Whorling-sclerosing meningioma. A review on the histological features of a rare tumor including an illustrative case.

Whorling-Sclerosing variant of meningioma (WSM) is a very rare variant of meningioma and only 28 cases were previously reported in the English medical literature. The term "whorling" describes different morphological features including psammoma bodies formed by precipitated calcium or by layered whorling sheets of tumor cells in meningothelial meningiomas. In WSM, the sclerosing structures are formed by typical paucicellular or acellular collagen whorls which form the majority of tumor volume. Hence, diagnosis of these tumors is based more often on morphological and histochemical features rather than on immunohistochemical findings. WSMs often contain cells with both fibroblast-like spindle cell morphology predominantly immunopositive for vimentin and meningoepithelial cells immnunopositive for EMA. The range of their Ki-67 indices differs between 0 and 4 percent. These tumors show no focal pleomorphism, necrosis and high mitotic activity. In some WSMs, entrapped GFAP immunopositive astrocytes may be seen during invasion of the adjacent neural parenchyma. Brain invasion by WSMs may give rise to erroneous diagnoses, i.e. malignant (Grade-3) meningioma, meningiosarcoma, ganglioglioma and even astrocytoma, leading detrimental overtreatment. However; hitherto, no WSM was reported exerting any aggressive behavior. Besides reviewing the literature, we also report a new WSM with abundant uncalcified paucicellular collagen whorls forming aggregates of nodules. Unlike to previous reports, this tumor was costained with p53 and progesterone receptor. The tumor showed no morphological malignancy characteristics, e.g. cellular atypia, prominent nucleoli, hypercellularity, micronecrosis/geographical necrosis, sheeting and small cells. This rare meningioma variant should be kept in mind among differential diagnoses to avoid overtreatment that might endanger patients' outcome.

Management of Failed Cranioplasty.

AIM: Failed cranioplasty attempts may lead to numerous complications in a broad spectrum including cosmetic problems, infection, neurological deterioration and even death. Selection of the most appropriate surgical technique for second and further surgical attempts for these patients still remains a debate. We aimed to share our experience and technical pitfalls on management of failed cranioplasty, particularly for patients with large cranial defects. MATERIAL AND METHODS: A retrospective data analysis of cranioplasty cases in our series was performed including the time period between 2002 and 2012. Patients required recurrent cranioplasty were analyzed in detail. RESULTS: Totally, 101 patients underwent cranioplasty for bony defect. Of 101 patients, eleven required a revision surgery due to infection or spontaneous resorption of the bone flap. All patients underwent revision cranioplasty with pre-surgical plaster cast mold technique modified from previous studies and/or tissue expansion technique. Polymethyl-metacrylate (PMMA) was used as substitute for reconstructions. Mean follow-up was 36 months. Two out of eleven cases (18.1%) developed major complications, which led to further revision. At the end, a satisfactory reconstruction was achieved for all patients. CONCLUSION: Our modified molded plaster cast technique is a safe and cost-effective approach for the revision of failed cranioplasty. We believe that the tissue expanding techniques have also great contribution to achieve successful results.

Impact of 1p/19q codeletion on the diagnosis and prognosis of different grades of meningioma.

BACKGROUND: Meningiomas are one of the most common tumours to affect the central nervous system. Genetic mutations are important in meningeal tumourigenesis, progression and prognosis. In this study, we aimed to examine the effect of 1p/19q deletion on the diagnosis and prognosis of meningioma subtypes using the fluorescence in situ hybridization (FISH) method. METHODS: Twenty-four patients with meningioma were retrospectively studied. Tumour samples were obtained from 10 typical, 11 atypical and three anaplastic malignant meningiomas. The most representative tumour sections were screened for 1p/19q deletion using the FISH method. RESULTS: Of the 24 patients, eight were women (33.3%) and 16 (66.7%) were men. The mean age was 56.6 years. The higher-grade meningioma was usually seen in males and had a higher rate of deletion on 1p (p = 0.001). There was a statistically significant difference between the grades and the rate of deletion on 19q (p = 0.042) and between the grades and the rates of polysomy, monosomy and amplification on 19q (p = 0.002; p = 0.001; p = 0.002, respectively). There was no statistical difference between 1p/19q codeletion and the grades of meningioma (p > 0.05). We detected higher level of Ki-67 in the condition of codeletion but did not find a statistical difference (p = 0.0553). CONCLUSION: Deletion on 1p, as well as deletion, polysomy, monosomy and amplification on 19q, are detected more frequently in high grade meningiomas. This amplification is most likely due to the amplification of oncogenes.

A Simple Technique for Bone Storage after Decompressive Craniectomy in Children.

Cranial vault reconstruction in the pediatric population is a specialized procedure, which requires additional considerations. Generally, inherent difficulties of bone storage and cranioplasty are neglected in the literature. We present a simple method of bone storage and autologous cranioplasty in a small child with severe head injury. The child underwent surgical treatment with decompressive craniectomy. A bone flap was transversally divided into two pieces and stored under the galea. Bone storage and reconstruction of the cranial vault with our surgical technique is a safe, easy and cost-effective choice excluding the surgical trauma to obtain a new subcutanous pocket for bone storage in pediatric decompressive craniectomy patients.

Intradural solitary fibrous tumor of the lumbar spine: a distinctive case report.

