Pre-operative embolization of a choroid plexus carcinoma: review of the vascular anatomy

Aim

The purpose of this case is to highlight the benefits of preoperative embolization as well as to review the vascular anatomy that needs to be recognized in order to perform pre-operative embolization of choroid plexus tumors.

Method

We achieve this by presenting the case of a 12-month-old female who had symptoms of raised intracranial pressure. MRI demonstrated a large vividly enhancing mass centered within the atria of the right lateral ventricle associated with hydrocephalus in keeping with a choroid plexus tumor.

Result

Enlarged anterior and posterior choroidal arteries supplying the tumor were noted on the MRI scan. Pre-operative embolization was performed with NBCA glue via the anterior and posterior choroidal arteries. Subsequently, total surgical resection was achieved with only 200 cc of blood loss. Pathology confirmed a choroid plexus carcinoma.

Conclusion

Pre-operative embolization can be useful in minimizing blood loss during excision of choroid plexus tumors. It is important to understand the anatomy of the anterior and posterior choroidal arteries to perform embolization of these tumors safely.

     

Preoperative embolization of hypervascular pediatric brain tumors: evaluation of technical safety and outcome

Background

Surgical management of pediatric hypervascular brain tumors is challenging because of the risk of bleeding. We sought to evaluate the technical factors associated with safety and outcome of preoperative embolization of pediatric hypervascular brain tumors.

Materials and methods

Eight pediatric brain tumor patients received preoperative endovascular embolization during the past 8 years. The cases included four choroid plexus papillomas, one yolk sac tumor, one intraventricular meningioma, one astrocytoma, and one hemangioblastoma. Embolization was done by superselection of the feeding arteries with microcatheters followed by slow injection of either n-butyl 2-cyanoacrylate (NBCA) or tris-acryl gelatin microspheres (Embosphere). Surgery for tumor removal was done in the same session right after embolization in all but one patient. Blood loss during surgery and clinical outcome were recorded.

Results

Preoperative embolization was successfully done in all patients. Technical complication was noted in two patients. One patient developed bleeding while embolizing the tumor with Embospheres but was immediately embolized with NBCA without sequel. The other patient experienced tumor bleeding 4 h after embolization with Embospheres, and suffered left hemiparesis despite an emergency surgery. Surgical intervention was successfully done in all patients without procedure-related complication. Surgical blood loss ranged from 50 to 1,600 ml.

Conclusion

Though associated with the risk of procedure-related bleeding, preoperative embolization of pediatric hypervascular brain tumors has high technical success rates and can enhance the surgical management. We suggest to perform the embolization and surgery in a single session and to use NBCA as the embolic agent to minimize the procedure-related risk.     

Preoperative embolisation of choroid plexus tumours in children: part I—does the reduction of perioperative blood loss affect the safety of subsequent surgery?

Objective

Operative management of choroid plexus tumours is hindered by excessive bleeding and significant CSF production. Our aim was to assess whether the use of preoperative embolisation would increase the safety of surgery by reducing the perioperative blood loss and achieve higher rates of resection of the tumour.

Methods

Between 1996 and 2009, 30 patients (mean age 2.25 years) with choroid plexus tumours (24 papillomas, 6 carcinomas) were treated. Fifteen of them underwent preoperative super-selective embolisation of the feeding vessels with histoacryl glue. The perioperative blood loss as a percentage of estimated blood volume loss (EBV) was recorded together with mortality and morbidity of the two groups (embolised, EMB+ vs. not, EMB?).

Results

The embolisation was successful in 13/15 (86.6 %) patients. This manoeuvre rendered the tumour relatively avascular making the operative field “less hazardous” as reported by the surgeon. In addition, higher gross total resection rate was achieved (100 vs. 41 %; p?=?0.001) at the first operative attempt in the EMB+ group. The percentage EBV loss was 96 % in EMB? group vs. 224 % in EMB+ group (p?=?0.038).

Conclusion

Our observations with regards to preoperative embolisation of choroid plexus tumours show an acceptable safety profile for the endovascular technique. At the same time, it renders the operative treatment of the tumours safer by reducing perioperative blood loss resulting in a high gross total resection rate. In summary, we suggest that preoperative embolisation is a useful adjunct that should be considered prior to surgical resection in managing these patients.     

