Intrasellar ependymoma: clinical, imaging, pathological, and surgical findings.

Ependymomas arising in the intrasellar compartment are extremely rare and most often are not included in the differential diagnosis of an intrasellar tumor mass. We review the literature to further advance awareness regarding unusual presentations of this type of tumor and present an illustrative case of an intrasellar cystic ependymoma that developed in an uncommon location. In our illustrative case, the patient had a 2 year history of hypopituitarism, but no headaches or visual disturbance. Preoperatively, the lesion was thought to be a pituitary macroadenoma.

Intrasellar pilocytic astrocytomas: clinical, imaging, pathological, and surgical findings.

A pilocytic astrocytoma is not usually considered in the differential diagnosis of an intrasellar tumor. An awareness of this tumor as primarily an intrasellar entity is important to avoid confusion during its diagnosis. We retrospectively examined the records of 631 patients treated at our institution between 2006 and 2010 who underwent transsphenoidal resection of pituitary tumors and identified those diagnosed with pilocytic astrocytoma. We excluded patients who harbored a pituicytoma. We also searched the literature for patients with a histologically confirmed diagnosis of intrasellar pilocytic astrocytoma. Only two patients in our series harbored intrasellar tumors and had a histologic diagnosis of pilocytic astrocytoma. We also found two other cases in the literature that met our criteria. Pilocytic astrocytoma should be considered in the differential diagnosis of an intrasellar lesion. An understanding of this tumor's radiological features can avoid diagnostic confusion.

Endovascular retrograde suction decompression as an adjunct to surgical treatment of ophthalmic aneurysms: analysis of risks and clinical outcomes.

OBJECTIVE: Endovascular retrograde suction decompression with balloon occlusion of the internal carotid artery is a useful adjunct in the surgical treatment of ophthalmic aneurysms. This technique helps establish proximal control, facilitates intraoperative angiography, and may aid dissection by evacuating blood and softening the aneurysm. Although the technical aspects of this procedure have been described, the published data on its safety are scant. This study analyzed 2 groups of patients who underwent craniotomies for treatment of ophthalmic aneurysms, comparing a group who received suction decompression with a group who did not. METHODS: A retrospective analysis of prospectively collected data on 118 craniotomies for ophthalmic aneurysms performed from 1990 to 2005 is presented. A group of 63 patients treated with endovascular suction decompression during surgery is compared with 55 patients who did not undergo this technique. RESULTS: In our overall analysis of ophthalmic aneurysms, the clinical outcome was statistically related to aneurysm size (P = 0.046). The endovascular suction decompression group in this study had overall larger aneurysms (P < 0.0001) compared with the other group. There was no statistical difference between the 2 groups in rates of complications, stroke, new visual deficit, or death. The clinical outcomes were statistically similar at discharge and at 1 year. CONCLUSION: Endovascular balloon occlusion and suction decompression did not increase the complication rate in a large cohort of craniotomy patients with ophthalmic aneurysms. This technique may be used to augment surgical capabilities without significantly increasing the operative risk.

Results, outcomes, and follow-up of remnants in the treatment of ophthalmic aneurysms: a 16-year experience of a combined neurosurgical and endovascular team.

OBJECTIVE: Ophthalmic aneurysms present unique challenges to a vascular team. This study reviews the 16-year experience of a multidisciplinary neurovascular service in the treatment, complications, outcomes, and follow-up of patients with ophthalmic aneurysms from 1990 to 2005. METHODS: A retrospective analysis of prospectively collected data of 134 patients with 157 ophthalmic aneurysms is presented. Subgroup analysis is performed based on treatment and clinical presentation of the patients. RESULTS: Clinical outcomes are reported using the Glasgow Outcome Scale. A "good" outcome is defined as a Glasgow Outcome Scale score of 4 or 5, and a "poor" outcome is defined as a Glasgow Outcome Scale score of 1 to 3. Outcome was related to patient age (P = 0.0002) and aneurysm size (P = 0.046). Outcomes for patients with ruptured aneurysms were related to hypertension (P < 0.0001) and clinical admission grade (P = 0.001). In patients with unruptured aneurysms, a good clinical outcome was noted in 103 (92.7%) of 111 patients at discharge and 83 (94.3%) of 88 patients at the time of the 1-year follow-up evaluation. Complete clipping was attained in 89 (79.5%) of 112 patients with angiographic follow-up. Patients with aneurysm remnants from both coiling and clipping had a low risk of regrowth, and there were no rehemorrhages. One of 25 patients with angiographic follow-up (average, 4.3 +/- 4.1 years) after "complete" clipping showed recurrence of the aneurysm. CONCLUSION: Despite the difficulties presented by ophthalmic aneurysms, these lesions can be successfully managed by a multidisciplinary team. Imaging follow-up of patients is important, as there is a risk of aneurysm regrowth after either coiling or clipping.

Idiopathic hypertrophic pachymeningitis resulting in delayed panhypopituitarism.

OBJECTIVE: To describe an adult man with idiopathic hypertrophic pachymeningitis (IHPM) that progressed to involve the pituitary gland and caused hypopituitarism 6 years after the onset of the first symptom. METHODS: We describe the slow 6-year progression of IHPM in a man being treated with steroids, radiation, and antineoplastic medications and present clinical, pathologic, and imaging data. The pertinent literature is also reviewed. RESULTS: A 35-year-old man who presented with headaches, pain, and sensory loss on the right side of his face had thickened, inflamed dura without granulomas. Initially, the right middle fossa, the lateral wall of the right cavernous sinus, and the tentorium were involved. Results from a dural biopsy specimen were consistent with IHPM. His symptoms were only partially controlled with continuous high-dose steroids, cyclophosphamide, azathioprine, and radiation therapy. IHPM was diagnosed based on findings from an open brain biopsy. Other pathologic causes of inflammatory dural thickening were excluded. Six years after the onset of the first clinical manifestation of IHPM, the patient developed panhypopituitarism. Magnetic resonance imaging showed that the inflammatory process had invaded the pituitary gland. IHPM was confirmed by findings from transsphenoidal biopsy. CONCLUSION: IHPM is a rare disorder characterized by an unexplained inflammatory thickening of the dura at the skull base. The usual clinical symptoms are intractable headache and cranial nerve palsies. Physicians must be aware that IHPM can be slowly progressive despite attempted treatment, and that the disease process can invade the sella with dysfunction of both the anterior and the posterior pituitary gland.

The natural history of untreated skull base meningiomas.

BACKGROUND: This study was undertaken to determine the natural history of untreated skull base meningiomas. Although there are reports on the natural history of meningiomas, most series contain only a few cases of meningiomas involving the skull base. Natural history information is important when recommending treatment and evaluating results. METHODS: The case records and imaging studies of 40 patients with skull base meningiomas from a single practice were reviewed. These patients either did not receive treatment or there was a long delay from the onset of symptoms to the initiation of treatment. RESULTS: Skull base meningiomas may be very indolent tumors. Patients with these tumors have lived long, comfortable, and relatively productive lives without treatment or with delayed treatment. Impairment may be much less than imaging studies would suggest. CONCLUSION: The authors are not advocating that skull base meningiomas not receive treatment. However, their unique experience with this group of patients provides convincing evidence that the indolent behavior of some skull base meningiomas must be considered when recommending various surgical and radiation procedures and interpreting their results in relationship to the functional outcome of the patient.