Surgical Treatment of Pineal Region Tumors: An 18 year-Experience at a Single Institution.

BACKGROUND: The pineal tumor was once considered as a restricted area for surgery. Such cases are rare, with many different opinions on surgical treatment. This study aimed to review our experience of tumor treatment in the pineal region and explore the optimal treatment strategy. METHODS: The clinical data of 72 patients with pineal tumors from January 1997 to May 2015 (18 years) were retrospectively analyzed. Preoperative preparation, pathology type, tumor resection rate, surgical approach, and follow-up outcomes were used as the indicators to evaluate the treatment efficacy. RESULTS: The Krause approach was used in 46 cases, the Poppen approach in 10 cases, and the transcallosal-lateral ventricle-choroid fissure approach in 16 cases. The postoperative pathological results were as follows: 24 cases of germinoma, 11 of teratoma, 15 of glioma, 6 of meningioma, 11 of Pineocytoma, 2 of cholesteatoma, 2 of cavernous hemangioma, and 1 of choriocarcinoma. Further, the study included 64 cases of total surgical resections, 8 of subtotal resections, and 2 deaths. The follow-up period was from 7 months to 10 years. Further, 51 (70.8%) patients were followed up. The multivariate regression model showed that the surgical method and the pathological type contributed significantly to predicting outcomes. CONCLUSIONS: The type of pathology, extent of excision, and surgical approach had a significant impact on the prognosis of patients. The transcallosal-lateral ventricle-choroid fissure approach for large and medium-sized pineal tumors near the posterior part of the third ventricle had good efficacy.

A giant cholesteatoma of the mastoid extending into the foramen magnum: A case report and review of literature.

Cholesteatomas are very rare benign, progressive lesions that have embryologic derivation and usually result in progressive exfoliation and confinement of squamous epithelium behind an intact or preciously infected tympanic membrane. To the best of our understanding no reports demonstrates the extension of cholesteatoma from the temporal bone into the foramen magnum. We therefore present a case of cholesteatoma extending down into the foramen magnum. We report a case of 67- year-old man with a giant cholesteatoma extending into the foramen magnum without substantial destruction of the mastoid and petrous temporal bones. The patient's major symptoms were recurrent tinnitus in the left ear and dizziness with unilateral conductive hearing loss. A working diagnosis of cholesteatomas was made combining the symptoms and magnetic resonance imaging findings. He was then successfully operated on with very minimal postoperative complications. Cholesteatomas originating from the mastoid bone often linger with the patients for many years in a subclinical state and progress into a massive size before causing symptoms. Patients with unilateral conductive hearing loss who are otherwise asymptomatic and have a normal tympanic membrane should be suspected with a progressive cholesteatoma. Cholesteatoma should be one of the working diagnosis when an elderly patient present with unilateral conductive hearing loss that is associated with tinnitus and dizziness.

An infantile alantoaxial dislocation with patent foramen ovale managed with titanium cabling and allogenic bone grafts.

Atlantoaxial dislocation is a disorder that is characterized with loss of stability of the atlas and axis (C1-C2) with consequential loss of usual articulation. Although this condition is very common, no one has reported a case as young as our patients. We present a 7-month infant with bilateral paralysis of the lower limbs for four (4) months with no history of trauma. Computer tomographic (CT-scan) imaging revealed alantoaxial dislocation with severe cervical spinal cord compression. The odontoid process is displaced outwardly with no bone destruction. Doppler echocardiogram done revealed patent foramen ovale. Thorough physical examination as well as radiological evaluation revealed no feather malformations. Electrophysio - logical studies reveal normal compound muscle action potentials (CMAP) and sensory nerve action potentials (SNAPs) in all the limbs. Electromyography (EMG) also revealed normal nerves in the limbs and the trunk. We attained a stable fusion and anatomical reduction using a posterior titanium wire and an iliac bone graft harvested from his mother. This is the youngest patient reported in literature. Infantile alantoaxial dislocation should be managed at early stage to prevent long-term neurologic disorders.

Thoracolumbar spinal neurenteric cyst with tethered cord syndrome and extreme cervical lordosis in a child: A case report and literature review.

RATIONALE: Neurenteric cysts, are rare benign tumors of the central nervous system that are mostly located in the spinal cord and predominantly seen in male children although adult form of the disorder also occurs. The etiology and treatment of this disorder is still a matter of debate. Our case further throws more light on the pathogenesis and treatment of this disorder. PATIENT CONCERNS: A 4-year-old boy presented with 5-month history of cervical lordosis and bilateral lower extremity pain that progressed to his abdomen and upper body. The pain was general, recurrent, non-persistent and progressive in nature with no paralysis. The pain was aggravated by trunk stretching and relieved when he assumed opisthotonos position so he preferred sleeping in this position at night. DIAGNOSES: Magnetic resonance imaging (MRI) revealed a cystic lesion at the thoracolumbar spine with tethering of spinal cord and cervical lordosis. INTERVENTIONS: He was operated on successfully and the cervical lordosis and pain resolved. OUTCOMES: The child recovered well with no tumor recurrence and massive improvement of his life. LESSONS: The gold standard treatment for this disorder is surgery although the precise surgical approach is still a matter of debate. We are of the view that surgical approach should be individualized and aim at total excision of the cyst.