The choroid plexus: a comprehensive review of its history,anatomy, function,histology, embryology,and surgical considerations

Introduction

The role of the choroid plexus in cerebrospinal fluid production has been identified for more than a century. Over the years, more intensive studies of this structure has lead to a better understanding of the functions, including brain immunity, protection, absorption, and many others. Here, we review the macro- and microanatomical structure of the choroid plexus in addition to its function and embryology.

Method

The literature was searched for articles and textbooks for data related to the history, anatomy, physiology, histology, embryology, potential functions, and surgical implications of the choroid plexus. All were gathered and summarized comprehensively.

Conclusion

We summarize the literature regarding the choroid plexus and its surgical implications.     

Arterial vascularization of the pineal gland

Purpose

The arterial vascularization of the pineal gland (PG) remains a debatable subject. This study aims to provide detailed information about the arterial vascularization of the PG.

Methods

Thirty adult human brains were obtained from routine autopsies. Cerebral arteries were separately cannulated and injected with colored latex. The dissections were carried out using a surgical microscope. The diameters of the branches supplying the PG at their origin and vascularization areas of the branches of the arteries were investigated.

Results

The main artery of the PG was the lateral pineal artery, and it originated from the posterior circulation. The other arteries included the medial pineal artery from the posterior circulation and the rostral pineal artery mainly from the anterior circulation. Posteromedial choroidal artery was an important artery that branched to the PG. The arterial supply to the PG was studied comprehensively considering the debate and inadequacy of previously published studies on this issue available in the literature.

Conclusions

This anatomical knowledge may be helpful for surgical treatment of pathologies of the PG, especially in children who develop more pathology in this region than adults.     

Pre-operative embolisation of choroid plexus tumours in children. Part II. Observations on the effects on CSF production

Objective

Choroid plexus tumours are one of the few causes of hydrocephalus secondary to increased CSF production. Operative treatment aided by pre-op embolisation is being used in our institution as a primary option of treatment. Our aim was firstly to quantify the effects of embolisation on CSF production and secondly to assess whether the use of pre-operative embolisation would lead to reduction of CSF production thus reducing the need for CSF diversion procedures in the perioperative and long term.

Methods

From 1996 till 2009, 30 patients (mean age, 2.25 years) underwent surgical treatment for 24 choroid plexus papillomas and 6 choroid plexus carcinomas. Thirteen underwent pre-operative super-selective embolisation of the feeding vessels with Histoacryl glue. The need for CSF diversion—external ventricular drain (EVD)/shunt—was recorded together with the daily CSF production between the two groups (embolised: EMB+ vs. not embolised: EMB?)

Results

The embolisation was successful in 13 of 15 (86.6 %) patients. The average post-op daily CSF production between the EMB+ and EMB? groups was (67 vs. 135 ml/day; p?=?0.005). EVD days in situ post-operatively was 7.9 vs. 12.1 (p?=?0.033). However, the need for permanent CSF diversion was similar in both groups (five vs. six).

Conclusion

We have established the safety of pre-operative embolisation as an adjunct to operative treatment of choroid plexus tumours. As we expected, this technique, by removing the tumour's blood supply, reduces the rate of CSF production. This has had a positive impact on the post-operative management of these patients. We cannot say the same for the need of permanent CSF diversion in our study.     

Giant cell reparative granuloma of the pediatric cranium: case report and review of the literature

Purpose

Giant cell reparative granulomas are rare bone tumors. Although benign, these tumors are locally destructive and can be highly vascular. They seldom occur in the cranial vault. We describe a multidisciplinary approach to a case of giant cell reparative granuloma of the cranium in a 3-year-old patient.

Case report

A 3-year-old girl female referred to the pediatric neurosurgery department for evaluation of a retro-auricular mass. She had a history of recurrent otitis media with two subsequent courses of antibiotics without resolution. CT imaging revealed an expansive lesion located in the right mastoid region. Open surgical biopsy revealed a hemorrhagic tumor consistent with a giant cell reparative granuloma. Angiography identified a hypervascular tumor blush that was supplied by the occipital artery. Preoperative transcatheter embolization was performed followed by a multidisciplinary surgical resection and reconstruction. Blood loss was minimal, and the patient recovered well after surgery.

Conclusion

Preoperative endovascular embolization and a multidisciplinary intraoperative approach with primary resection and cranial vault reconstruction is an effective approach to hypervascular giant cell reparative granulomas.     

