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Open access

Cerebral arterial vasospasm complicating supratentorial meningioma resection: illustrative cases

Andrew C Pickles, John T Tsiang, Alexandria A Pecoraro, Nathan C Pecoraro, Ronak H Jani, Brandon J Bond, Anand V Germanwala, Joseph C Serrone, and Vikram C Prabhu

BACKGROUND

Cerebral arterial vasospasm is a rare complication after supratentorial meningioma resection. The pathophysiology of this condition may be similar to vasospasm after aneurysmal subarachnoid hemorrhage, and treatment options may be similar.

OBSERVATIONS

The authors present two cases of cerebral vasospasm after supratentorial meningioma resection and perform a systematic literature review of similar cases.

LESSONS

Cerebral arterial vasospasm after supratentorial meningioma resection may be associated with significant morbidity due to cerebral ischemia if not addressed in a timely manner. Treatment paradigms may be adopted from the management of arterial vasospasm associated with subarachnoid hemorrhage.

Open access

Delayed fatal intracranial hemorrhage in a pediatric patient following resection and adjuvant cranial radiotherapy for ependymoma: illustrative case

Matthew L. Farmer, Adam M. Conley, and Joseph F. Dilustro

BACKGROUND

Cranial radiotherapy (CRT) is an important treatment modality for malignancies of the central nervous system. CRT has deleterious effects that are commonly classified into acute, early delayed, and late delayed. Late-delayed effects include weakening of the cerebral vasculature and the development of structurally abnormal vasculature, potentially leading to ischemic or hemorrhagic events within the brain parenchyma. Such events are not well reported in the pediatric population.

OBSERVATIONS

The authors present the case of a 14-year-old patient 8.2 years after CRT who experienced intracerebral hemorrhage. Autopsy demonstrated minimal pathological change without evidence of vascular malformation or aneurysm. These findings were unexpected given the degree of hemorrhage in this case. However, in the absence of other etiologies, it was believed that late-delayed radiation effect was the cause of this patient’s fatal hemorrhage.

LESSONS

Although not all cases of pediatric spontaneous intracerebral hemorrhage will have a determined etiology, the authors’ patient’s previous CRT may represent a poorly defined risk for late-delayed hemorrhage. This correlation has not been previously reported and should be considered in pediatric patients presenting with spontaneous hemorrhage in a delayed fashion after CRT. Neurosurgeons must not be dismissive of unexpected events in the remote postoperative period.

Open access

Vascular steal and associated intratumoral aneurysms in highly vascular brain tumors: illustrative case

Christopher S. Hong, Neelan J. Marianayagam, Saul F. Morales-Valero, Tanyeri Barak, Joanna K. Tabor, Joseph O’Brien, Anita Huttner, Joachim Baehring, Murat Gunel, E. Zeynep Erson-Omay, Robert K. Fulbright, Charles C. Matouk, and Jennifer Moliterno

BACKGROUND

Intratumoral aneurysms in highly vascular brain tumors can complicate resection depending on their location and feasibility of proximal control. Seemingly unrelated neurological symptoms may be from vascular steal that can help alert the need for additional vascular imaging and augmenting surgical strategies.

OBSERVATIONS

A 29-year-old female presented with headaches and unilateral blurred vision, secondary to a large right frontal dural-based lesion with hypointense signal thought to represent calcifications. Given these latter findings and clinical suspicion for a vascular steal phenomenon to explain the blurred vision, computed tomography angiography was obtained, revealing a 4 × 2–mm intratumoral aneurysm. Diagnostic cerebral angiography confirmed this along with vascular steal by the tumor from the right ophthalmic artery. The patient underwent endovascular embolization of the intratumoral aneurysm, followed by open tumor resection in the same setting without complication, minimal blood loss, and improvement in her vision.

LESSONS

Understanding the blood supply of any tumor, but highly vascular ones in particular, and the relationship with normal vasculature is undeniably important in avoiding potentially dangerous situations and optimizing maximal safe resection. Recognition of highly vascular tumors should prompt thorough understanding of the vascular supply and relationship of intracranial vasculature with consideration of endovascular adjuncts when appropriate.

Open access

Cerebral tumor embolism from thyroid cancer treated by mechanical thrombectomy: illustrative case

Yuta Fujiwara, Kentaro Hayashi, Yohei Shibata, Tatsuya Furuta, Tomohiro Yamasaki, Kazuhiro Yamamoto, Masahiro Uchimura, Fumio Nakagawa, Mizuki Kambara, Hidemasa Nagai, and Yasuhiko Akiyama

BACKGROUND

Development in mechanical thrombectomy is progressing dramatically. Tumor embolism has been rarely reported on the basis of pathological study of the retrieved thrombus. Herein, the authors report a case of cerebral tumor embolism from advanced thyroid cancer, which was successfully treated with mechanical thrombectomy.

OBSERVATIONS

A 57-year-old man was diagnosed with thyroid cancer with multiple lung metastases and chemotherapy was planned. He experienced left hemiparesis and was bought to the emergency section of the authors’ hospital. Magnetic resonance angiography revealed right internal carotid artery occlusion and endovascular treatment was performed. Using a combination of aspiration catheter and stent retriever, white jelly-like embolus was retrieved. The pathological study demonstrated thyroid cancer embolism. Pulmonary vein invasion following lung metastasis of thyroid cancer was most presumably the cause of the tumor embolism.

LESSONS

Lung metastasis invading the pulmonary vein may be a cause of tumor embolism. Mechanical thrombectomy using a combination of stent retriever and aspiration catheter is effective in removing the tumor embolus and the pathological examination of the embolus is essential.

