoma. Other imaging studies like brain computed tomography (CT) and positron emission tomography/computed tomography (PET/CT) scans, and chest X-ray were normal. On follow-up, the patient reported improvement in the power of his lower limbs with intact sensory function and sphincters. The first radiotherapy session was scheduled for six weeks postoperatively. There was no recurrence at a two-year follow-up. The possibility of a melanocytic tumor should be considered for a spinal lesion with paramagnetic properties as early surgical intervention is important for diagnosis and improved survival.

Pathology-proven extradural ("distant") metastases of gliomas in adults in the Netherlands between 1971 and 2018: a systematic case series

Background

Diffuse gliomas are the most frequent primary tumors originating in the central nervous system parenchyma. Although the majority of these tumors are highly malignant, extradural metastases (EDM) are extremely rare. We aimed to perform a systematic review of patients with pathology-proven EDM of diffuse gliomas in the Netherlands.

Methods

From the Nationwide Network and Registry of Histo- and Cytopathology in the Netherlands information on all cases with EDM between 1971 and October 2018 was retrieved. Patients aged < 18 years or with a diagnosis of ependymoma or continuous tumor growth from intradural to extradural were excluded. Demographics, initial tumor diagnosis, treatment characteristics, location of the EDM, and survival data were collected. IDH1 R132H immunohistochemistry was performed on cases in which a paraffin block of the metastatic tumor could be retrieved.

Results

Twenty-five patients with diffuse glioma and pathology-proven EDM were identified. Median age at diagnosis of glioma was 46 years (IQR: 35-59); 21 patients (84%) were male. Histopathologic diagnosis was glioblastoma in 17 patients (68%) and lower-grade tumor in eight patients. In 3 out of 12 patients of which a paraffin block could be retrieved immunohistochemistry revealed an IDH1-mutant glioma. Most frequent EDM locations were bone/bone marrow (14/25 patients; 56%), and lymph nodes (6/25 patients; 24%).

Conclusion

EDM of diffuse glioma are rare. They occur most frequently in patients with glioblastoma, however, they can also originate from lower-grade, IDH-mutant gliomas. In daily practice, EDM of diffuse glioma should be considered in patients with tumefactive lesions of the bone or lymph nodes.

Lumbar Extradural Angiolipoma: Clinical Presentation and Management

Angiolipomas are rare primary benign tumors that can arise in the epidural canal and cause stenosis. Of the few cases of spinal angiolipomas described, most lesions have been located in the thoracic spine, and presentation of angiolipoma in the lumbar spine is very rare. The surgical management of a 39-year-old morbidly obese woman with angiolipoma that caused stenosis with neurogenic claudication and urinary changes is described. The lesion spanned L1-L2 and surgical management consisted of T12-L2 laminectomy and en-bloc resection of the lesion. During the latest follow-up, four years after the surgery, the patient’s neurological symptoms showed improvement and there was no recurrence.

Epidermoid cyst of the anterior clinoid process: report of a unique finding and literature review of the middle cranial fossa locations

BACKGROUND

Epidermoids cysts are relatively rare, benign, congenital tumours, representing from 0.3% to 1.8% of all intracranial lesions. When extradural, they are most commonly reported in the temporal or parietal bones as intradiploic lesions; when intradural their most common location is the cerebellopontine angle and less frequently the middle cranial fossa. Herein we present a unique case of an extradural-intraosseous epidermoid cyst of the anterior clinoid process, integrating our single-case experience into a focused literature review of these lesions, when located in the middle cranial fossa.

CASE DESCRIPTION

A 49 years old man came to our attention with history of head trauma. Urgent brain CT and elective brain MRI showed imaging suggestive for an anterior clinoid process epidermoid cyst. Through a pterional approach, the lesion was completely removed with microsurgical endoscope assisted technique. MRI at one year follow up showed no recurrence.

METHODS

Current literature on epidermoid cysts located in middle cranial fossa was reviewed. A total of 22 papers, containing 70 epidermoid cyst were selected for the review. Symptoms at presentation; anatomic location; surgical approach; extent of resection and recurrence; outcome after surgery and at follow up were analysed for each case.

