Topographic Patterns of Intracranial Meningioma Recurrences-Systematic Review with Clinical Implication.

BACKGROUND: While several risk factors for recurrences have been defined, the topographic pattern of meningioma recurrences after surgical resection has been scarcely investigated. The possibility of theoretically predicting the site of recurrence not only allows us to better understand the pathogenetic bases of the disease and consequently to drive the development of new targeted therapies, but also guides the decision-making process for treatment strategies and tailored follow-ups to decrease/prevent recurrence. METHODS: The authors performed a comprehensive and detailed systematic literature review of the EMBASE and MEDLINE electronic online databases regarding the topographic pattern of recurrence after surgical treatment for intracranial meningiomas. Demographics and histopathological, neuroradiological and treatment data, pertinent to the topography of recurrences, as well as time to recurrences, were extracted and analyzed. RESULTS: Four studies, including 164 cases of recurrences according to the inclusion criteria, were identified. All studies consider the possibility of recurrence at the previous dural site; three out of four, which are the most recent, consider 1 cm outside the previous dural margin to be the main limit to distinguish recurrences closer to the previous site from those more distant. Recurrences mainly occur within or close to the surgical bed; higher values of proliferation index are associated with recurrences close to the original site rather than within it. CONCLUSIONS: Further studies, including genomic characterization of different patterns of recurrence, will better clarify the main features affecting the topography of recurrences. A comparison between topographic classifications of intracranial meningioma recurrences after surgery and after radiation treatment could provide further interesting information.

Posterolateral approaches to the thoracic spine for calcific disc herniation: is wider exposure always better?

OBJECTIVE: To compare the costotransversectomy (CTV) and transpedicular (TP) approaches versus the transfacet (TF) approach for the surgical treatment of calcific thoracic spine herniations (cTDH), in terms of surgical and clinical outcomes. BACKGROUND: Surgical approaches for cTDH are debated. Anterior approaches are recommended, while posterolateral approaches are preferred for non-calcific, paramedian, and lateral hernias. Currently, there is limited evidence about the superiority of a more invasive surgical approach, such as CTV or TP, over TF, a relatively less invasive approach, in terms of neurological outcome, pain, and surgical complications, for the treatment of cTDH. METHODS: A retrospective, observational, monocentric study was conducted on patients who underwent posterolateral thoracic approaches for symptomatic cTDH, between 2010 and 2023, at our institute. Three groups were drafted, based on the surgical approach used: TF, TP, and CTV. All procedures were assisted by intraoperative CT scan, spinal neuronavigation, and intraoperative neuromonitoring. Analyzed factors include duration of surgery, amount of bone removal, intraoperative blood loss, CSF leak, need of instrumentation for iatrogenic instability, degree of disc herniation removal, myelopathy recovery. Afterwards, a statistical analysis was performed to investigate the bony resection of the superior posterior edge of the vertebral soma. The primary outcome was the partial or total herniation removal. RESULTS: This study consecutively enrolled 65 patients who underwent posterolateral thoracic surgery for cTDH. The TF approach taking the least, and the CTV the longest time (p < 0.01). No statistical difference was observed between the three mentioned approaches, in terms of intraoperative blood loss, dural leakage, post-resection instrumentation, total herniation removal, or myelopathy recovery. An additional somatic bony resection was successful in achieving total herniation removal (p < 0.01), and the extent of bony resection was directly proportional to the extent of hernia removal (p < 0.01). CONCLUSIONS: No statistically significant differences were highlighted between the TP, TF, and CTV regarding the extent of cTDH removal, the postoperative complications, and the neurological improvement. The described somatic bone resection achieved significant total herniation removal and was directly proportional to the preop against postop anteroposterior diameter difference.

Spheno-Orbital Meningiomas: The Rationale behind the Decision-Making Process of Treatment Strategy.

