José Pedro Lavrador

Recent technological advances in pediatric brain tumor surgery

X-rays and ventriculograms were the first imaging modalities used to localize intracranial lesions including brain tumors as far back as the 1880s. Subsequent advances in preoperative radiological localization included computed tomography (CT; 1971) and MRI (1977). Since then, other imaging modalities have been developed for clinical application although none as pivotal as CT and MRI. Intraoperative technological advances include the microscope, which has allowed precise surgery under magnification and improved lighting, and the endoscope, which has improved the treatment of hydrocephalus and allowed biopsy and complete resection of intraventricular, pituitary and pineal region tumors through a minimally invasive approach. Neuronavigation, intraoperative MRI, CT and ultrasound have increased the ability of the neurosurgeon to perform safe and maximal tumor resection. This may be facilitated by the use of fluorescing agents, which help define the tumor margin, and intraoperative neurophysiological monitoring, which helps identify and protect eloquent brain.

Revisiting Lipomatous Meningioma: A Case Report and Review of an Unusual Entity.

Lipomatous meningioma is a very rare subtype of metaplastic meningioma. It is defined by the presence of adipocytic-like cells, which are thought to result from lipid accumulation in meningothelial cells or true metaplastic change. We report a case of a lipomatous meningioma arising in a female patient complaining of recent seizures. Imaging studies revealed a 4-cm dural-based mass, with severe perilesional edema. Histologically, the tumor was composed of meningothelial whorls intermixed with adipocytic-like cells. No atypical criteria or brain invasion were found. The 2 components have differences in progesterone receptor expression and Ki-67 labeling, which may suggest that adipocytic-like cells may represent some quiescent form of meningothelial neoplastic cells, characterized by metabolic abnormalities, leading to lipid accumulation and very low proliferative activity. Lipomatous meningioma should also be kept in mind when considering the differential diagnosis of dural lesions with vasogenic edema in the absence of brain invasion.

Atypical teratoid/rhabdoid tumour following craniopharyngioma radiotherapy during childhood.

Dear Editor: This letter reports a rare clinical issue based on the onset of an atypical teratoid/rhabdoid tumour (AT/RT), consequently after radiotherapy. Besides being rare, this is a first report of this event after craniopharyngioma radiotherapy. Craniopharyngioma radiotherapy (RTh) is considered in situations of subtotal surgical excision, performed when there is a high risk of morbidity associated with total resection. Tumour development after RTh is well known and accepted. To the best of our knowledge, this is the third case of an AT/RT after RTh and the first after craniopharyngioma RTh. The case refers to a 22-year-old female patient submitted to 3D conformational RTh (34Gy) at the age of 12 years, after a subtotal surgical removal of a craniopharyngioma. During follow-up, the tumour residue remained stable. She was admitted to the hospital with a 2-days evolution of headaches, nausea and vomiting. Neurological findings showed somnolence with psychomotor slowing but reacting to verbal stimulus, without focal deficits. MRI showed a large sagittal frontal lesion with left frontal extension andmarkedmass effect with heterogeneous contrast enhancement (Fig. 1). Surgery was performed but the tumour was highly vascularized and only a partial removal was possible. At D2 post-operation, a clinical worsening was observed. CT scan showed a bilateral anterior cerebral artery ischemia with intra-tumour haemorrhage. The patient died 4 days after surgery. Neuropathology disclosed a malignant neoplastic tumour, with a high mitotic and proliferative index and areas of geographic necrosis. Immunohistochemical study showed extensive, immunoreactivity for vimentin and epithelial membrane antigen (EMA), polyfocal for neurofilaments, and only focal for glial fibrillary acidic protein (GFAP). INH1 was negative. A diagnosis of AT/RT was done. FISH analysis was performed with several probes for chromosome 22 targeting the SMARCB1/INI1 gene, the PDGFRβ gene, the EWS, HIRA and ARSA genes (Fig. 2). Chromosomal comparative genomic hybridization (CGH) was also performed, and abnormalities were detected by comparing the dynamic standard reference interval to the confidence interval of the mean ration profile of the test samples. CGH analysis revealed a relatively complex karyotype where the chromosomal alterations were observed, namely a deletion involving 22q. AT/RT affects more frequently children less than 3 years old, with only 42 adult cases published so far. Despite aggressive treatment protocols, it has a poor prognosis mainly in children with less than 1-year survival. Our case showed the histological hallmark of this entitywhich are rhabdoid cells with undifferentiated elements with areas of differentiated mesenchymal cells. In immunohistochemical * Edson Oliveira edsoliveira@gmail.com

Foreign body reaction to hydroxyapatite after anterior cervical discectomy with fusion

