Cedric Shorter

An update on unilateral sporadic small vestibular schwannoma

Advances in neuroimaging have increased the detection rate of small vestibular schwannomas (VSs, maximum diameter < 25 mm). Current management modalities include observation with serial imaging, stereotactic radiosurgery, and microsurgical resection. Selecting one approach over another invites speculation, and no standard management consensus has been established. Moreover, there is a distinct clinical heterogeneity among patients harboring small VSs, making standardization of management difficult. The aim of this article is to guide treating physicians toward the most plausible therapeutic option based on etiopathogenesis and the highest level of existing evidence specific to the different cohorts of hypothetical case scenarios. Hypothetical cases were created to represent 5 commonly encountered scenarios involving patients with sporadic unilateral small VSs, and the literature was reviewed with a focus on small VS. The authors extrapolated from the data to the hypothetical case scenarios, and based on the level of evidence, they discuss the most suitable patient-specific treatment strategies. They conclude that observation and imaging, stereotactic radiosurgery, and microsurgery are all important components of the management strategy. Each has unique advantages and disadvantages best suited to certain clinical scenarios. The treatment of small VS should always be tailored to the clinical, personal, and social requirements of an individual patient, and a rigid treatment protocol is not practical.

Multicentric glioblastoma multiforme determined by positron emission tomography: a case report

UNLABELLED The actual incidence of true multicentric glioblastoma multiforme (GBM) varies between 2.4 and 4.9% of all GBMs. True multicentric tumors are described as widespread lesions in different lobes or hemispheres, which cannot be explained by spreading along the cerebrospinal fluid or blood pathways. We present here a case of multicentric GBM identified with positron emission tomography. CASE REPORT A 73-year-old woman with sudden onset headaches, balance problems, and one episode of syncope was diagnosed as having an irregular, contrast-enhancing, space-occupying lesion in the left-temporal-parietal region on magnetic resonance imaging (MRI). The tissue diagnosis was confirmed as GBM, and she received stereotactic radiosurgery using the Leksell Gamma Knife (Elekta Instruments, Atlanta, GA). A 3-month, follow-up, MRI scan showed a remarkable decrease in the size of the contrast-enhancing area that was targeted during radiosurgery. A suspicious area of enhancement was detected on the right side, although no surrounding edema was evident. Fluorodeoxyglucose (FDG)-PET scanning revealed a large irregular neoplasm extending from the inferior left-temporal lobe into the deep parietal lobe with extremely intense FDG uptake, suggesting a very aggressive tumor. A smaller lesion was also discovered in the deep right-frontal lobe, representing a second neoplastic focus. The patient refused any further treatment. CONCLUSION PET scans, in conjunction with MRI scans, allow for the best possible and most comprehensive diagnosis and treatment plans.

Do cystic vestibular schwannomas have worse surgical outcomes? Systematic analysis of the literature

OBJECT The goal of this study was to perform a systematic quantitative comparison of the surgical outcomes between cystic vestibular schwannomas (CVSs) and solid vestibular schwannomas (SVSs). METHODS A review of English-language literature published between 1990 and 2011 was performed using various search engines including PubMed, Google Scholar, and the Cochrane database. Only studies that reported surgical results of CVSs in comparison with SVSs were included in the analysis. The primary end point of this study was surgical outcomes, defined by the following: 1) facial nerve outcomes at latest follow-up; 2) mortality rates; or 3) non-facial nerve complication index. Secondary end points included extent of resection and brainstem adherence. RESULTS Nine studies comprising 428 CVSs and 1287 SVSs were included in the study. The mean age of patients undergoing surgery was 48.3 ± 6.75 and 47.1 ± 9 years for CVSs and SVSs, respectively (p = 0.8). The mean tumor diameter for CVSs was 3.9 ± 0.84 cm and that for SVSs was 3.7 ± 1.2 cm (p = 0.7). There was no significant difference in the extent of resection among CVSs and SVSs (81.2% vs 80.7%, p = 0.87) Facial nerve outcomes were significantly better in the cohort of patients with SVSs than in those with CVSs (52.1% vs 39%, p = 0.0001). The perioperative mortality rates for CVSs and SVSs were not significantly different (3% and 3.8%, respectively; p = 0.6). No significant difference was noted between the cumulative non-facial nerve complication rate (including mortality) among patients with CVSs and SVSs (24.5% and 25.6%, respectively; p = 0.75) CONCLUSIONS Facial nerve outcomes are worse in patients undergoing resection for CVSs than in patients undergoing resection for SVSs. There were no significant differences in the extent of resection or postoperative morbidity and mortality rates between the cohorts of patients with vestibular schwannomas.

Primary calvarial angiosarcoma: A case report and review of the literature.

Background: Angiosarcomas are high-grade endothelial tumors remarkable for their rarity and malignant behavior. Primary calvarial angiosarcoma is an extremely rare entity and its behavior usually sets it apart from other angiosarcoma types. We highlight the successful management of cranial angiosarcoma using a multidisciplinary approach. Case Description: We present a 16-year-old male who was first noted to have a right-sided parietal cranial mass that was biopsied in 2008. Pathology was initially thought to be Kaposiform hemangioendothelioma. The patient subsequently underwent chemotherapy with vincristine. The patient did well until early 2010, when he suffered a right-sided intraparenchymal intratumoral hemorrhage. At this time, the original pathologic diagnosis was revisited and the diagnosis was upgraded to an angiosarcoma. The patient underwent a second round of chemotherapy using vincristine, cyclophosphamide, and actinomycin. The tumor continued to progress despite this treatment and he developed extensive skull deformity. At this point more definitive surgical intervention was reconsidered. Preoperative embolization of the mass was performed followed by aggressive surgical resection of the bony disease. The patient tolerated the procedure well and was discharged 6 days postoperatively without any new deficits. The patient is currently in the process of completing radiation therapy to entire tumor bed. He has clinically done well with no neurologic deterioration and has demonstrated long-term survival (>3 years). Conclusion: With the combined efforts of pediatric oncology, radiation oncology, interventional neuroradiology, and neurosurgery, a survival of greater than 3 years is possible with this aggressive pathology.