An endolymphatic sac tumor with imaging features of aneurysmal bone cysts: differential diagnostic considerations

Background

Endolymphatic sac tumors (ELSTs) are rare, slow-growing tumors of the petrous bone. Despite the typical localisation, their radiological diagnosis can be challenging due to the variety of other tumors potentially showing similar features.

Case report

We present a 16-year-old child with progressive hearing loss, vertigo, and tinnitus who had a large petrous bone lesion showing imaging features of both ELSTs and aneurysmal bone cysts (ABCs). The patient underwent preoperative embolization of the tumor-supplying vessels and subsequently a subtotal resection. Histological examination revealed an ELST.

Conclusion

Despite the rarity of petrous bone ABCs, they should be considered as a differential diagnostic alternative of ELSTs due to their similar imaging appearance.     

Choroid plexus tumors in children less than 36?months: the Canadian Pediatric Brain Tumor Consortium (CPBTC) experience

Background

Choroid plexus tumors (CPT) are rare pediatric tumors. A population-based study on choroid plexus carcinoma (CPC) and choroid plexus papilloma (CPP) was carried out to describe the incidence, demographic, and outcome data and to identify potential prognostic factors.

Methods

The CPT population from the Canadian databank of CNS tumor in children ??36?months diagnosed between 1990 and 2005 was reviewed

Results

Out of the 579 reported cases of CNS tumors, 37 were CPT. The annual age-adjusted incidence rate was 0.22?+?0.12 (95% CI 0.16?C0.28)/100,000 children <3?years. There were 21 (56.7%) CPP and 16 (43.3.5%) CPC. Twenty patients (54%) were males. Median age at diagnosis was 7?months(range 0?C30). Ten patients(62.5%) with CPC and one with CPP were metastatic at diagnosis. Twenty patients with CPP (95%) had a complete resection, whereas 6/16 CPC (37.5%) achieved a resection >90%. Fourteen CPC patients received adjuvant chemotherapy. None of the 37 patients received adjuvant radiation. At completion of survey, all CPP and five CPC were alive. Median survival time for CPC patients was 15?months (0?C120). One death was related to intraoperative hemorrhage, another to chemotherapy-induced toxicity, and one to secondary AML. Age at diagnosis, degree of resection and metastatic status were not significant prognostic factors for CPC.

Conclusion

By contrast to CPC, CPP have an excellent prognosis following surgery alone. Survival of CPC remains poor. However, these data may suggest adjuvant chemotherapy can alter the aggressive natural history of CPC. As with other rare CNS tumors, international collaboration is required to identify optimal therapy.     

Congenital brain tumors in a series of 56 patients

Introduction

Central nervous system tumors diagnosed before the end of the first year of life differ from those found in older children and in adults. The differences include mode of clinical presentation, anatomical distribution, histopathological diagnoses, response to therapy, and outcome.

Materials and methods

The material consists of 56 children (23 girls and 33 boys), aged at recognition 32Hbd–12?months. We reviewed charts and MR exams according to age of the onset of symptoms, location of tumors, treatment, histopathology, and outcomes. Data of the outcome were analyzed using Kaplan–Meier plots and chi-square test.

Results

Eleven cases were recognized before 6?weeks of life, 24 before the age of 6?months, and 21 were diagnosed up to the end of 1?year of age. Thirty-eight tumors were located in the supratentorial compartment; 18 were infratentorial. Median age of tumors’ recognition was 5.2?months; 4.3?months for supratentorial and 7.2?months for infratentorial tumors. We found 18 glial cell tumors (high and low grade), 15 embryonal tumors, and 12 choroid plexus tumors.

Conclusions

The outcome of congenital CNS tumors depends on the size, location, time of diagnosis, histological type of the tumor, and therapeutic option. Neurosurgical procedures are necessary in most cases. Despite the notable advances in therapy, the outcome remains poor.     

Effective coil embolization of intracavernous carotid artery pseudoaneurysm with parental artery preservation following severe head trauma in a pediatric patient

Background

Intracranial traumatic pseudoaneurysms are rare in children. If left untreated, mortality rate can be as high as 50 % due to delayed rupture and disastrous bleeding. Endovascular embolization is considered the preferred treatment option because of its minimal invasiveness and negligible mortality. However, exclusion of the pseudoaneurysm with preservation of the parental vessel is not always possible. In comparison with peripheral aneurysms, intracavernous internal carotid artery lesions are technically more challenging with both open surgery and endovascular techniques.

Case report

We report the case of a successful two-stage coil embolization of a traumatic intracavernous carotid artery pseudoaneurysm with preservation of parental vessel in a 6-year-old boy.