Dear Editor, The surgical management of cervical disc herniation has greatly evolved over the last century. Shortly after the anterior cervical approach and fusion with a horseshoe bone graft [5], the interbody fusion using autologous iliac bone was described [2], and recent studies have highlighted the morbidity associated with these autografts [3, 8, 9], mainly donor site morbidity and limited supply. Consequently, the use of allograft or synthetic materials for fusion has been increasing. Nevertheless, the fusion rates are similar for the three methods, with synthetic materials averting the pain of autograft bone sourcing and being less expensive than allograft bone use [1, 7]. We are reporting an unexpected complication following the use of phosphocalcic hydroxylapatite after anterior cervical discectomy with fusion. A 68-year-old man with type 2 diabetes mellitus, came to the out–patient clinic of our department complaining of decreased strength on the right limbs. He presented with a right hemiparesis (grade 2) and hemihyposthesia, with ipsilateral gait disturbance; no changes in muscle stretch reflexes were elicited and the Babinsky sign was present on the right side only. The cervical spine MRI revealed right paramedian C4-C5 cervical disc extrusion, with upward and downward migration, and compression of the spine cord. The patient was submitted to surgery: anterior cervical C4-C5 discectomy; fusion with cage filled with autologous bone and hydroxyapatite, and fixation with an anterior plate (over C4 and C5). He recovered motor function, being discharged 48 h later with grade 4 muscle strength and the ability to use the right hand in activities of daily living. However, he was readmitted at 15 days postoperatively with a paraparesis and paraesthesias in both forearms and hands. The MRI showed spinal cord compression at C4-C5 and upward migration of the cage into the C4 vertebral body. He was reoperated and the anterior plate and screws were removed. We did a C4 corpectomy, dissection and excision of epidural tissue and fusion with mesh filled with autologous bone and anterior plate between C3 and C5, with fixed screws over both vertebral bodies. The epidural tissue was sent for microbiology and for histopathology analysis. The patient was treated empirically with a high dose of flucloxacilin for an eventual empyema, and was discharged with partial recovery of autonomous gait with orthosthasis, and no paraesthesies. The microbiological evaluation was negative but neuropathology revealed a foreign body reaction with calcium-positive material surrounded by giant-multinucleated cells (Fig. 1). The patient was followed in the immunoallergy out-patient clinic in order to test hypersensivity to hydroxyapatite, which was negative. At 4 weeks after reoperation, the patient showed a J. P. Lavrador : S. Livraghi Department of Neurosurgery, Hospital de Santa Maria, CHLN, Lisbon, Portugal

Navigated Transcranial Magnetic Stimulation In A Patient With A Cranioplasty In Situ: A Safe And Accurate Procedure

BACKGROUND Navigated transcranial magnetic stimulation (nTMS) is a nonsurgical mapping technique used in mapping of motor and language eloquent areas within and/or surrounding brain tumors. Previous reports support this as a safe technique with minor side effects associated with minor headaches and discomfort around the stimulation area. Currently there are no published reports concerning the accuracy and safety of this procedure in patients with a titanium cranioplasty in situ. CASE PRESENTATION A 59-year-old lady was diagnosed with a recurrent glioma in the context of increasing seizure frequency, left-sided numbness, and weakness. She was diagnosed with a World Health Organization grade 2 oligodendroglioma 10 years before her presentation, which was initially treated with radiotherapy and then surgical resection of this lesion 5 years later. The procedure was complicated with a wound infection, treated with a craniectomy and wound washout, followed by a titanium cranioplasty. Before proceeding with surgery for recurrence, nTMS was performed for motor mapping. No complications were identified. She underwent a craniotomy for tumor resection with aminolevulinic acid HCl (Gliolan), and the tumor was completely removed. Intraoperatively, the direct cortical stimulation correlated with the preoperative nTMS. The pathologic diagnosis on recurrence was an anaplastic oligodendroglioma grade III, and the patient is currently undergoing adjuvant chemotherapy. CONCLUSION This report confirms that nTMS is a safe and accurate procedure in patients who have a titanium cranioplasty in situ.

Meningioma and Breast Cancer: Survival of Patients with Synchronous and Metachronous Meningioma and Breast Cancer

The prognosis of the association between Breast Cancer (BC) and Meningioma (M) is unknown. To evaluate the survival impact of tumor exposure sequence in patients with both tumors. Patients were divided in groups according to the tumors sequence: BC before M (group 1), synchronous BC + M (group 2) and BC after M (group 3). The SEER database was used. Demographics, meningioma and breast cancer variables were analyzed. The primary outcome was oncological survival. A total of 1715 patients were included (median follow-up:84 months). Group 2 had the shortest survival (median:32 months) and group 1 the longest (median:110 months). On the unadjusted analysis, group 2 had the shortest survival (HR:3.13, 95% CI 1.62–6.04) and adjusted analysis confirmed this finding (HR 3.11, 95% CI 1.58–6.19), with no statistical difference between the metachronous tumors groups. Increasing age (HR:1.13, 95% CI 1.11–1.15, p < 0.005) and grade III meningioma (HR:4.51, 95% CI 1.90–10.69, p < 0.005) were related with lower survival. Meningioma treatment had no influence on the survival (p > 0.05). The association between surgery and radiotherapy in BC treatment improved the outcome (HR 0.37, 95% CI 0.23–0.93, p < 0.05). Grade III meningioma and receptor hormonal status influenced synchronous tumors (p < 0.05) but had no influence on metachronous tumors survival (p > 0.05) on stratified analysis. Synchronous tumors were associated with lower survival. Increasing age had a negative influence on patient survival. Although surgery and radiotherapy for breast cancer had a positive influence in the outcome, meningioma treatment was not related with survival. Grade III meningioma and hormonal receptor status only influenced synchronous tumors patient survival.

