A ventral brainstem neurenteric cyst - A case report and review of the pre-brainstem location.

Background: Neurenteric cysts are uncommon, benign endoderm-derived lesions that result from aberrant embryologic development of the notochord. They are typically located in the intradural extramedullary spinal cord and rarely located intracranially. Contrary to spinal-located cysts, intracranial cysts are rarer in the pediatric population. Clinically, they may present with symptoms of mass effect, or they can be incidentally discovered. Case Description: A 10-year-old healthy female child presented with recurrent headaches. The physical and neurological examination was unremarkable. Brain magnetic resonance imaging (MRI) showed a well-demarcated lesion anterior to the pontomedullary junction with striking T1 and T2/T2 fluid-attenuated inversion recovery high-signal intensity and a small rounded nodule within of low signal on T1, T2, and T2*. On initial conservative strategy with serial brain MRI, there was a progressive enlargement of the lesion with significant mass effect on the brainstem. The patient underwent a right retrosigmoid craniotomy, and the cyst wall was fenestrated and drained. Part of the cyst wall and the solid nodule were adherent to the brainstem and basilar artery and were not removed. The histologic findings were consistent with the diagnosis of a benign endodermal cyst. The postoperative period was uneventful. Conclusion: We report a successful surgical treatment of this rare congenital cyst located in the ventral brainstem. We present pre-and post-operative imaging findings, intraoperative microscopic images of the procedure, and a brief review of relevant clinical literature on the topic.

Giant sacral aneurysmal bone cyst treated with endovascular embolization.

Background: Spine aneurysmal bone cysts (SABC) are osteolytic tumor-like lesions with cystic, blood-filled cavities that represent 15% of all primary spinal bone tumors. The sacrum is a rare site for SABC, and sacral lesions typically carry higher morbidity rates. Here, a 19-year-old female with a large primary multisegmental sacral SABC was successfully managed with 2-staged endovascular embolization. Case Description: A 19-year-old female presented with progressive worsening of axial lumbosacral pain, and a left L5/S1 radiculopathy. The lumbosacral computed tomography and magnetic resonance studies showed a large (10 cm [AP] × 11 cm [Tr] × 12 cm [CC]) heterogeneous, osteolytic lesion containing multiple fluid-fluid levels. The biopsy confirmed the diagnosis of a primary SABC. She was treated with a 2-staged endovascular embolization that resolved her pain. This was followed by radiographic confirmation of occlusion of the SABC. Conclusion: A 19-year-old female presented with an atypical SABC that was successfully managed with 2-staged endovascular embolization.

HIPTCN: Prospective Observational Study of Hypocoagulated Head Trauma Patients with Normal Admission Computed Tomography Scan.

INTRODUCTION: Our national protocol for traumatic brain injury dictates that hypocoagulated patients with mild trauma and initial tomography scan with no intracranial traumatic changes must be hospitalized for 24 hours and do a post-surveillance tomography scan. The main goal of this study was to evaluate the clinical relevance of these measures. MATERIAL AND METHODS: A prospective observational study was undertaken in four hospitals. Adult hypocoagulated traumatic brain injury patients with a normal tomography scan were included. The main outcomes evaluated were rate of delayed intracranial hemorrhage, rate of admission in a neurosurgical department, rate of complications related with surveillance and rate of prolonged hospitalization due to complications. An analysis combining data from a previously published report was also done. RESULTS: A total of 178 patients were included. Four patients (2.3%) had a delayed hemorrhage and three (1.7%) were hospitalized in a neurosurgery ward. No cases of symptomatic hemorrhage were identified. No surgery was needed, and all patients had their anticoagulation stopped. Complications during surveillance were reported in seven patients (3.9%), of which two required prolonged hospitalization. DISCUSSION: The rate of complications related with surveillance was higher than the rate of delayed hemorrhages. The initial period of in-hospital surveillance did not convey any advantage since the management of patients was never dictated by neurological changes. Post-surveillance tomography played a role in deciding about anticoagulation suspension and prolongation of hospitalization. CONCLUSION: Delayed hemorrhage is a rare event and the need for surgery even rarer. The need for in-hospital surveillance should be reassessed.

Introdução: O nosso protocolo nacional para traumatismos cranioencefálicos recomenda que doentes hipocoagulados com trauma craniano ligeiro e tomografia inicial sem alterações traumáticas intracranianas sejam hospitalizados 24 horas e façam uma tomografia computorizada pós-vigilância. O principal objetivo deste estudo foi avaliar a relevância clínica dessas medidas. Material e Métodos: Foi realizado em quatro hospitais um estudo prospetivo e observacional. Foram incluídos adultos hipocoagulados com trauma craniano e tomografia normal. Os principais outcomes avaliados foram: taxa de hemorragia intracraniana tardia, taxa de internamento numa enfermaria de neurocirurgia, taxa de complicações relacionadas com a vigilância e taxa de hospitalização prolongada por complicações. Resultados: Foram incluídos um total de 178 doentes. Quatro doentes (2,3%) apresentaram hemorragia tardia e três (1,7%) foram mantidos hospitalizados numa enfermaria de Neurocirurgia. Não foram documentados casos de hemorragia tardia sintomática. Nenhuma cirurgia foi necessária e em todos estes doentes a anticoagulação foi interrompida. Durante a vigilância, foram relatadas complicações em sete doentes (3,9%), dos quais dois exigiram hospitalização prolongada. Discussão: A taxa de complicações relacionadas com a vigilância foi maior do que a taxa de hemorragia tardia. O período inicial de vigilância intra-hospitalar não trouxe qualquer vantagem, já que o manejo dos doentes nunca foi ditado por alterações neurológicas. A tomografia pós-vigilância desempenhou um papel importante na decisão sobre a suspensão da anticoagulação e o prolongamento da hospitalização. Conclusão: A hemorragia tardia é um evento raro e a necessidade de cirurgia ainda mais. Deve ser reavaliada a necessidade de vigilância intra-hospitalar.