Conclusion

Endovascular embolization with parental vessel preservation should be considered the first treatment option for traumatic intracavernous internal carotid artery pseudoaneurysms in children. Although treatment of pseudoaneurysms in this location may be technically difficult, it is feasible in experienced hands.     

Traumatic carotid-cavernous fistula at the anterior ascending segment of the internal carotid artery in a pediatric patient

Introduction

Traumatic carotid-cavernous fistula (CCF) in children is a rare condition. Early diagnosis and treatment is still a challenge, and it is associated with good neurological recovery.

Case summary

We present a rare case of a 10-year-old boy with mild head trauma, who developed a CCF at the anterior segment of the ascending internal carotid artery. The patient was treated with endovascular coil embolization and evolved with a favorable outcome.

Discussion

Most of reports in the literature address the traumatic CCF in adult patients, in which early treatment may prevent poor recovery or fatal outcomes. The diagnosis and management of this condition are discussed based on a literature review.

Conclusion

It is important to keep a high degree of suspicion for CCF, especially in traumatic head injury associated with skull base fracture, since the early diagnosis and treatment may prevent potentially permanent neurological deficits.     

Intra-arterial Dantrolene for Refractory Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage

Background

Intravenous dantrolene has been used to prevent and treat cerebral vasospasm. We report a case of refractory cerebral vasospasm treated with intra-arterial dantrolene after aneurysmal subarachnoid hemorrhage.

Methods

A 56-year-old woman suffered a diffuse subarachnoid hemorrhage from a ruptured anterior communicating artery aneurysm which was successfully treated with coil embolization. She subsequently developed bilateral severe angiographic vasospasm which was treated with intra-arterial vasodilators. However, owing to the recurrence of vasospasm, intra-arterial dantrolene followed by balloon angioplasty was used.

Results

There was moderate improvement of the severe vasospasm in bilateral A1 segments of the anterior cerebral arteries after microcatheter-based intra-arterial infusion of 30?ml (1?mg/ml) dantrolene. Patient??s hemodynamic parameters were monitored during and after the procedure and no significant changes were seen after dantrolene infusion. A follow up cerebral angiogram after 1?day demonstrated the persistence of therapeutic effect.

Conclusion

Intra-arterial dantrolene induced a sustained improvement in cerebral vasospasm secondary to ruptured aneurysm. No significant side effects were observed during or after the infusion of the drug.     

Pseudoprogression after proton beam irradiation for a choroid plexus carcinoma in pediatric patient: MRI and PET imaging patterns

Purpose

Pseudoprogression is a rare complication of radiation therapy, and discrimination between true progression and pseudoprogression is of paramount importance for further medical care. We present a case of intra-axial pseudoprogression following complementary proton radiation therapy for a choroid plexus carcinoma in a child. We aim to highlight radiological patterns of pseudoprogression after proton beam therapy.

Case report

A 6-year-old girl presented with choroid plexus carcinoma, manifesting as change in behavior, tremor, and balance disorder. Partial resection and chemotherapy were performed. Complementary localized proton beam therapy (54 Gy) was administered on the residual tumor. Eight month follow-up MRI showed an abnormal, irregular, rim-like enhancement in the pons and both temporal lobes within the field of irradiation. These lesions had a low cerebral blood volume (CBV) on perfusion MR imaging and no restricted diffusion. However, the lesions were hypermetabolic on O-(2-[18F]fluoroethyl)-l-tyrosine (FET)-PET MRI. Follow-up MRI showed disappearance of these lesions confirming the perfusion MR diagnosis of pseudoprogression.

Conclusion

Based on this case, radiological patterns of pseudoprogression after proton beam therapy may be a low CBV and no restricted diffusion. Lesions can be hypermetabolic on FET-PET imaging.     

Pediatric temporal low-grade glial tumors: epilepsy outcome following resection in 48 children

Purpose

This paper summarizes our experience with surgical treatment of pediatric low-grade glial temporal lobe tumors focusing on the long-term outcome of seizures and identifying factors associated with seizure control and failure.

Methods

We reviewed all medical records of pediatric patients that underwent temporal lobe surgery due to seizures at our institution between 1997 and 2009. Only patients with temporal lobe tumors were included in this series. The files were retrospectively reviewed for seizure history. All children had undergone pre- and postoperative evaluation, neurological examination, EEG, and MRI.