Surgery stands as the primary treatment for spheno-orbital meningiomas, following a symptoms-oriented approach. We discussed the decision-making process behind surgical strategies through a review of medical records from 80 patients who underwent surgical resection at the University of Naples Federico II. Different surgical approaches were employed based on the tumor's location relative to the optic nerve's long axis, categorized into lateral (type I), medial (type II), and diffuse (type III). We examined clinical, neuroradiological, surgical, pathological, and outcome factors. Proptosis emerged as the most frequent symptom (97%), followed by visual impairment (59%) and ocular motility issues (35%). Type I represented 20%, type II 43%, and type III 17%. Growth primarily affected the optic canal (74%), superior orbital fissure (65%), anterior clinoid (60%), and orbital apex (59%). The resection outcomes varied, with Simpson grades I and II achieved in all type I cases, 67.5% of type II, and 18% of type III. Recurrence rates were highest in type II (41.8%) and type III (59%). Improvement was notable in proptosis (68%) and visual function (51%, predominantly type I). Surgery for spheno-orbital meningiomas should be tailored to each patient, considering individual characteristics and tumor features to improve quality of life by addressing primary symptoms like proptosis and visual deficits.

Percutaneous Vertebroplasty as the Treatment of Choice for Multiple Adjacent Lumbar Atypical Haemangiomas: A Case Report.

Atypical vertebral haemangiomas (VHs) are uncommon lesions that cause lumbar pain and motor symptoms. Current management mainly relies on radiotherapy, surgical spine decompression, or percutaneous techniques. We describe a unique case of a patient with two adjacent lumbar VHs and an underlying lumbar fracture which was treated only by percutaneous vertebroplasty (PV). The non-invasive technique relieved the patient's pain and did not affect column stability. PV may be considered an amenable pain-relieving treatment for adjacent atypical VHs in selected patients.

Giant Thoracic Meningocele: A Multidisciplinary Surgical Approach with Innovative Exclusion Technique.

Thoracic meningocele is a rare medical condition that is usually linked to neurofibromatosis type I.1 Respiratory and neurologic symptoms characterize it.2 Although there have been some improvements in surgical techniques, the condition has a high recurrence rate, with most cases recurring within a year of surgery.3 A 56-year-old woman was observed due to respiratory and pyramidal signs. A chest computed tomography scan and magnetic resonance imaging revealed a thoracic meningocele, occupying the lower sectors of the right hemithorax, communicating with the cerebrospinal fluid space at the T10-T11 level. Multidisciplinary surgery was performed. After selectively intubating both bronchi, the patient was placed in prone position and a posterior median thoracic spine approach was performed. After T10-T11 laminectomy, 3 dural longitudinal incisions were performed. The first incision was placed in the middle to deflate the collection, the second was made on the right side to obtain a complete view of the meningocele, and the third was made on the right lateral side to exclude the meningocele. The lateral dura at the last incision was sutured to the dura propria lining the vertebral body of T11 and T10. The paramedian and median incisions were closed, with Tachosil placed above and below the sutures. Subsequently, the patient was placed in a supine position, the right lung was deflated, and a triportal thoracoscopic approach was performed to dissect and remove the lesion.4 The breach was closed using Tachosil (Baxter Healthcare Corp, Deerfield, Illinois, USA) and fibrin glue. An early 1-month computed tomography and magnetic resonance imaging confirmed the surgery was successful.

Single versus multiple reoperations for recurrent intracranial meningiomas.

