Peizhi Zhou

Symptomatic Rathke cleft cyst

Rathke cleft cysts (RCC) are uncommon intrasellar lesions. Although their clinical manifestations, radiological features and treatment are frequently reported, controversy remains as a result of their rarity. We reviewed the preoperative clinical manifestations, neurological examination findings, visual acuity and fields, endocrinological function, radiographic study findings, surgical and pathological records, and prognosis of 45 patients with RCC (21 males, 24 females, average age: 47 years) admitted to our department between January 2002 and January 2011. The most common clinical manifestations included headaches, and visual and hormonal disturbances. Most RCC were intrasellar with a suprasellar extension. The most common MRI patterns were hypointense on T1-weighted and hyperintense on T2-weighted images, isointense on T1-weighted and hyperintense on T2-weighted images, and hyperintense on T1-weighted and hyperintense on T2-weighted images. Aspiration and biopsy of the cyst wall were performed in most patients. Most patients experienced improved headaches and visual disturbance, but the hormonal disturbance rarely returned to normal, especially in those patients with a serious preoperative hormonal disturbance. The recurrence rate was 14%, which was associated with the extent of cyst removal, inflammation and rim enhancement, as well as the surgical approach. Aspiration and biopsy of the cyst wall still seems to be an effective treatment for most RCC for its low morbidity and good prognosis. Conservative treatment and close follow-up may be suitable for small cysts with subtle clinical manifestations.

Three risk factors for WHO grade II and III meningiomas: A study of 1737 cases from a single center

BACKGROUND Meningiomas account for 35.5% of central nervous system (CNS) tumors, of which 21-37.8% are atypical or anaplastic/malignant. High-grade meningiomas have higher rates of recurrence and worse outcome than grade I/II meningiomas. Thus, it is of importance to assess the tumor biology before treatment initiation. MATERIALS AND METHODS This study reviewed 1737 patients with histologically confirmed meningioma at a single institution. Meningiomas were classified according to World Health Organization (WHO) 2007 grading and the location of the tumor was confirmed from the operation records and preoperative imaging. Univariate and multivariate logistic regression were used to analyze the potential risk factors for high-grade pathology. RESULTS Young men and pediatric patients were less likely to have meningioma, but they had high-grade meningioma. Tumors originated from non-skull base and lateral intracranial are more likely to be grade II/III meningioma. CONCLUSIONS Lateral and non-skull base location, male sex, and the younger patients increase the risk for grade II and III pathology. These factors should be considered while deciding treatment choice, surgical resection, and prognosis as well.

Combined gangliocytoma and non-functioning pituitary adenoma of the pituitary gland

311 Neurology India | May-Jun 2012 | Vol 60 | Issue 3 pituitary adenomas develop, are also derived from the cells of Rathke’s pouch. Although RCC and pituitary adenoma have a shared ancestry, they rarely occur together. Common symptoms of RCC are headache, visual disturbance, hypopituitarism, and hypothalamic dysfunction. Other rare symptoms include decreased libido, impotence, and diabetes insipidus.[3] When RCC and pituitary adenoma are found together, symptoms of mass effect may be accompanied by hormonal changes caused by the functioning tumor as in this patient. MRI is the modality of choice in detecting RCC. MRI also helps to diagnose the coexisting RCC and pituitary adenoma. RCCs almost always are homogeneous in signal intensity, whereas other lesions, such as cystic craniopharyngiomas and hemorrhagic adenomas, more frequently have heterogeneous signal intensity. Kunii et al.[4] concluded that singleshot fast spin-echo (SSFSE), diffusion-weighted MR imaging (DWI) with apparent diffusion coefficient (ADC) can be employed in the differentiation of RCCs from craniopharyngiomas and hemorrhagic pituitary adenomas. Some cases may be mistakenly diagnosed as arachnoid cyst, craniopharyngioma, and pituitary apoplexy. A combination of clinical, biochemical, and radiographic findings must be used to establish a diagnosis of RCC and the histologic examination seems to be much more important. Pituitary adenoma can be easily diagnosed by histologic examination of the resected mass. Most RCC have cuboidal or columnar epithelium and ciliated epithelium. But some researchers note that 12% of RCC displayed stratified squamous epithelium, a characteristic feature commonly associated with craniopharyngioma.[5] Decompression and biopsy may represent the optimal surgical management of RCC, with low morbidity rates; this patient underwent a transsphenoidal approach, where we excised not only the adenoma but also the Rathke’s cleft cyst at one go. The recurrence rate during postoperative follow-up can be up to 19%. [5]

Pituitary atypical adenoma or carcinoma sensitive to temozolomide combined with radiation therapy: a case report of early identification and management.