CONCLUSIONS

In the 70 published cases of middle fossa epidermoid cysts, the majority presented with trigeminal neuralgia. Most of the cases were operated through a pterional approach, while recent literature showed an increasing interest in endonasal endoscopic techniques. Subtotal resection is not a straight predictive value for recurrence; post-operative neurological deficits incidence is low and generally resolve at follow-up.

Recurrent Extradural Myxopapillary Ependymoma With Oligometastatic Spread

Myxopapillary ependymomas are a slow-growing, grade I type glial tumor in the lumbosacral region. More rarely, they can present as extradural, subcutaneous sacrococcygeal, or perisacral masses, and it is under these circumstances that they are more likely to spread. Here, we report the presentation of a sacrococcygeal mass in patient that was initially resected confirming extradural myxopapillary ependymoma. At initial resection, multiple small pulmonary nodules were detected. This mass recurred 2 years later at the resection site with an interval increase in the previously imaged pulmonary nodules. Resection of both the post-sacral mass and largest lung metastasis confirmed recurrent myxopapillary ependymoma with oligometastatic spread. Because these tumors are rare, with extradural presentation being even more infrequent, to this date there are no definitive therapeutic guidelines for initial treatment and continued surveillance. For myxopapillary ependymoma, current standard of care is first-line maximal surgical resection with or without postoperative radiotherapy depending on the extent of disease and extent of resection. However, there remains insufficient evidence on the role of radiotherapy to oligometastatic foci in providing any further survival benefit or extending time to recurrence. Thus, prospective studies assessing the role of upfront treatment of oligometastases with local resection and adjuvant radiotherapy are needed for improved understanding of extradural myxopapillary ependymoma.

Endovascular treatment of extradural internal carotid artery aneurysm with a flow diverter stent

Extradural internal carotid artery aneurysms are rare and the indications for treatment are not well defined. We report successful management of two high extradural internal carotid artery aneurysms treated with flow diverter stents. The endovascular repair of extradural internal carotid artery aneurysms is effective because with surgical treatment there is always the possibility of cranial nerve injury.

Intradural and Extradural Ligation of a Left Dural Arteriovenous Fistula of the Sigmoid Sinus Using a Retrosigmoid Approach: 3-Dimensional Operative Video

Dural arteriovenous fistulas (dAVFs) are acquired dural shunts between an artery and a vein without parenchymal nidus. DAVFs represent 10%-15% of intracranial arteriovenous malformations, and their manifestations vary from asymptomatic to devastating intracranial hemorrhage.1 They are classified according to their drainage and presence/absence of cortical venous reflux (CVR).2,3 The junction between transverse and sigmoid sinus (SS) is the most common location, and their treatment in case of CVR can involve the sacrifice of the sinus. DAVF occlusion may be achieved with both endovascular and surgical technique and frequently with combined techniques. This video demonstrates the management of a left dAVF of the SS in a 54-yr-old male with recent onset of diplopia and imbalance with venous congestion seen in the left cerebellum on T2 sequence MRI. Angiography revealed a Borden grade 2, Cognard grade IIa + b left SS dAVF supplied by the jugular and hypoglossal branches of the neuromeningeal trunk with retrograde filling of the partially thrombosed SS and drainage to the superior petrosal sinus and multiple cerebellar veins. Endovascular repair was not feasible due to high risk of postoperative cranial neuropathy. The patient consented to surgery. A left retrosigmoid craniotomy was performed to achieve intradural ligation of the fistula at the dural edge along the inferior aspect of the tentorium. After drainage occlusion and cauterization of the transmastoid extradural feeders (via mastoidectomy), the SS was entirely exposed and clipped to prevent any further retrograde arteriovenous shunting. The postoperative course was without complication and angiography showed complete occlusion of the dAVF.