PURPOSE: To identify the risk factors and management of the multiple recurrences and reoperations for intracranial meningiomas. METHODS: Data of a neurosurgical series of 35 patients reoperated on for recurrent intracranial meningiomas were reviewed. Analyzed factors include patient age and sex, tumor location, extent of resection, WHO grade, Ki67-MIB1 and PR expression at initial diagnosis, time to recurrence; pattern of regrowth, extent of resection, WHO grade and Ki67-MIB1 at first recurrence were also analyzed. All these factors were stratified into two groups based on single (Group A) and multiple reoperations (Group B). RESULTS: Twenty-four patients (69%) belonged to group A and 11 (31%) to group B. The age < 65 years, male sex, incomplete resection at both initial surgery and first reoperation, and multicentric-diffuse pattern of regrowth at first recurrence are risk factors for multiple recurrences and reoperations. In group B, the WHO grade and Ki67-MIB1 increased in further recurrences in 54% and 64%, respectively. The time to recurrence was short in 7 cases (64%), whereas 4 patients (36%) further recurred after many years. Eight patients (73%) are still alive after 7 to 22 years and 2 to 4 reoperations. CONCLUSION: The extent of resection and the multicentric-diffuse pattern of regrowth at first recurrence are the main risk factors for multiple recurrences and reoperations. Repeated reoperations might be considered even in patients with extensive recurrent tumors before the anaplastic transformation occurs. In such cases, even partial tumor resections followed by radiation therapy may allow long survival in good clinical conditions.

Massive bilateral paraclinoidal subdural empyema and parenchymal temporopolar abscess with anatomical infection pathway in a chronic inhaling cocaine-addicted patient: A case report and literature review.

Background: Focal suppurative bacterial infections of the central nervous system (CNS), such as subdural empyemas and brain abscesses, can occur when bacteria enter the CNS through sinus fractures, head injuries, surgical treatment, or hematogenous spreading. Chronic cocaine inhalation abuse has been linked to intracranial focal suppurative bacterial infections, which can affect neural and meningeal structures. Case Description: We present the case of a patient who developed a cocaine-induced midline destructive lesion, a vast bilateral paraclinoidal subdural empyema, and intracerebral right temporopolar abscess due to cocaine inhalation abuse. The infection disseminated from the nasal and paranasal cavities to the intracranial compartment, highlighting a unique anatomical pathway. Conclusion: The treatment involved an endoscopic endonasal approach, followed by a right frontal-temporal approach to obtain tissue samples for bacterial analysis and surgical debridement of the suppurative process. Targeted antibiotic therapy helped restore the patient's neurological status.

Time to Recurrence of Intracranial Meningiomas from a Monoinstitutional Surgical Series.

BACKGROUND: Meningiomas show variable tendency to recur. While risk factors of recurrence have been largely investigated in literature, a paucity of data is available on the time to recurrence. Our purpose was to identify main factors affecting the time to recurrence to assist preoperative treatment decision-making strategy and to define a tailored clinical and neuroradiological follow-up. METHODS: Data of 35 patients with intracranial meningioma recurrences have been retrospectively reviewed. Demographic (patient age at initial diagnosis and sex), radiologic (meningioma location, pattern of regrowth and topography of recurrences at first reoperation), pathologic (WHO grade and Ki67-MIB1 at initial surgery and at first reoperation, progesterone receptor [PR] expression), and surgical (extent of resection at initial surgery according to Simpsons grading system, number of reoperations) factors were analyzed. RESULTS: Time to recurrence ranged from 20 to 120 months. Extent of resection at initial surgery was Simpson grade I in 7 patients (20%), grade II in 10 (28.5%), grade III in 14 (40%), and grade IV in 4 (11.5%). Longer median time to recurrence was observed for skull base localization (P < 0.01), Simpson grades I and II versus grades III (P = 0.01) and IV (P = 0.02), values of Ki67-MIB1 ≤ 4% (P = 0.001), and PR > 60% (P = 0.03); conversely, sex, age, number of reoperations, unchanged/progression of Ki67, and/or World Health Organization grade between first surgery and reoperation did not correlate in statistically significant way with time to recurrence. CONCLUSIONS: The extent of resection and the Ki67-MIB1 represent the most important factors predicting shorter recurrence time of intracranial meningiomas. Patients with incomplete (Simpson grades III and IV) resection and high Ki67-MIB1 values, especially at non-skull base localization and with low PR values, require a closer short-term clinical and radiologic follow-up in the first years after surgery.

Giant "Dumbbell" Thoracic Schwannoma: Radical Excision of Rare Lesion in One Surgical Time by Combined Neurosurgical and Thoracoscopic Approach.

