Intravascular papillary endothelial hyperplasia arising within a posteroinferior cerebellar artery aneurysm: case report and review of the literature.

OBJECTIVE AND IMPORTANCE: Intravascular papillary endothelial hyperplasia (IPEH) is an atypical proliferation of endothelium that results in abnormal organization for thrombus formation. Intracranial IPEH is a rare entity and has not been reported to arise from within an intracranial aneurysm. Furthermore, the elapsed time during which acquired intracranial IPEH develops has not been previously documented. CLINICAL PRESENTATION: In this case report, a patient with facial and neck pain was noted to have an enhancing mass lesion lateral to the medulla in magnetic resonance imaging scans. Angiography revealed a vascular mass adjacent to the posteroinferior cerebellar artery. Normal magnetic resonance imaging and magnetic resonance angiographic findings had been obtained for the patient 29 months earlier. INTERVENTION: During surgery, a thrombosed, 2.5-cm, posteroinferior cerebellar artery aneurysm was resected and noted to contain florid IPEH. There has been no evidence of recurrence in 1 year of follow-up monitoring. A literature search revealed 13 cases of intracranial IPEH, in which recurrence was observed for incompletely resected lesions. CONCLUSION: IPEH can develop in a relatively short time, can present as a hypervascular mass lesion or within an intracranial aneurysm, and should be completely resected to prevent recurrence.

Functional outcomes of the retromaxillary-infratemporal fossa dissection for advanced head and neck/skull base lesions.

The retromaxillary-infratemporal fossa (RM-ITF) dissection, using a preauricular incision, was initially popularized for the treatment of temporomandibular joint disorders, facial fractures, and orbital tumors. This approach has been expanded for the treatment of advanced head and neck and skull base tumors extending into the infratemporal fossa. We studied prospectively eight consecutive patients requiring a RM-ITF dissection. Pre- and postoperative functional outcomes measured were mastication, speech, swallowing, cranial nerve function, pain, and cosmesis. A significant reduction in pain was noted postoperatively in all patients studied. Limited changes were identified in mastication, speech, swallowing, vision, hearing, or cosmesis postoperatively. The RM-ITF dissection should be considered when resecting advanced head and neck/skull base lesions that extend into this region. We have found minimal morbidity associated with this dissection. This procedure may have a useful place in palliation of patients with incurable pain caused by tumor invasion into the infratemporal fossa.

Magnetic resonance imaging of intercranial plasmocytic granuloma.

The objective of this study is to determine characteristic magnetic resonance imaging (MRI) features of intracranial plasmocytic granulomas. Pathological confirmation of three patients with intracranial pathologically confirmed plasmocytic granuloma are presented. Clinical records as well pre- and postgadolinium-enhanced images from each patient are reviewed. The location of the abnormalities is compared with previous reported cases of plasmocytic granulomas, to determine if there is a characteristic finding in this disense. The predominance of this abnormality in the pediatric and young adult patient was striking. On T(1)-weighted MRI, plasmocytic granulomas appear as hypointense lesions, with isointense appearance on T(2) images, and significant, variable patterns of enhancement after the infusion of gadolinium. Typically, the lesion is infiltrating, and causes little mass effect. A dural based lesion, as well as a sellar region abnormality and an infiltrating cortical lesion with little mass effect in the pediatric or young adult age group may lead the observer to suspect the diagnosis of plasmocytic granuloma.

Surgical management of complex middle cerebral artery aneurysms.

Complex middle cerebral artery (MCA) aneurysms are defined in this review as aneurysms larger than 20 mm, arising from the MCA bifurcation, and requiring unusual surgical approaches for their obliteration. The direct surgical approaches to complex MCA aneurysms can be divided into five techniques: 1) direct clipping, 2) trapping, 3) trapping and extracranial-intracranial anastomosis, 4) excision and end-to-end anastomosis, and 5) external wrapping. The pertinent surgical anatomy, preoperative preparation, intraoperative procedures, operative approaches, and potential complications will be reviewed.

Three-dimensional magnetic resonance angiography in the planning of aneurysm surgery.

Standard planning for intracranial aneurysm surgery relies on the surgeon's intellectual reconstruction of the three-dimensional (3D) surgical field on the basis of a two-dimensional (2D) imaging modality, biplanar cerebral angiography. This method is relatively imprecise, and it relies on previous experience for optimal results. We describe a stereotactic magnetic resonance angiographic (MRA)-guided method based on computer segmentation techniques for the planning of aneurysm surgery that has the potential of bringing a 3D perspective to the lesion. The method has been evaluated retrospectively on 20 surgical patients in whom the aneurysm orientation and relationship to parent vessels were shown to match presurgical 3D stereotactic display. When it is adapted to frameless interactive surgical navigation, this method may become a useful adjunct in the surgical obliteration of these life-threatening lesions.

Lipofibromatous hamartoma of the median nerve: case report with magnetic resonance imaging correlation.

The authors report a case of lipofibromatous hamartoma of the median nerve in a patient who presented with symptoms of carpal tunnel syndrome. The diagnosis was made by magnetic resonance imaging and confirmed by intraoperative findings and histological diagnosis; distinctive magnetic resonance imaging features of this entity are described. In this patient, surgery was limited to biopsy to confirm the diagnosis and external neural decompression, which helped to stop the progression of the symptoms. In their review of the literature, the authors found four types of lipomatous masses in the extremities affecting the function of peripheral nerves, commonly the median nerve. Treatment and the extent of surgery differ for each patient, based on the anatomical findings and extent of neurological deficit. The etiology, pathogenesis, differential diagnosis, and surgical management of lipofibromatous hamartoma are described.

Simultaneous presentation of facial nerve neuroma and otosclerosis.

Otosclerosis often occurs as a unilateral mixed or conductive hearing loss. In the absence of retrocochlear findings, otologists usually do not pursue further diagnostic testing. A patient who presented to the Warren Otologic Group with a unilateral mixed hearing loss is discussed. He was followed for 1 year with the intent of scheduling a stapedectomy. Two weeks prior to the surgical date, the patient developed a sudden hearing loss and was admitted to the hospital for treatment. Magnetic resonance imaging demonstrated a tiny, enhancing mass in the lateral internal auditory canal, measuring 7 mm in diameter. At surgery, the tumor was found to originate at the union of the nervus intermedius and the facial nerve. The simultaneous occurrence of facial nerve neuroma and otosclerosis is discussed, with emphasis on a thorough evaluation of all unilateral mixed hearing losses, including those attributable to otosclerosis.

Extraneural metastases in gliosarcoma: a case report and review of the literature.

This report details the case of an 11-year-old girl with gliosarcoma and her rapid demise after a brief asymptomatic postcraniotomy period. The discussion that follows is a collective review of the several aspects illustrated by the case history. Special attention is directed toward the pathological features of this histological variant of glioblastoma multiforme. The topic of extraneural metastasis is reviewed with regard to frequency, mechanisms, sites, and prognosis.

Spinal subdural hematoma: case report and review of the literature.

A case of lumbar spinal subdural hematoma in a patient who had been on anticoagulant therapy is reported. Thus far 19 cases of spinal subdural hematoma have been reported in the literature, the majority in patients with a bleeding diathesis and after a lumbar puncture. Our case is the third reported to be in association with anticoagulant therapy. The hematoma was lumbosacral, in contrast to the usual location in the dorsal-lumbar area. A possible mechanism for the production of spinal subdural hematoma after a lumbar puncture is discussed. An early decompressive laminectomy and evacuation of the hematoma is the recommended treatment to obtain the best possible recovery of neurological function. (Neurosurgery, 5: 614--616, 1979).