Preoperative stent placement for intradural vertebral artery stenosis from a rare xanthogranuloma

Case report

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✓ In this report, the authors discuss a novel use of intradural vertebral artery (VA) stent placement to protect a tumor-encased vessel from injury during lesion resection. The tumor was a rare foramen magnum region xanthogranuloma and a component of Erdheim—Chester disease (ECD). This 64-year-old man presented with large masses encasing and compressing the intracranial segments of each VA. Preoperatively, a left VA stent was placed to protect the arterial wall during resection of the tumor. Histopathological study results on the subtotally resected mass were consistent with xanthogranuloma, a rare benign histiocytic tumor frequently occurring in patients with ECD. Further radiographic evaluation in the patient revealed an osteolytic lesion of the eleventh thoracic vertebra supporting the diagnosis of ECD disease. Based on this case study, the authors recommend the following: 1) tumor-encased vessels can be protected preoperatively by stent placement to assist with tumor debulking; and 2) patients diagnosed with a xanthogranuloma should be evaluated for multisystem involvement consistent with ECD.

Article Information

Address reprint requests to: Alan S. Boulos, M.D., Albany Medical Center, MC61, Division of Neurosurgery, 47 New Scotland Avenue, MC61, Albany, New York 12208. email: boulosa@mail.amc.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Left: A T1-weighted Gd-enhanced axial MR image demonstrating bilateral encasement of the VAs (small arrows) by mass lesions (large arrows) in the region of the foramen magnum. Note that the left VA flow void is more prominent than the right. Right: A T1-weighted sagittal MR image without Gd demonstrating a large extraaxial lesion (arrow) displacing the brainstem dorsally and compressing the medulla.

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    Left: Diagnostic cerebral angiogram of the vertebrobasilar system (right oblique Towne view, left VA injection) revealing severe focal stenosis (arrow) of the left VA and absence of retrograde right VA filling. Right: Diagnostic cerebral angiogram obtained after stent placement, demonstrating robust filling (arrow) of the previously stenotic segment of the left VA (right oblique Towne view, left VA injection); the right VA now fills by retrograde flow.

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    Postoperative CT scan of the head. Bone windows demonstrate the removal of the left foramen magnum and posterior half of the condyle during the far lateral transcondylar approach. A cross-section of the left VA stent is visualized in this slice.

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    Postoperative T1-weighted Gd-enhanced axial MR image demonstrating resection of the tumor from the lateral wall of the left VA (arrow). The left VA flow void is more prominent than that on the right.

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    Photomicrographs of a foramen magnum xanthogranuloma. Low- (upper left) and high-power (upper right) views of the lesion showing foamy macrophages and multinucleated giant cells in a background of chronic inflammatory infiltration and fibrosis. Arrows indicate Touton giant cells. Cytoplasmic stain is demonstrated in the macrophages and giant cells (lower left and right). H & E (upper left and right), CD68 (lower left), and factor 13a (lower right). Original magnification × 100 (upper right), × 400 (upper left and lower left and right).

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