Dumbbell-shaped schwannomas are slow-growing tumors that are typically benign lesions. They account for 6%-14% of spinal neoplasms, with 30% having intradural and extradural components.1 A schwannoma is considered "giant" if it extends beyond the spine by >2.5 cm and involves more than 2 vertebral levels.2 The Eden classification categorizes these tumors into 4 types on the basis of the primary component.3 Surgery is recommended for individuals experiencing prolonged nerve damage and persistent neurogenic pain that cannot be managed.2 There are 3 surgical options for managing thoracic dumbbell schwannomas4: the single-stage posterior-only approach,5 the single-stage anterior-only approach,6 and the single-stage combined posteroanterior neurosurgical and video-assisted thoracoscopic approach. The latter option allows for the most comprehensive lesion control including vascular and nerve structures and optimal hemostasis control. It also avoids spinal instrumentation and provides certainty for complete tumor removal.7Video 1 shows a surgical procedure performed on a 58-year-old woman to remove a thoracic dumbbell neurinoma. The patient consented to the procedure and publication of her image. A simultaneous thoracoscopic and neurosurgical approach was performed. The surgical team successfully removed the schwannoma, and the patient's recovery was smooth, with no neurologic issues or pain. This case highlights the benefits of using a single-stage combined approach for treating Eden II and Eden III giant dumbbell thoracic schwannomas.

The Goutallier Classification System: How Does Paravertebral Adipose Degeneration Change in Patients With Symptomatic Lumbar Spinal Stenosis?

STUDY DESIGN: Retrospective, observational study. OBJECTIVE: To determine the relationship between the Goutallier classification system (GS) and anthropometric, clinical, and radiologic features in 168 patients with lumbar spinal stenosis (LSS). BACKGROUND: There is no agreement on a classification system that is both reliable and easy to use for describing the severity of fatty degeneration in the paravertebral muscles of the lower back in patients with symptomatic LSS. This study aimed to determine the statistical relationship between the GS and anthropometric, clinical, and radiologic factors in 168 patients with LSS. MATERIALS AND METHODS: This study was conducted on 168 patients with LSS scheduled for elective decompressive surgery. A control group of 110 healthy individuals was enrolled. The study assessed paralumbar musculature fatty infiltration using GS on preoperative magnetic resonance imaging. The authors evaluated the statistical association between patient age, body mass index (BMI), preoperative Oswestry disability index (ODI) questionnaire, and cross-sectional areas (CSAs) of the dural sac and lumbar paraspinal muscles. Multivariate analysis was performed to adjust for confounding. RESULTS: This study enrolled 168 patients with symptomatic LSS (95 men, 73 women); mean±SD age: 67.81±9.38 (range: 32.78-92.34) years; BMI: 28.29±3.36 (19.95-38.10) kg/m 2 . The control group was comprised of 110 healthy patients (61 men and 49 women). Age, sex, BMI, and erector spinae (ES)-CSA were not significantly different between the two groups. The authors found a direct relationship between GS grade and age and an inverse relationship between GS grade and dural sac-, multifidus lumbaris (LM)-, ES-, and psoas muscle (PM)-CSAs. Univariate analyses showed the variables statistically related to a higher GS grade included patient age ( P <0.001), ODI ( P =0.136), dural sac-CSA ( P =0.011), LM-CSA ( P < 0.001), ES-CSA ( P <0.001), and PM-CSA ( P <0.001). Multivariate least squares analysis showed the GS grade to be influenced by patient age ( P =0.01), LM-CSA ( P =0.002), ES-CSA ( P =0.002), and PM-CSA ( P =0.003). CONCLUSIONS: GS shows great potential as a tool for evaluating fat infiltration in the paralumbar muscles. This measure does not correlate with the ODI and BMI but is related to all radiologic parameters and patient age. Further prospective studies are required to establish a link between preoperative and postoperative outcomes in the setting of paraspinal fat infiltration.