Nonprojectile penetrating iron rod from the oral cavity to the posterior cranial fossa: a case report and review of literature.

INTRODUCTION: Nonprojectile penetrating skull base injuries as a result of falls have rarely been confronted in normal neurosurgery although a few nonmissile injuries have been reported. These kinds of injuries represent a life-threatening emergency. CASE PRESENTATION: We present an unusual case of a 25-year-old male construction worker who suffered an accidental penetrating skull base injury when he fell on a metal rod while he was walking on a 2-meter-high platform. He was clinically stable at presentation. Skull radiograph showed a solid metallic bar, 30 cm long, that penetrated through the right anguli oris eminence and was lodged low in the right occipital bone. CONCLUSION: Penetrating injury to the head is considered a form of severe traumatic brain injury. Although case of penetrating head injuries as a result of fall from heights are very rare, we anticipate the construction works on high-rise buildings are at maximum risk. We advise that removal of this kind of foreign bodies be done in the theater and not outside because of risk of involvement of larger vessels leading to fatal hemorrhage. We further suggest that patients with nonprojectile injuries should undergo a preoperative computed tomography-angiography to rule out any vascular injury.

Chiari type I malformation with cervicothoracic syringomyelia subterfuge as flail arm syndrome.

Chiari type I malformation with cervicothoracic syringomyelia although very common in clinical practice usually in children can progress slowly and mimic muscular dystrophies in adulthood. We present a rare adult case of Chiari type I malformation with cervicothoracic syringomyelia subterfuge as Flail arm syndrome. A 44-year-old man was diagnosed with congenital type I Chiari malformation with cervicothoracic syringomyelia about 21 years ago without surgery. His health status deteriorated over the years until 21 days prior to presentation when he had severe pain in the right knee. In his upper limbs, he had bilateral corresponding severe weakness of 0/5 proximal strength and 0/5 strength in his distal muscles. Magnetic resonance imaging (MRI) revealed an enlargement of the spinal cord from C1-C4 level with a mass that appeared hypo-dense on T1 and hyperdense on T2. Syringomyelia is a potentially serious neurologic condition that can mimic other neuromuscular disorders. Early detection and diagnosis with MRI is crucial to avoid irreversible neurological complications. We suggest that whether asymptomatic or symptomatic, decompressive surgery should be carried out to allow for free flow of cerebrospinal fluid thereby improving the quality of life for the patient.

A fully thrombosed giant posterior inferior cerebellar aneurysm mimicking an intracranial tumour in a child.

This report presents a fully thrombosed giant aneurysm of the posterior inferior cerebellar artery (PICA) mimicking an intracranial tumour in a 9-year-old paediatric patient. Surgical clipping and aneurysmectomy were performed. Postoperative imaging studies confirmed the removal of the lesion and the patient was discharged with no neurological deficits. Our case shows that giant thrombosed aneurysms involving the PICA could be potentially misdiagnosed as neoplasms in children and great care must be exercised when managing such cases.

One-stage removal of a giant thoracic paraspinal shamrock-shaped schwannoma via modified hemilaminectomy and posterolateral thoracotomy.

BACKGROUND CONTEXT: Paraspinal neurogenic tumors in the thoracic region are not a rare clinical entity in neurosurgical practice. They usually consist of intrathoracic and intraspinal parts, namely dumb-bell type. However, in some rare cases, they might display a bidirectional extraspinal growing pattern, compromising three components with intraspinal, intrathoracic, and subcutaneous parts, thus appearing to be shamrock-like. Despite its benign nature, the removal of this type of tumor could be challenging for both neurosurgeons and thoracic surgeons, especially when the tumor has grown to an enormous size. PURPOSE: We present a case of a giant paraspinal shamrock-shaped schwannoma in the T9-T12 level resected completely by one-stage combined surgery of hemilaminectomy and posterolateral thoracotomy performed by an interdisciplinary team of neurosurgeons and thoracic surgeons. STUDY DESIGN/SETTING: Operating room of a large tertiary medical center where expertise and equipment of neurosurgery, thoracic surgery, and neuroanesthesia are readily available. METHODS: Under generalized anesthesia, the patient was intubated with a double-lumen endotracheal tube to allow one-lung ventilation during the thoracotomy, and he was then placed in the left lateral position. Because of the giant subcutaneous mass, the normal hemilaminectomy could not be carried out like it usually would be. Thus, we did slight modification to the standard hemilaminectomy; first, by elevation of a skin flap to allow in situ excision of the subcutaneous portion of the tumor, then followed by a standard unilateral laminectomy to remove the intraspinal portion, done by neurosurgeons, and finally, posterolateral thoracotomy to remove the intrathoracic part, performed by a thoracic team. RESULTS: The postoperative magnetic resonance imaging scan showed complete removal of the tumor, and the patient experienced an improvement in lower extremity muscle weakness with no new neurological deficits. CONCLUSIONS: This is the first case to demonstrate the removal of giant paraspinal shamrock-shaped schwannoma in the thoracic level. The combined approach of modified hemilaminectomy and posterolateral thoracotomy was proven to be appropriate in managing such cases, making this procedure a potential addition to present methods.