Results

The cohort includes 48 children with mean follow-up time of 5.15?years (1?C12?years). The mean age at surgery was 8.2?years (1?C18.1) and the mean seizure duration until surgery was 2.6?years. All lesions in the cohort were low-grade tumors; pilocytic astrocytoma was the most common (41%). Eighty-three percent of the patients were classified as Engel class I following surgery. There was no correlation between Engel score and the preoperative epilepsy duration, age of seizure onset or type of seizures, and pathology. The surgical complication rate was 4.1% (2/48).

Conclusions

Surgical treatment for seizure control in children and adolescents with low-grade temporal tumors provides excellent long-term results.     

High-grade lumbosacral spondylolisthesis reduction and fusion in children using transsacral rod fixation

Purpose

There is no consensus on how to treat surgically high-dysplastic developmental spondylolisthesis in children and adolescents. Although reducing spinal deformity seems mandatory, the issue of surgical reduction versus in situ fusion remains controversial.

Methods

The files of 12 consecutive patients surgically treated for a grade 3 or 4 spondylolisthesis were reviewed. The treatment consisted in L4 to sacrum reduction and fusion by posterior approach. The reduction of lumbopelvic imbalance was made intraoperatively using a trans-sacral rod fixation technique.

Results

Mean preoperative L5 anterior slippage was 72.3 % (60 to 95 %). The mean preoperative lumbosacral tilt angle was 70.5° (43 to 92°). Mean final lumbosacral tilt angle was 102° (91 to 114°). Mean final L5 anterior slippage was 19 % (7 to 63 %). Neurological complications (radicular L5 or S1 deficits) were noted in five patients. At final follow-up L4 to S1 fusion was achieved in all patients. No patient had persistent deficit or radicular pain.

Conclusions

The fusion rate in our series proved to be optimal. Thanks to the trans-sacral rod fixation, lumbosacral kyphosis correction was very good. The intrasacral positioning of the screws reduces the risk of implant prominence especially in such pediatric patients. We stress the importance to avoid complete slip reduction in such patients to minimize stretching on L5 and S1 roots. No additional immobilization is needed due to solid posterior instrumentation. Doing such procedure only by posterior approach avoids anterior approach-related complications.     

Total ipsilateral C7 root neurotization to the upper trunk for isolated C5-C6 avulsion in obstetrical brachial plexus palsy: a preliminary technical report

Background

C5-C6 root avulsion in obstetrical brachial plexus palsy (OBPP) is a rare injury with poor prognosis usually associated with breech delivery. The treatment is challenging and requires high microsurgical skills. The triple nerve transfer (spinal accessory nerve, ulnar fascicles, and triceps long or lateral head branch) represents the gold standard treatment. The total ipsilateral C7 nerve root neurotization is a promising technique, which has never been described in OBPP.

Objective

The total ipsilateral C7 nerve root is used as a neurotizer transferred to the upper trunk as an alternative method to other intra- or extra-plexual reconstruction techniques.

Methods

During brachial plexus surgical exploration, an intraoperative neurostimulation was performed to confirm the integrity of C7 and the lesion of C5 and C6. The entire C7 nerve root and the upper trunk are cut. The C7 root was transferred to the upper trunk with a fibrin sealant.

Result

This technique was easily performed with a single approach and avoided intercalated nerve grafts. The C7 nerve root provided a large number of nerve fibers with an adequate diameter to be transferred to the upper trunk. We illustrated this technique with a typical case of a child at 8 years of follow-up.

Conclusion

The total ipsilateral transfer of the C7 root to the upper trunk is a viable alternative procedure for newborns with C5-C6 avulsion.     

Primary Ewing's sarcoma of the skull: radical resection and immediate cranioplasty after chemotherapy. A technical note

Purpose

The current standard treatment of Ewing's sarcoma is chemotherapy followed by surgery, making an immediate cranial reconstruction in a one-step surgical procedure possible.

Methods

We describe the technique used to repair a cranial defect after the resection of a primary Ewing's sarcoma of the skull in a one-step surgical procedure.

Results

Bone repair with a custom-made cranioplasty immediately after resection of a primary Ewing's sarcoma of the skull avoids deformities and late complications associated with reconstructive surgery after radiotherapy and not interfere with radiotherapy and neither with follow-up.

Conclusion

A one-step surgical procedure after chemotherapy for primary Ewing's sarcoma of the skull could be safer, less aggressive and more radical; avoiding deformities and late complications.