Antithrombotic therapy and spinal surgery: a retrospective cohort study of 289 consecutive elderly patients with degenerative lumbar stenosis.

OBJECTIVE: Lumbar spinal stenosis (LSS) is a disabling degenerative process of the spine, mainly affecting older patients. LSS manifests with low-back and leg pain and neurogenic claudication. Disability and impairment in activities of daily living are consequences of the progressive narrowing of the lumbar spinal canal. Surgical decompression has been shown to be superior to conservative management. Nonetheless, intraoperative and postoperative blood loss in elderly patients taking antiplatelet or anticoagulant drugs owing to cardiovascular comorbidities may be a special issue. This study describes and compares early outcomes after surgical procedures in different groups of patients receiving antithrombotic drugs. METHODS: The authors' study retrospectively recruited 289 consecutive patients aged ≥ 65 years who received lumbar decompression for spinal stenosis between January 2021 and May 2022. First, 183 patients taking antiplatelet therapy were divided into two groups according to the rationale for use: primary versus secondary prophylaxis of cardiovascular events (group 1 vs group 2). Primary prevention was stopped preoperatively, or secondary prevention was not discontinued during the perioperative period. Secondly, 106 patients who were not taking antiplatelet mediation were divided into two groups, depending on whether preoperative low-molecular-weight heparin had not been administered or had been (group A vs group B). Intraoperative blood loss, surgical time, and postoperative hospitalization were analyzed. RESULTS: No significant statistical differences were observed between groups 1 and 2 in terms of intraoperative blood loss and time of surgery, or between groups A and B in terms of all analyzed variables. No early or delayed complications were observed, perioperatively or during the postoperative 3-month follow-up period. CONCLUSIONS: The results of this study suggest that the use of anticoagulant and antiplatelet therapies in elective decompressive surgery could be devoid of early complications and could be safely continued perioperatively.

Multiple univariate analysis of radiologic and clinical features on 168 patients with lumbar spinal stenosis: what is the role of the erector spinae in the development of a patient's disability?

BACKGROUND: The weakening of paraspinal muscles in the paravertebral area may play a role in developing central lumbar spinal stenosis, resulting in lower back discomfort. OBJECTIVE: The study thoroughly examined the correlation between the Oswestry Disability Index, Dural Sac cross-sectional area, Schizas grading Scale, Body Mass Index, and the cross-sectional areas of Erector Spinae, Multifidus, and Psoas muscles. The findings were also compared between patients with central Lumbar Spinal Stenosis and healthy individuals. STUDY DESIGN: Retrospective monocentric observational study. METHODS: The study recruited 168 consecutive patients aged 60 or older diagnosed with central Lumbar Spinal Stenosis between January 2020 and July 2022. The patients' condition was evaluated by administering a preoperative Oswestry Disability Index questionnaire, measuring their Body Mass Index, and performing preoperative Magnetic Resonance Imaging. The analyzed parameters were the cross-sectional area of paraspinal muscles at the L4-L5 level, dural sac cross-sectional area, and Schizas grading Scale at the most stenotic level, using multiple linear univariate analyses. Two groups of healthy individuals were recruited: Group A (under 60 years old) and Group B (over 60 years old). The same data extrapolated from these groups were compared with those of patients with central lumbar stenosis using a two-tailed Mann-Whitney test. RESULTS: As the Erector Spinae degenerates, the Oswestry Disability Index tends to increase. Similarly, an increase in Body Mass Index is often accompanied by a decrease in the cross-sectional area of the Erector Spinae. Low dural sac cross-sectional area is statistically linked to a reduced Multifidus cross-sectional area. Interestingly, the Schizas grading scale does not appear to correlate with changes in the cross-sectional area of the paraspinal muscles. Additionally, there is no significant difference in the cross-sectional area of the Psoas muscle between individuals with central lumbar spinal stenosis and healthy individuals. CONCLUSIONS: Our study found that degeneration of the Erector Spinae plays a crucial role in the progression of perceived disability in Lumbar Spinal Stenosis. Prospective studies should investigate the long-term evolution of paraspinal muscles in decompressed patients.

