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This study aimed to reveal the preferred initial treatment for Koos grade 3 vestibular schwannomas (VS). We performed a two-institutional retrospective study on 21 patients with Koos grade 3 VS undergoing resection at Yokohama Medical Center and 37 patients undergoing radiosurgery at Yokohama Rosai Hospital from 2010 to 2021. Tumor control, complications, and functional preservation were compared. The median pre-treatment volume and follow-up duration were 2845 mm3 and 57.0 months, respectively, in the resection group and 2127 mm3 and 81.7 months, respectively, in the radiosurgery group. In the resection group, 16 (76.2%) underwent gross total resection, and three patients (14.3%) experienced regrowth; however, no one required additional treatment. In the radiosurgery group, the tumor control rate was 86.5%, and three cases (8.1%) required surgical resection because of symptomatic brainstem compression. Kaplan-Meier analyses revealed that tumors with delayed continuous enlargement and large thin-walled cysts were significantly associated with poor prognostic factors (p = 0.0027, p < 0.001). The pre-radiosurgery growth rate was also associated with the volume increase (p = 0.013). Two cases (9.5%) required additional operation due to complications such as post-operative hematoma and cerebrospinal fluid leaks in the resection group, whereas temporary cranial neuropathies were observed in the radiosurgery group. Two patients (9.5%) had poor facial nerve function (House-Brackmann grading grade 3) in the resection group, while no one developed facial paresis in the radiosurgery group. Trigeminal neuropathy improved only in the resection group.Radiosurgery can be considered for the treatment of Koos grade 3 VS for functional preservation. However, resection may also be considered for patients with severe trigeminal neuropathy or a high risk of volume increments, such as large thin-walled cysts and rapid pre-treatment growth.
Asunto(s)
Neuroma Acústico , Radiocirugia , Humanos , Neuroma Acústico/cirugía , Masculino , Femenino , Persona de Mediana Edad , Radiocirugia/métodos , Adulto , Anciano , Estudios Retrospectivos , Resultado del Tratamiento , Complicaciones Posoperatorias/epidemiología , Procedimientos Neuroquirúrgicos/métodos , Clasificación del TumorRESUMEN
Background: Extra-axial cerebellopontine angle (CPA) hemangioblastomas are rare clinical entity and surgical treatment is challenging due to the anatomical difficulties and multi-directional blood supplies. On the other hand, the risk of endovascular treatment for this disease has also been reported. Herein, we successfully applied a posterior transpetrosal approach to remove a large solid CPA hemangioblastoma without preoperative feeder embolization. Case Description: A 65-year-old man presented with a complaint of diplopia during downward gaze. Magnetic resonance imaging revealed a solid tumor with homogeneous enhancement measuring about 35 mm at the left CPA, and the tumor compressed a left trochlear nerve. Cerebral angiography disclosed tumor-staining fed by both left superior cerebellar and left tentorial arteries. After the operation, the patient's trochlear nerve palsy improved dramatically. Conclusion: This approach offers more optimal surgical working angle to the anteromedial part compared to the lateral suboccipital approach. In addition, the devascularization from the cerebellar parenchyma can be performed more reliably than the anterior transpetrosal approach. After all, this approach can be particularly useful when vascular-rich tumors receive blood supplies from multiple directions.
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OBJECTIVE: Posterior cerebral artery (PCA) aneurysms are extremely rare and can be difficult to treat. We report successful trapping and thrombectomy of a giant thrombosed P2 segment aneurysm via a transpetrosal approach. CASE PRESENTATION: A 62-year-old woman was admitted to our hospital with a progressive left hemiparesis. Magnetic resonance imaging (MRI) showed a 30 mm mass lesion in the right ambient cistern. On vertebral angiography, the right P2 trunk was deviated medially and inferiorly, and the right posterior temporal artery (PTA) was not visualized. We diagnosed a giant thrombosed aneurysm of the right PTA. Surgery was performed via a right posterior transpetrosal approach. The proximal P2 was identified above the oculomotor nerve in the ambient cistern, and a giant PTA aneurysm was found. After coagulating the distal PCA, a temporary clip was applied to the proximal P2, the aneurysm wall was incised, thrombus was removed, and a permanent titanium clip was applied to complete trapping. Postoperative MRI showed disappearance of the aneurysm. The patient's left hemiparesis was resolved 2 months after the operation, and she was discharged home. CONCLUSION: Although trans-sylvian and subtemporal approaches are often performed for P2 aneurysms, they have difficulty identifying the distal PCA and may require excessive brain retraction. The transpetrosal approach can also be effective for giant thrombosed P2 aneurysms.
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We report a case of primary central nervous system lymphoma(PCNSL)originating from an optic chiasma, which was difficult to diagnose but was finally diagnosed by biopsy. A 62-year-old immunocompetent man presented with bilateral visual field disturbance, hypopituitarism, and diabetes insipidus;an optic chiasm lesion was detected on MRI. After starting steroid supplementation for adrenal insufficiency, visual field disturbance immediately improved. Since the lesion completely disappeared three months after its onset, it became the follow-up without histological confirmation. Six months after the onset, visual field disturbance progressed, and the lesion recurred. We performed a left optic nerve biopsy to maintain the right visual field, which remained partially. The pathology was PCNSL. We performed postoperative chemoradiotherapy, and the patient showed remission and improvement of the visual field. Isolated PCNSLs arising from optic chiasma are very rare. The diagnosis of optic chiasm lesions is difficult due to their similarity with a variety of inflammatory/autoimmune disease and neoplastic lesions. When a lymphoma is considered to be differentiated, early biopsy should be performed before administering a steroid. The approach and sampling site to prevent the function are also important for biopsy.
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Neoplasias del Sistema Nervioso Central , Linfoma no Hodgkin , Linfoma , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Quiasma Óptico/diagnóstico por imagenRESUMEN
Histologically, hepatocellular carcinoma (HCC) and atypical pituitary adenoma are similar, posing a potential clinical problem. A 76-year-old woman, whose past medical history was significant for hepatitis C virus (HCV), positivity without liver cirrhosis was presented with abducens nerve (CN VI) palsy. Contrast-enhanced magnetic resonance imaging (MRI) showed a clival tumor with infiltration of the right cavernous sinus. Subtotal resection was performed using a right anterior petrosal approach. Histological diagnosis was pituitary adenoma. Thirty-four days after the operation, MRI imaging showed residual tumor growth without any liver masses on computed tomography (CT). The patient underwent a second operation using an endoscopic transnasal transsphenoidal approach. Histological examination of the specimen gave a positive reaction for α -fetoprotein. Repeat whole-body CT showed an enhanced liver mass. Based on these findings, the lesion was diagnosed as metastatic HCC. The patient died of liver failure 6 months later. In this case, tumor diagnosis was difficult because of the histological similarity of HCC and pituitary adenoma, and the fact that the clival tumor grew prior to presentation of the liver mass on CT. This case emphasizes the importance of comparing the pathological diagnosis with the patient's clinical course.