T3 infantile hemangioma: first case of a tumor involving epidural, intradural extramedullary, and intradural intramedullary spaces

Infantile hemangiomas (IHs) are the most common benign neoplasm of the neonatal and newborn period, affecting approximately 5% of infants. However, true IHs presenting in the neuraxis are quite rare with only 15 documented cases in the literature. Management of IH consists of utilizing steroids and immunomodulatory therapies to reduce the size of the tumor and surgery to remove the tumor to decrease symptoms and the risk of bleeding. Operative management of epidural and intradural extramedullary spinal hemangiomas has been described; however, management of intradural intramedullary IH has not been detailed in the literature. In this report, the authors describe the case of a 3-year-old girl who presented with multiple hemangiomas involving the liver, lung, and spine, with one component of the tumor involving the posterior intramedullary aspect of the spinal cord at the level of T3. After medical therapies had failed, the patient underwent endovascular embolization of the spinal hemangioma followed by resection of the tumor. While there is extensive literature on IH throughout many organ systems, only a handful of cases involving the neuraxis have been described. Operative management of refractory IH seems to allow for the reduction of tumor burden and the prevention of hemorrhagic injury.

Symptomatic extradural spinal arachnoid cyst: More than a simple herniated sac

Introduction and Study Design:

Spinal arachnoid cyst is an uncommon entity, presenting with radiculopathy or paraparesis. These cysts are usually found in intradural extramedullary region; and the extradural region is a rare location. The exact pathogenesis in the existence of these cysts in the extradural region is still debated. In this article, we have retrospectively analyzed the clinical profile of the rare extradural arachnoid cyst (EDAC).

Methodology:

In this study, 19 patients of EDAC operated at our institute between January 2006 to June 2016 are analyzed. All patients with the Oswestry disability index score of >20 were managed surgically (open laminectomy and cyst excision). The clinical outcome was assessed at using 5-point satisfaction scale and McCormick grading.

Results:

All 13 operated patients had EDACs with communication with the intradural compartment. In 11 (84.6%) patients, cyst wall was excised completely, in 2 (15.3%) patients underwent partial excision of cyst wall; dural communication was closed in all patients (n = 13). None of the patients had clinical deterioration or radiological recurrence till the last follow-up. Mean follow-up was 52.2 months (range 1–160); all patients were satisfied after surgery (median score was 3).

Discussion:

Symptomatic EDACs account <2% of all spinal tumors. The EDACs have communication with the intradural compartment. In our article, we have discussed the approach and management of EDAC, including minimally invasive percutaneous procedures.

Conclusion:

One should aim for preoperative or intraoperative localization of dural communication and try to disconnect the extradural cyst from the intradural connection to prevent recurrence. Surgical treatment is complete excision of the cyst.

Contrecoup Extradural Hematoma Without Fracture: A Case Report and Review of Literature

Extradural hemorrhages are commonly seen in coup head injuries, rarely seen in contrecoup head injuries. Acute extradural hemorrhage in the coup head injuries associated with a fracture is common, but the incidence of acute contrecoup extradural hemorrhage not associated with the fracture is extremely rare. Only 21 cases have been reported previously. A 28-year-old male patient presented to the emergency department with complaints of sustaining injuries in a road traffic accident by fall from a two-wheeler. No history of loss of consciousness, vomiting, seizures, and ear/nose bleed. On examination, the patient was conscious and coherent with a Glasgow Coma Scale score of 15/15 and a laceration on the right frontotemporal region which was sutured. Contrast tomography of the brain revealed an extradural hemorrhage of 10 mm thickness in the left parieto-occipital region with soft tissue swelling in the right temporoparietal region, without any evident fractures in the calvarium. The patient was managed conservatively. Contrecoup extradural hematoma is a rare entity, and those without fracture are extremely rare. Early diagnosis, careful observation, and management lead to a good outcome.

Concurrent Schwannoma and Meningioma Arising in the Same Spinal Level: A Report of Two Cases