Atypical Teratoid/Rhabdoid Tumor of the Nervous System in Adults: Location-Related Features and Outcome.

BACKGROUND: Atypical teratoid/rhabdoid tumor (AT/RT) of the nervous system is a rare and highly malignant neoplasm, mainly affecting children, first recognized as a pathologic entity in 1996 and added to the World Health Organization Classification of the Tumors of the Central Nervous System in 2000. AT/RT is even rarer among adults and is associated with a worse prognosis. The aim of the present study was to analyze the different tumor features according to the location in adults. METHODS: A comprehensive and detailed literature review of AT/RTs in adults was made. The demographic, management, and outcome data associated with tumor location were analyzed and compared; histopathologic and molecular features were also discussed. Furthermore, we added our personal case with brain hemispheric localization and reported a progression-free survival of 103 months after gross total resection and adjuvant radiotherapy showing a peculiar histopathologic pattern. RESULTS: Female sex is mainly affected by AT/RT on median localizations, both intracranial and spinal, and by all sellar region cases. Gross total resection is mainly achieved among lateral compared with median localizations. Combined radiotherapy and chemotherapy is the most adopted adjuvant treatment in all tumor localizations and is related to better outcome. Postoperative death is reported only among sellar region localizations, whereas brain hemispheric cases show the best overall survival. CONCLUSIONS: AT/RTs show different and peculiar features according to their location, which significantly affects the outcome; precise knowledge of them helps the neurosurgeon in planning the best strategy for treatment.

Cervical epidural abscess complicated by a pharyngoesophageal perforation after anterior cervical spine surgery for subaxial spondylodiscitis.

Background: The anterior approach to the cervical spine is safe and effective, but not without risks. The pharyngoesophageal perforation (PEP) is a rare but potentially life-threatening complication of this surgical route. A prompt diagnosis and adequate treatment are crucial for the prognosis; nevertheless, there is no unique consent about the best management. Case Description: A 47-year-old woman was referred to our neurosurgical unit for clinical and neuroradiological signs of multilevel cervical spine spondylodiscitis, which was conservatively treated with long-term antibiotic therapy and cervical immobilization after computed tomography-guided biopsy. Nine months later, when the infection was resolved, the patient underwent C3-C6 spinal fusion with anterior plate and screws through anterior approach to the cervical spine for degenerative vertebral changes causing severe myelopathy, and C5- C6 retrolisthesis with instability. Five days after surgical procedure, the patient developed a pharyngoesophageal-cutaneous fistula, detected through wound drainage, and confirmed by swallowing contrast study, without systemic signs of infection. The PEP was conservatively treated, with antibiotic therapy and parenteral nutrition, and it was monitored through seriate swallowing contrast and magnetic resonance studies up to the complete resolution. Conclusion: The PEP is a potentially fatal complication of the anterior cervical spine surgery. We suggest an accurate intraoperative control of the pharyngoesophageal's tract integrity at the end of the surgical procedure and a longtime follow-up, because the risk of occurrence is up to several years after surgery.

A challenging recurrent thoracic disc herniation.

Background: Thoracic disc herniations are rare and occur at the rate of 1/1,000,000/year. Surgical approach must be individually tailored to the size, location, and consistency of the herniated disc. Notably, here, we report the unusual recurrence of a thoracic herniated disc. Case Description: In 2014, a 53-year-old female presented with thoracic back pain, and paraparesis, attributed to an magnetic resonance imaging/computed tomography (CT)-documented left paramedian T8-T9 calcific disc herniation. She underwent a left hemilaminectomy/costotrasversectomy following which she experienced complete regression of her symptoms. Notably, the postoperative radiological studies at that time demonstrated some residual although asymptomatic calcific disc herniation. Eight years later, she again presented, but now with the chief complaint of difficulty breathing. The new CT scan showed a new calcified herniated disc fragment superimposed on the previously documented residual disc. Through a posterolateral transfacet approach, she underwent resection of the disc complex. An intraoperative CT scan confirmed complete removal of the recurrent calcified disc herniation. Following the second surgery, the patient fully recovered and remains asymptomatic. Conclusion: A 53-year-old female first presented with a left-sided T8/T9 thoracic calcified disc herniation that was initially partially resected). When another larger fragment appeared 8 years later, superimposed on the previously documented residual disc, it was successfully removed through a posterolateral transfacet approach completed with CT guidance and neuronavigation.