Posterior fossa arachnoid cyst causing torticollis and gastro-oesophageal reflux in an infant

IntroductionArachnoid cysts (ACs) account for a small proportion of all intracranial lesions. They are often incidental but can become symptomatic and even cause a threat to life. Symptoms are usually due to direct compression of neural elements and/or raised intracranial pressure.Case reportWe report the case of an infant with an enlarging posterior fossa arachnoid cyst (PFAC) causing torticollis and gastro-oesophageal reflux (GOR), the combination of which had been previously unreported in this context. Endoscopic fenestration and cyst decompression were followed by complete resolution of the symptoms. We discuss the possible mechanisms of torticollis and GOR in this context.

Grade II Sylvian fissure meningiomas without dural attachment: case report and review of the literature

Sylvian fissure meningiomas (SFMs) represent a rare subgroup of nondural-based tumors arising from the meningothelial cells within the arachnoid of the Sylvian fissure. SFMs are more frequent in young males, usually manifest with seizures and display the same radiological features of meningiomas in other locations. Although the absence of dural attachment makes these tumors suitable for a complete resection, their anatomical relationships with the middle cerebral artery branches have impaired its achievement in half of them. To the best of our knowledge, only five atypical WHO grade II SFMs have been previously described. We provide a literature review of SFMs WHO grades I–II and discuss common characteristics and surgical challenges we found in a similar case.

PP84. ENDOSCOPIC RESECTION OF A THIRD VENTRICULAR PILOCYTIC ASTROCYTOMA WITH PILOMYXOID FEATURES IN AN 86-YEAR OLD PATIENT: CASE REPORT AND REVIEW OF THE LITERATURE

AbstractOBJECTIVE: Pilocytic astrocytomas are extremely rare in octagenarians especially those occurring in the third ventricle. They are similar histopathologically to pilomyxoid astrocytomas but the latter are more aggressive. We report the case of an 86-year old patient presenting with confusion and lethargy secondary to a third ventricular lesion causing obstructive hydrocephalus. The lesion was approached endoscopically and sub-totally resected. Histologically the lesion was classified as a pilocytic astrocytoma with pilomyxoid features. The patient made a full recovery and did not require a shunt. MATERIALS AND METHODS: Case report with pictures and video of the operative approach as well as discussion of the imaging sequences and histology, and review of the literature. RESULTS: Sub-total resection of the tumour was achieved using a monoportal image-guided endoscopic approach. Normal cerebrospinal fluid circulation was restored and a shunt was not required. Histologically, the mass was confirmed to be a pilocytic astrocytoma with pilomyxoid features. The patient made a full recovery with resolution of her symptoms. No such case has been reported in the literature to date. CONCLUSION: This is the first report of a third-ventricular pilocytic astrocytomas with pilomyxoid features in an octogenarian. The endoscopic approach in the case at hand, allowed safe direct visualisation and sub-total resection of the lesion, providing histological diagnosis to guide management and obviating the need for a shunt. The minimally invasive nature of the approach translated into full recovery, despite the age of the patient.

Corpus callosum and neglect syndrome: Clinical findings after meningioma removal and anatomical review

Two types of neglect are described: hemispatial and motivational neglect syndromes. Neglect syndrome is a neurophysiologic condition characterized by a malfunction in one hemisphere of the brain, resulting in contralateral hemispatial neglect in the absence of sensory loss and the right parietal lobe lesion being the most common anatomical site leading to it. In motivational neglect, the less emotional input is considered from the neglected side where anterior cingulate cortex harbors the most frequent lesions. Nevertheless, there are reports of injuries in the corpus callosum (CC) causing hemispatial neglect syndrome, particularly located in the splenium. It is essential for a neurosurgeon to recognize this clinical syndrome as it can be either a primary manifestation of neurosurgical pathology (tumor, vascular lesion) or as a postoperative iatrogenic clinical finding. The authors report a postoperative hemispatial neglect syndrome after a falcotentorial meningioma removal that recovered 10 months after surgery and performs a clinical, anatomical, and histological review centered in CC as key agent in neglect syndrome.