Concurrent multiple tumors developing in the spinal cord are rare, except for in genetic disorders, such as neurofibromatosis and von Hippel-Lindau disease. Furthermore, concurrent tumors arising in the same spinal level with discrete histopathology are much rarer. We report two such cases. Case 1: A 53-year-old man presented with intracranial hemorrhage that manifested as disturbed consciousness and right hemiparesis. Magnetic resonance (MR) angiography demonstrated severe stenosis of the terminal portion of the bilateral internal carotid arteries, implying Moyamoya disease. Cranial MR images showed a hematoma in the left basal ganglia perforating into the lateral ventricle, which was incidentally detected as a spinal tumor compressing the cervical cord at the C2 level. After conservative management for cerebral hemorrhage, the patient underwent total removal of the spinal tumor. Surgical findings showed that the tumor consisted of extra- and intradural components. Histopathological findings showed that the extra- and intradural components were schwannoma and meningioma, respectively. Case 2: A 70-year-old man presented with progressive left hemiparesis and numbness in both lower extremities. Craniocervical MR images demonstrated a paraspinal tumor compressing the spinal cord at C2 level. Surgical findings disclosed that the tumor consisted of major extradural- and minor intradural components. Histopathological study showed that these components had discrete histological findings: extradural lesion was schwannoma and intradural lesion was meningioma. Concurrent tumors with discrete histopathology should be considered in tumors with extra- and intradural components, particularly, when they are located in the high cervical spine.

Autologous cervical fascia duraplasty in 123 children and adults with Chiari malformation type I: surgical technique and complications

OBJECT Techniques for combined extradural and intradural decompression with expansile duraplasty for Chiari malformation type I (CM-I) have been well described, with various allogenic and autologous materials used for duraplasty. However, the approach and surgical technique used for duraplasty in our treatment of CM-I and developed by the senior author in the 1990s has not been described. METHODS A prospective database was initiated in March 2003 to denote the use of cervical fascia for duraplasty and incorporate an ongoing detailed record of complications during the surgical treatment of children and adults with CM-I with and without syringomyelia. A total of 389 surgeries for CM-I were performed on 379 patients from March 2003 to June 2016. A total of 123 posterior procedures were performed on 123 patients in which both a posterior fossa extradural and intradural decompression with duraplasty (extra-intradural) was performed. In this paper the authors describe the surgical technique for harvesting and using cervical fascia for duraplasty in the surgical treatment of CM-I and analyze and discuss complications from a prospective database spanning 2003-2016. RESULTS The authors found that cervical fascia can be harvested in patients of all ages (2-61 years old) without difficulty, and it provides a good substitute for dura in creating an expansile duraplasty in patients with CM-I. Cervical fascia is an elastic-like material with a consistency that allows for a strong watertight closure. Harvesting the cervical fascia graft does not require any further extension of the incision superiorly or inferiorly to obtain the graft. Complications were uncommon in this study of 123 children and adults. The risk of any type of complication (aseptic meningitis, CSF leak, pseudomeningocele, infection, development of hydrocephalus, and need for ventriculoperitoneal shunt) for the 78 patients in the pediatric age group was 0%. The risk of complication in the adult group was 6.7% (1 patient with aseptic meningitis and 2 patients with CSF leak). CONCLUSIONS Autologous cervical fascia is easy to obtain in patients of all ages and provides an effective material for duraplasty in the treatment of CM-I. Complications from the combination of both an extradural and intradural decompression with autologous cervical fascia duraplasty are uncommon.

Trauma-induced Acute Epidural Hematoma: The Rising Sun in a Progressively Lethargic Man

A young adult, 18 years of age, presented to the emergency department with severe traumatic brain injury (TBI) resulting from a bicycle versus vehicle head-on collision. The patient initially presented in a promising condition but quickly deteriorated into a state of unconsciousness with no meaningful responses to stimuli or coordinated voluntary movement. Stat computed tomography (CT) revealed a large, right-sided, acute epidural hematoma (EDH) with mass-effect and a severe midline shift indicative of immediate surgery. This case highlights the importance of closely monitoring traumatic brain injury patients regardless of initial presentation and neurological exam results, as the patient's condition may drastically and rapidly change without much warning. Additionally, it is key to utilize regular radiological studies on these patients, to detect any neurological changes as close to onset as possible. Lastly, it is imperative that neurosurgeons closely monitor the patients/ state of consciousness as a rapid decline serves as a key diagnostic indicator of the need for immediate surgery.