Brain Gliomas and Ollier Disease: Molecular Findings as Predictive Risk Factors?

Background: Ollier disease (OD) is a rare nonhereditary type of dyschondroplasia characterized by multiple enchondromas, with typical onset in the first decade of life. Surgery is the only curative treatment for primary disease and its complications. Patients with OD are at risk of malignant transformation of enchondromas and of occurrence of other neoplasms. Methods: A wide literature review disclosed thirty cases of glioma associated with OD, most of them belonging to the pre-molecular era. Our own case was also included. Demographic, clinical, pathologic, molecular, management, and outcome data were analyzed and compared to those of sporadic gliomas. Results: Gliomas associated with OD more frequently occur at younger age, present higher rates of multicentric lesions (49%), brainstem localizations (29%), and significantly lower rates of glioblastomas (7%) histotype. The IDH1 R132H mutation was detected in 80% of gliomas of OD patients and simultaneously in enchondromas and gliomas in 100% of cases. Conclusions: The molecular data suggest a higher risk of occurrence of glioma in patients with enchondromas harboring the IDH1 R132H mutation than those with the IDH1 R132C mutation. Thus, we suggest considering the IDH1 R132H mutation in enchondromas of patients with OD as a predictive risk factor of occurrence of glioma.

Spinal cervical extradural hemangioblastoma.

Spinal cervical extradural and intra-extradural hemangioblastomas are exceptional, with only nine reported cases. This study reviews the diagnostic and surgical problems of this rare entity. Two female patients, aged 80 years and 25 years, respectively, one with Von Hippel-Lindau disease (VHLD), experienced brachial pain and weakness. On magnetic resonance imaging, a dumbbell intra-extraspinal hemangioblastoma was evidenced. The surgical resection through posterior laminectomy resulted in clinical remission of brachial pain and weakness. The magnetic resonance aspect of a dumbbell lesion suggests a neurogenic tumor; the correct preoperative diagnosis is possible in individuals with VHLD. The surgical problems include high tumor vascularity, vertebral artery control, and nerve root preservation. However, the surgical excision results in clinical remission.

Gliosarcoma with direct involvement of the oculomotor nerve: Case report and literature review.

Gliosarcoma is a rare malignant brain tumor, characterized by a biphasic tissue pattern with alternating areas displaying glial and mesenchymal differentiation. We first report a case of temporo-mesial gliosarcoma, extended to the crural and ambient cisterns, with direct involvement of the ipsilateral third cranial nerve and encasement of anterior choroidal, posterior communicant and posterior cerebral arteries, presenting without symptoms of peripheral neuropathy. A 61-year-old woman with 1-month history of intense bilateral frontal-temporal headache resistant to pharmacological therapy and paresis of the left lower midface underwent surgical resection, through pterional trans-sylvian approach, of a right temporo-mesial gliosarcoma which directly involved the ipsilateral oculomotor nerve. Reported cases of gliomas with direct involvement of a cranial nerve, from the third to the twelfth, are very rare, whit no cases of gliosarcoma described. Because of its rarity, sometimes this entity is not considered as diagnostic hypothesis and is misdiagnosed, both during preoperative diagnostic evaluation and during the surgery. Gliosarcoma is a strong challenge for neurosurgeons and neurooncologists because of low incidence, poor prognosis and limited reported cases on literature. This case shows unique features for localization, pattern of growth and clinical presentation.