Pituitary carcinoma is extremely rare and difficult to diagnose early. Here we present a case of highly suspected pituitary malignant adenoma with early chemotherapy and radiation. A 30-year-old woman was admitted for headache and impaired vision, MRI found a sellar mass. Since there was no disturbance in serum hormone levels, she was diagnosed with non-functioning pituitary adenoma before surgery. Transsphenoidal removal of tumor was attempted but only partial resection of tumor was achieved. Pathology findings suggested a diagnosis of adenocarcinoma. PET-CT scan showed the tumor had elevated max standardized uptake value. No other abnormal sites were found, which excluded metastasis to pituitary. After surgery, the patient was treated with temozolomide assisted with radiation and tumor disappeared on MRI. No recurrence was observed on 1-year follow up. In conclusion, early temozolomide with radiation therapy for highly suspected pituitary carcinoma might be beneficial.

Interleaving subthalamic nucleus deep brain stimulation to avoid side effects while achieving satisfactory motor benefits in Parkinson disease: A report of 12 cases

Background: Deep brain stimulation (DBS) of the subthalamic nucleus is an effective treatment for advanced Parkinson disease (PD). However, achieving ideal outcomes by conventional programming can be difficult in some patients, resulting in suboptimal control of PD symptoms and stimulation-induced adverse effects. Interleaving stimulation (ILS) is a newer programming technique that can individually optimize the stimulation area, thereby improving control of PD symptoms while alleviating stimulation-induced side effects after conventional programming fails to achieve the desired results. Methods: We retrospectively reviewed PD patients who received DBS programming during the previous 4 years in our hospital. We collected clinical and demographic data from 12 patients who received ILS because of incomplete alleviation of PD symptoms or stimulation-induced adverse effects after conventional programming had proven ineffective or intolerable. Appropriate lead location was confirmed with postoperative reconstruction images. The rationale and clinical efficacy of ILS was analyzed. Results: We divided our patients into 4 groups based on the following symptoms: stimulation-induced dysarthria and choreoathetoid dyskinesias, gait disturbance, and incomplete control of parkinsonism. After treatment with ILS, patients showed satisfactory improvement in PD symptoms and alleviation of stimulation-induced side effects, with a mean improvement in Unified PD Rating Scale motor scores of 26.9%. Conclusions: ILS is a newer choice and effective programming strategy to maximize symptom control in PD while decreasing stimulation-induced adverse effects when conventional programming fails to achieve satisfactory outcome. However, we should keep in mind that most DBS patients are routinely treated with conventional stimulation and that not all patients benefit from ILS. ILS is not recommended as the first choice of programming, and it is recommended only when patients have unsatisfactory control of PD symptoms or stimulation-induced side effects after multiple treatments with conventional stimulation. A return to conventional stimulation may be required if ILS induces new side effects or the needs of the patient change.

Clinical Features, Treatment, and Long-term Outcomes of Central Neurocytoma: A 20-Year Experience at a Single Center

OBJECTIVE Central neurocytoma (CN) is a rare central nervous system tumor the optimal management strategy of which remains controversial because of their rarity. Detailed information on CN is necessary to establish optimal management strategies. The purpose of this study was to show the clinical features, treatments, and long-term clinical outcomes of CN. METHODS A total of 63 patients with CN were surgically treated between 1995 and 2016 at West China Hospital. All pathologically proven CN cases were identified. Epidemiologic characteristics, clinical features, imaging features, functional outcomes, overall survival, and progression-free survival according to multimodal treatments were reviewed retrospectively. RESULTS There were 29 males and 34 females, with a median age of 29 years (range, 15-58 years). Thirty-four patients underwent gross total resection (GTR) and 29 patients underwent subtotal resection (STR). The surgical approaches to CNs in this study included a transcortical approach (39 cases) and an interhemispheric transcallosal approach (24 cases). There were no differences in functional outcomes or initial extent of resection according to the surgical approach used. The extent of resection was GTR in 34 patients (54.0%), and STR in 29 patients (46.0%). At the median follow-up of 74 months (range, 6-205 months), the actuarial 5-year and 10-year overall survival were 93.3% and 85.4%. At the last follow-up, 8 patients had experienced tumor progression. The 5-year and 10-year progression-free rate was 73.4% and 57.5%. The initial extent of resection and multimodal treatment was not related to overall survival; however, the actuarial local control rate differed significantly according to the initial extent of resection and multimodal treatment. CONCLUSIONS CN is a rare type of World Health Organization grade II primary brain tumor with a tendency to recur. Complete resection of CNs with maximal safety remains the primary treatment to minimize local progression. Adjuvant radiotherapy should be considered in patients receiving incomplete resection. The long-term clinical outcomes of CN after multimodal treatment seem to be satisfactory.