Spinal extradural angiolipoma: a report of two cases and review of literature

Spinal extradural angiolipomas (SEALs) are extremely extraordinary benign extradural lesions. They are infrequently encountered in normal clinical practice although several authors have report single cases or case series. We present two cases of SEAL which we successfully surgical resected with no further neurological deficits. Our cases comprise of a male and a female with ages ranging from 30 to 60 years. Their principal presenting complains were numbness and pain at the lower extremity with associated fecal and urinary incontinence. In all our cases, MRI revealed extradural spinal lesions that exerted compressive effect on the spinal cord. The male patient had an infiltrating type while the female had non-infiltrating type. We attained total resection in both cases without any further neurological complication. The diagnosis of SEALs initially can be challenging radiologically since they may mimic other spinal lesions. The gold standard treatment modality should always be surgery although total resection may not be achievable in some cases.

Primary dorsal spine primitive neuroectodermal tumor in an adult patient: Case report and literature review

Primary spinal primitive neuroectodermal tumor (psPNET) is a rare entity with few cases reported in literature. We report a case of a 50-year-old female who presented to us with paraplegia and was diagnosed with extradural dorsal spine psPNET. The diagnosis was not suspected at presentation or on radiology but was established on histopathological examination. It is important to distinguish it from central nervous system primitive neuroectodermal tumors and from other spinal tumors since it follows a different clinical course and therapeutic outcome.

Frontal intradiploic meningioma with progressive intracranial invasion: A rare case report

RATIONALE

Intradiploic meningiomas are a subset of extradural meningiomas that arise in the skull. They are mostly localized in the frontoparietal and orbital regions, and they are often mistaken for primary bone tumors.

PATIENT CONCERNS

The patient was a 48-year-old man with headache and a 12-year history of frontal cranium occupation, which was first discovered in 2005 and enlarged in 2009. The patient had a history of fracture in his frontal cranium 12 years ago. The computed tomography and magnetic resonance imaging revealed an occupation and intracranial invasion in frontal cranium. And the angiography showed an occlusion at the anterior part of sagittal sinus.

INTERVENTIONS

Bilateral frontal craniotomy, intracranial tumor resection, and cranioplasty were performed.

DIAGNOSIS

Histologic examination confirmed an intradiploic ectopic meningioma (World Health Organization Grade I).

OUTCOMES

He was discharged with no neurological deficits 3 days after surgery. At the 6-month clinical follow-up, there was no tumor recurrence or other complaints.

LESSONS

In this study, we present the case of a frontal intradiploic meningioma with progressive intracranial invasion and review the radiographic and clinical findings of patients with primary intraosseous meningioma.

Discrimination between spinal extradural meningioma and both intra and extradural meningioma: Case Report

Meningiomas are common spinal tumor and mostly located at intradura. Recurrence rate after surgery for extradural meningioma was higher than intradural meningioma. A patient with intra and extradural spinal meningioma was treated and discussed its features and clinical management. A 41-year-old woman noted numbness of bilateral legs, gait disturbance, and mild bladder disturbance for over the two-month period. Magnetic resonance imaging revealed an epidural mass at T8-9 involving the dura mater from the left side. Intraoperatively, ultrasonography showed extradural tumor suppress the dura from the left side and no subarachnoid space. Therefore, it was difficult to diagnose the tumor was located at only extradural or both intra and extradural. The extradural tumor was resected as much as possible, then ultrasonography was performed for the second time. The spinal cord was decompressed and subarachnoid space was appeared with intradural tumor. The dura mater was opened in the midline for intradural exploration, and the intradural tumor appeared beside the spinal cord. The dura mater with attachment to the tumor was rescected. To prevent a recurrence, ultrasonography after removing extradural tumor is recommended to detect intra dural tumor and invasion of tumor into dura mater. In such case, removing only extradural meningioma is not enough, and gross total resection including intradural meningioma and dura mater is required.

The Epidural Ligaments (of Hofmann): A Comprehensive Review of the Literature

The epidural space contains the internal vertebral venous plexus, adipose, and other connective tissues. In the anatomical literature, there are nonspecific descriptions of varying fibrous connective tissue bands in the epidural space, mainly mentioned in the lumbar region, that tether the dural sac to the posterior longitudinal ligament, the vertebral canal, and the ligamentum flavum. These ligaments have been termed as Hofmann’s ligaments. This review expands on the anatomy and function of Hofmann’s ligaments, increasing the awareness of their presence and serves as an impetus for further study of their histology, innervation, and function. 