Background. Solitary fibrous tumors are ubiquitous mesenchymal neoplasms of putative fibroblastic origin. They were originally described in the pleura but subsequently have been reported in many extraserosal sites. Solitary fibrous tumors may also occur in the meninges, central nervous system parenchyma, and spinal cord. Case. A 67-year-old male patient with progressive lower extremity weakness, urinary urgency, and sexual dysfunction has been admitted to our hospital. On his lumbar MRI, we detected an intradural lesion posterior to the L3 vertebral corpus. We resected the lesion by L3 total laminectomy. Immunohistological findings revealed strong and diffuse immunopositivity with vimentin, CD34, and bcl-2. Ki-67 proliferation index was 5-8%. We did not detect any recurrence 12 months after his operation. Conclusion. SFT is mostly seen in young and middle-aged patients and should be considered among differential diagnosis in cases suffering from pain, hypoesthesia, and urinary dysfunction. Gross total resection should be primary treatment. Tumors that have high Ki-67 labeling should be followed up for potential recurrences.

Correlation between SPARC (Osteonectin) expression with immunophenotypical and invasion characteristics of pituitary adenomas.

Pituitary adenomas are the third most common intracranial tumors. Invasive adenomas account for only 0.1-0.2% of pituitary tumors. SPARC is a matrix glycoprotein that plays a role in progression and invasiveness of neoplasms. In this study, we examined the potential role of SPARC in invasive pituitary adenomas. Forty pituitary adenomas have been examined with histopathological and immunohistochemical techniques. The cohort has been classified into two groups as invasive (n = 25) and non-invasive (n = 15) utilizing the Hardy classification. Formalin fixed tissues have been stained with hematoxylin eosin. Ki-67, p53, and SPARC monoclonal antibodies have been used. We did not detect any significant difference on Ki-67, SPARC, and p53 expression patterns correlating with the pathological subtype or invasiveness. Only 24% of invasive adenomas had Ki-67 levels over 1%. A total of 67.7% non-invasive adenomas had Ki-67 levels below 1%. We did not detect any relation between SPARC levels and invasiveness of pituitary adenomas. Absence of significant SPARC expression in tumor progression, sellar dilatation, erosion and destruction suggest that SPARC scores are not related with invasiveness or progressiveness of pituitary adenomas.

Spinal arachnoid cyst associated with arachnoiditis following subarachnoid haemorrhage in adult patients: A case report and literature review.

OBJECTIVE: Arachnoiditis is an inflammatory process resulting with the fibrosis of arachnoid mater. It can vary in severity from mild thickenings to catastrophic adhesions that ruins subarachnoid space. As a result, arachnoid cysts can be formed. Arachnoid cyst induced by symptomatic spinal arachnoiditis is a rare complication of subarachnoid haemorrhages. In this article, we aimed to present a case of spinal arachnoid cyst formation following subarachnoid haemorrhage and examine similar cases in the literature. CASE REPORT: Forty-six years old, previously healthy female patient has been treated medically for headaches due to perimesencephalic subarachnoid bleeding. Approximately two and a half months later, she started to have severe headaches and diplopia. We detected hydrocephalus and performed ventriculoperitoneal shunt surgery. Two months later, she started to have complaints of weakness in her lower extremities. On neurological examination, she had paraparesis and on spinal magnetic resonance imaging she had an arachnoid cyst lengthening from C7 to T2 and compressing the spinal cord posteriorly. We performed partial laminectomy, drainage of arachnoid cyst and replacement of cystopleural T tube shunt. On follow-up, her lower extremity strength has ameliorated. She was taken into a physical therapy and rehabilitation programme. Three months later she was able to walk with a crutch. CONCLUSION: Subarachnoiditis and associated arachnoid cyst can cause severe morbidity. This rare situation (which especially occurs following subarachnoid haemorrhage of posterior fossa) should be known and physicians should keep in mind that it requires urgent surgical procedure.

Surgical treatment of huge congenital extracranial immature teratoma: a case report.

Congenital cranial teratomas are usually characterized by complete loss of the normal intracranial architecture. In the majority of reports, the tumors are associated with stillbirth, perinatal death, or significant morbidity after surgical resection. The few reported attempts at total or subtotal tumor resection have had poor outcomes, although there are rare reports of prolonged survival up to 3.5 years following resection of smaller tumors. Neonatal teratomas are rarely located in the scalp. In the literature, there were only a few patients who underwent surgery during the neonatal period with a good outcome; however, all such patients survived. In this paper, we present a neonatal case of huge congenital extracranial immature teratoma on the scalp extending to the orbita, ears, and brain. Examination of the patient revealed a large craniofacial mass and head circumference that was bigger than normal; there were no other neurological deficits. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a multiloculated, heterogeneous cystic mass that was larger than the patient's head, displacing and distorting anatomical structures. MRI showed mass with calcifications, soft tissue, fat, and fluid components. There was deformity and remodeling of the adjacent calvaria. A total surgical excision was performed and histopathological examination showed immature teratoma. The patient's early postoperative course was uneventful. Postoperative CT and MRI were normal. To date, the patient has survived for 6 months without neurological deficit. We conclude that acceptable functional outcomes in the context of massive congenital craniofacial teratomas can be achieved by early radical resection.