Management of large medial sphenoid wing meningiomas: a series of 178 cases.

AIM The aim of this study was to evaluate our treatment and outcome in patients with large medial sphenoid wing meningiomas (SWMs). MATERIAL AND METHODS Data from 178 patients with large medial SWMs treated was collected and analyzed retrospectively. Most of patients underwent microsurgical resection under electrophysiological monitoring and Doppler probe. Radiation therapy was administered in 64 patients with residual tumor and malignant pathology. RESULTS Total resection of the tumor was achieved in 118 of 178 cases (66.3%), subtotal in 60 of 178 (33.7%) at the time of initial surgery without serious surgical complications except 2 patients with ptosis. Postoperative vision improved in 84 patients (87.5%), remained unchanged in 8 (8.3%) and deteriorated in 4 (4.2%). The progress free survival (PFS) and Karnofsky performance score (KPS) between patients with gross total resection (GTR) and patients with subtotal resection (STR) followed by radiation therapy (RT) had no significant difference. CONCLUSION Surgery still remains a principal treatment option for SWMs. Good craniotomy techniques, proper hemostasis and optimal surgery strategy are critical to improve resection rate and elevate prognosis. Likewise, it is expected that STR with adjuvant RT can provide satisfactory results in case of total removal impossible.

Presurgical treatment with somatostatin analogues in growth hormone-secreting pituitary adenomas: A long-term single-center experience

OBJECTIVE Acromegalic patients with macro- or giant adenomas often had poor prognosis after surgery. Somatostatin analogues (SSAs) show high effectiveness in both tumor shrinkage and serum GH reduction. But the role of SSAs in pre-surgical treatment and the management among macro- and giant adenomas remains controversial. PATIENTS AND METHODS A total of 100 acromegalic patients with macro- or giant adenomas that underwent surgery in our institution between January 2010 and December 2016 were enrolled in the current retrospective study. The relationships between several potential parameters and surgical outcomes were further analyzed. RESULTS The overall long-term remission rate was 45% accompanied by gross total resection (GTR) rate of 44%. GTR (adjusted OR = 16.346; p = .001) and nadir GH level on OGTT 7 days after surgery (GH-7, adjusted OR = 0.660, p = .039) showed predictive significance for remission after surgery. Tumor size and invasiveness as well as cavernous sinus invasion were risk factors for residual tumor. For invasive macro- or giant adenomas, 6 of 15 patients achieved long-term remission with SSA pre-treatment whereas none of the 18 patients without any preoperative treatment was endocrine controlled. CONCLUSIONS Acromegalic patients did not gain more benefits from SSAs pretreatment. But, pre-treatment with SSA could be recommended to patients with invasive macro- or giant adenomas for significant improvement in long-term remission. GTR and GH-7 could be significant predictors in postoperative management of macro- or giant adenomas.

Bilateral anterior capsulotomy and amygdalotomy for mental retardation with psychiatric symptoms and aggression: A case report

Rationale: Mental retardation (MR) is a chronic condition that often has no readily identifiable cause or treatment. Aggression and psychiatric symptoms are prevalent in children with MR. Surgical treatment of aggression and psychiatric symptoms of MR is seldom investigated and studies are limited. Patient concerns: We encountered a 19-year-old female who had MR with aggression and psychiatric symptoms. Diagnoses: She was diagnosed with mild MR with aggressiveness and psychiatric symptoms. Interventions: Because the patient was refractory to conservative treatment, bilateral anterior capsulotomy and amygdaloid neurosurgery were performed for her psychiatric symptoms and aggression. The benefits and side effects of the surgery were analyzed. Outcomes: After surgery, the patient showed significant alleviation of her psychiatric symptoms and aggression with no observed side effects. Lessons: Bilateral anterior capsulotomy in combination with amygdaloid neurosurgery may resolve both psychiatric and aggressive symptoms. Future investigations of control studies with large patient cohorts are needed.

Calcified otogenic brain abscess

A 33-year-old man presented with a 2-year history of recurrent episodes of purulent discharge from the left ear. Examination revealed eardrum perforation. CT and MRI (figures 1 and 2) suggested left otitis media and mastoiditis associated with a temporal lobe calcified otogenic brain abscess. Radical mastoidectomy and tympanoplasty were performed; however, removal of the asymptomatic calcified mass was not performed. The mass was stable at 2-year follow-up.