Extradural spinal meningioma: Revisiting a rare entity

Spinal meningiomas are mostly intradural in location although at times these are associated with some extradural extensions. Purely extradural spinal meningiomas (EDSMs) are however, extremely rare and when present, may cause diagnostic dilemma preoperatively. Only seven cases of pure EDSM have been reported till date. In this paper, we describe two cases of EDSM affecting the cervical spine and present their clinical profiles, radiological findings, operative management, and follow-up data, along with a review of the literature.

Dorsal spinal epidural psammomatous meningioma in an adult male

Meningiomas are benign in nature and arise from the arachnoid cells. They are mostly situated in the intracranial compartment, whereas spinal meningiomas are rare. Approximately, in 10% of cases, an extradural component is seen but an exclusively extradural meningioma is quite uncommon. However, WHO Grade II (atypical) and Grade III (anaplastic) tumors can behave aggressively. We reported a case of purely extradural psammomatous meningioma in an adult male affecting the dorsal spine although uncommon meningiomas should be included in the differential diagnosis of extradural intraspinal masses.

Extradural Dermoid Cyst of the Anterior Infratemporal Fossa. Case Report

Dermoid cysts are rare in the skull base. There have been 10 reported cases of dermoid cysts in the cavernous sinus, two in the petrous apex, and one in the extradural Meckel cave. This is the first case report of a dermoid cyst in the anterior infratemporal fossa attached to the anterior dura of the foramen ovale. The clinical presentation, radiologic findings, histologic features, tumor origin, and operative technique are described along with a review of the literature.

Traumatic bifrontal extradural haematoma resulting from superior sagittal sinus injury: case report

Traumatic bilateral extradural haematoma resulting from injury to the superior sagittal sinus is rare; in such cases, early surgical evacuation of the haematoma and control of bleeding from the sinus can achieve an excellent patient outcome.

Bilateral assymetric epidural hematoma

Background:

Acute bilateral extradural hematoma is a rare presentation of head trauma injury. In sporadic cases, they represent 0.5–10% of all extradural hematomas. However, higher mortality rates have been reported in previous series.

Case Description:

The authors described the case of a 28-year-old male presenting head injury, comatose, Glasgow Coma Scale of 6, anisocoric pupils without puppilary light reflex. Computed tomography showed asymmetric bilateral epidural hematomas, effacement of the lateral ventricles and sulci, midline shift and a bilateral skull fracture reaching the vertex. Surgical evacuation was performed with simultaneous hematoma drainage. Patient was discharged on the 29^th postoperative day with no neurological deficit.

Conclusion:

The correct approach on bilateral epidural hematomas depends on the volume, moment of diagnosis, and neurological deficit level. Simultaneous drainage of bilateral hematomas has been demonstrated to be an effective technique for it, which soon decreases the intracranial pressure and promotes an efficient resolution to the neurological damage.

Primary Extradural Tumors of the Spine - Case Review with Evidence-guided Management

Background:

Primary extradural tumors of the spine comprise only a small percentage of all spinal tumors. However, given their relative radioresistance and their typical malignant, invasive nature, surgery may be associated with fairly high morbidity and mortality rates. Furthermore, it may be especially difficult to achieve gross total resections with tumor-free margins.

Case Descriptions:

We present two cases and review the literature regarding the presentation, diagnosis, and evidence-based guidance/treatment of primary extradural spinal tumors. The first patient with an L1 chordoma presented with cauda equina syndrome. Following surgery, the second patient, with a giant cell tumor of the cervicothoracic junction, responded well to the novel drug denosumab, a monoclonal antibody to the RANK ligand.

Conclusion:

Primary extradural spine tumors pose significant challenges to surgeons as the aim is to achieve satisfactory surgical outcomes with clean tumor margins (e.g, thus avoid recurrence) while minimizing morbidity. Improvements in radiotherapy, chemotherapy, and novel molecular drugs may increase survival rates and improve overall outcomes.