Epidemiological features of 1 281 patients with head injuries arising from the 2008 Wenchuan earthquake.

OBJECTIVE: To analyze the epidemiological features of patients with head injuries in the 2008 Wenchuan earthquake. METHODS: Medical records of patients with head injuries who were admitted to 14 hospitals in Deyang, Mianyang and Chengdu cities after the earthquake were retrospectively analyzed. The patients'age, gender, cause of injury, diagnosis, and outcome were analyzed retrospectively. RESULTS: A total of 1 281 patients with 807 males and 474 females were included. According to Glasgow Coma Scale score at admission, 1 029 patients presented with mild injury, 161 moderate injury and 91 severe injury. The major cause of injuries (83%) was bruise by collapsed buildings. Open head injuries accounted for 60.8%. A total of 720 patients underwent surgical treatment. Good recovery was achieved in 1 056 patients, moderate disability in 106, severe disability in 71, coma in 29 and death in 19. CONCLUSIONS: In this series, male patients were more than female patients. The main cause of injury was hit by falling objects due to building collapse. Minor and open craniocerebral injuries were most common. The epidemiological features of head injuries in Wenchuan earthquake may be helpful to preparation for future rescue.

Large and giant ventral paraclinoid carotid aneurysms: surgical techniques, complications and outcomes.

OBJECTIVES: Surgical treatment of large and giant ventral paraclinoid carotid aneurysms (vPCAs) continues to be challenging and technically demanding for vascular neurosurgeons. Due to both physiological barriers and limitations of current surgical technology in the treatment of vPCAs, higher rates of morbidity and mortality are a given. To improve the current available data and assess the most effective microsurgical management techniques with the goal of decreased morbidity and mortality, we present this retrospective study of a series of 15 consecutive patients with large and giant vPCAs. MATERIALS AND METHODS: Between January 2005 and December 2010, fifteen patients presented with large or giant vPCAs were surgically treated at West China Hospital and were included in this study. The data was retrospectively analyzed. RESULTS: Five men and ten women with an averaging 50 years of age (ranged 32-70 years) were included in this study. The average aneurysm size was 21 mm (ranged 13-36 mm). All patients were treated microsurgically. Twelve patients (80%) had desirable surgical outcomes (Glasgow Outcome Score 4-5) at follow-up for a mean of 32 months (range 3-72 months). One patient (7%) died of severe vasospasm after surgery. The surgical mortality was 7%; overall morbidity was 27%, including the hemiplegia, oculomotor paresis and visual deficit. None of the 14 following patients had rebleeding or regrowth of residual aneurysm during this follow-up period. Age and Hunt-Hess grade were significantly correlated with clinical outcome. CONCLUSIONS: Despite the difficulties presented by large and giant vPCAs, our increased knowledge of anatomy and refinements in operative techniques and intraoperative monitoring have greatly improved the clinical outcome with a more acceptable mortality and morbidity.

Traumatic carotid-cavernous fistulas treated with covered stents: experience of 12 cases.

OBJECTIVE: Covered stents have recently become available for intracranial use, such as aneurysms, arterial dissections and carotid-cavernous fistulas (CCFs). However, there have been few reports of the successful application of covered stents for the treatment of traumatic CCFs (TCCFs). The purpose of this study is to investigate the efficacy and safety of endovascular treatment of TCCFs with covered stent. METHODS: Twelve consecutive patients with TCCFs treated with covered stent after initial failure of traditional techniques are presented. All the patients were followed up both clinically and angiographically for a mean of 22.5 months. RESULTS: Eleven of the 12 patients had covered stents placed successfully. In one case, the covered stent placement failed after multiple attempts because of the tortuous anatomy of the internal carotid artery (ICA). Complete occlusion was achieved in nine cases immediately after stent deployment. Endoleak was observed in case 4 and redilation was performed to avoid the endoleak. In case 8, improved symptoms recurred the next morning, and cerebral angiogram revealed a small endoleak; redilation was performed to eliminate the endoleak successfully. Spasm of the ICA was observed in six cases, but angioplasty was not required. Symptoms improved in all cases after stent placement. Angiographic follow-up demonstrated complete occlusion of the TCCFs and patency of ICA, and no intra-stent stenosis or embolization occurred in the 11 patients who received successful stent placement. CONCLUSION: Although larger sample and long-term follow-up are required, our series shows that covered stent is an effective, safe, and microinvasive method to treat TCCFs.