Open access

Pituitary macroadenoma causing vision loss in Wyburn-Mason syndrome: illustrative case

Nicholas F. Hug, David A. Purger, Heather E. Moss, and Robert L. Dodd

BACKGROUND

Wyburn-Mason syndrome (WMS) is a neurocutaneous disorder consisting of vascular malformations of the brain, eye, and skin. These include characteristically high-flow intracranial and intraorbital arteriovenous malformations (AVMs) that present commonly with visual deterioration, headache, and hemiplegia. Complete removal of these lesions is challenging. Most patients are followed closely, and intervention occurs only in the setting of worsening symptoms secondary to AVM growth or hemorrhage. Here the authors present the first known case of a patient with WMS and a pituitary macroadenoma.

OBSERVATIONS

A 62-year-old man with a 30-year history of WMS with right basal ganglia and orbital AVMs and right eye blindness presented for new-onset left-sided vision loss. A pituitary adenoma was identified compressing the optic chiasm and left optic nerve. Magnetic resonance imaging and digital subtraction angiography studies were obtained for surgical planning, and the patient underwent an endoscopic transnasal transsphenoidal resection, with significant postoperative vision improvement.

LESSONS

Given the variable presentation and poor characterization of this rare syndrome, patients with WMS presenting with new symptoms must undergo evaluation for growth and hemorrhage of known AVMs, as well as new lesions. Further, in patients undergoing intracranial surgery, extensive preoperative imaging and planning are crucial for safe and successful procedures.

Open access

Skull base chondroblastoma with aneurysmal bone cyst–like changes treated with percutaneous radiofrequency ablation and doxycycline sclerotherapy: illustrative case

Madeline I. Foo, Kathleen Nicol, and James W. Murakami

BACKGROUND

Chondroblastomas (CBs) are rare benign bone tumors that are often difficult to treat because of their locations. CBs can be even more challenging to successfully manage when they present alongside aneurysmal bone cyst (ABC)-like changes. To minimize operative morbidity, especially in hard-to-reach lesions, percutaneous approaches for both lesions have been individually described. We present a skull base CB with associated ABC-like changes treated by combining two different previously described percutaneous modalities.

OBSERVATIONS

The authors report successful percutaneous treatment of a skull base CB with adjacent ABC-like changes in a 17-year-old male. The CB was treated with radiofrequency ablation (RFA) and the adjacent ABC area with doxycycline sclerotherapy. After 3 years of follow-up, there has been no clinical or radiological evidence of recurrence.

LESSONS

CBs occur in the skull base and, as elsewhere in the body, can be associated with ABC-like changes. Successful percutaneous treatment of such a CB with ABC-like changes is possible by combining previously described techniques of RFA and doxycycline sclerotherapy.

Open access

The surgical management of pituitary apoplexy with occluded internal carotid artery and hidden intracranial aneurysm: illustrative case

Jian-Dong Zhu, Sungel Xie, Ling Xu, Ming-Xiang Xie, and Shun-Wu Xiao

BACKGROUND

Approximately 0.6% to 12% of cases of pituitary adenoma are complicated by apoplexy, and nearly 6% of pituitary adenomas are comorbid aneurysms. Occlusion of the internal carotid artery (ICA) with hidden intracranial aneurysm due to compression by an apoplectic pituitary adenoma is extremely rare; thus, the surgical strategy is also unknown.

OBSERVATIONS

The authors reported the case of a 48-year-old man with a large pituitary adenoma with coexisting ICA occlusion. After endoscopic transnasal surgery, repeated computed tomography angiography (CTA) demonstrated reperfusion of the left ICA but with a new-found aneurysm in the left posterior communicating artery; thus, interventional aneurysm embolization was performed. With stable recovery and improved neurological condition, the patient was discharged for rehabilitation training.

LESSONS

For patients with pituitary apoplexy accompanied by a rapid decrease of neurological conditions, emergency decompression through endoscopic endonasal transsphenoidal resection can achieve satisfactory results. However, with occlusion of the ICA by enlarged pituitary adenoma or pituitary apoplexy, a hidden but rare intracranial aneurysm may be considered when patients are at high risk of such vascular disease as aneurysm, and gentle intraoperative manipulations are required. Performing CTA or digital subtraction angiography before and after surgery can effectively reduce the missed diagnosis of comorbidity and thus avoid life-threatening bleeding events from the accidental rupture of an aneurysm.

Open access

Treatment of postoperative vasospasm with intraarterial verapamil after removal of intracranial tumor: patient series

Ketevan Mikeladze, Anton Konovalov, Andrey Bykanov, Evgeniy Vinogradov, and Sergey Yakovlev

BACKGROUND

The authors report on four clinical cases with intraarterial verapamil administration to resolve vasospasm in patients who underwent surgery for intracranial tumors. Iatrogenic subarachnoid hemorrhage after tumor resection and subsequent vasospasm (an increase in the systolic linear velocity of blood flow through the M1 segment of the middle cerebral artery of more than 250 cm/sec; Lindegaard index: 4.1) were observed in four patients during the early postoperative period after the removal of intracerebral tumors. Each vasospasm case was confirmed by angiography data, was clinically significant, and manifested as the development of a neurological deficit.

OBSERVATIONS

Resolution of vasospasm with the intraarterial administration of verapamil was achieved in all four cases as confirmed by angiographic data in all four cases and complete regression of neurological symptoms in two cases. In all four presented cases, vasospasm was resolved; unfortunately, the resolution did not always lead to significant clinical improvement. However, lethal outcomes were avoided in two cases, and almost full recoveries were achieved in the other two.

LESSONS

The authors believe that the removal of intracranial tumors can cause expected and potential complications, such as cerebral vasospasm, which must be diagnosed and treated in a timely manner.