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Open access

Adaptive treatment strategy for a vestibular schwannoma in a patient with vascular Eagle syndrome: illustrative case

Nilay Karaman, Ali Haluk Düzkalir, Mehmet Orbay Askeroglu, Yunus Emre Senturk, Yavuz Samanci, and Selcuk Peker

BACKGROUND

Eagle syndrome, an uncommon condition, causes symptoms due to neural and/or vascular compression from an elongated styloid process or calcified stylohyoid ligament and can also complicate other planned surgical procedures.

OBSERVATIONS

A 42-year-old female with loss of balance, dizziness, and ataxic gait underwent cranial magnetic resonance imaging (MRI), revealing a right-sided Koos grade IV vestibular schwannoma. Initially, a retrosigmoid craniotomy for tumor resection was planned. However, preoperative MRI and computed tomography (CT) showed a dilated right-sided mastoid emissary vein, tortuous scalp and paraspinal veins, and bilateral elongated styloid processes. CT angiography and digital subtraction angiography indicated Eagle syndrome–related compression of both internal jugular veins and concurrent occlusion of the left internal jugular vein at the jugular foramen. Consequently, given the risk of damaging venous structures, Gamma Knife radiosurgery was chosen over resection.

LESSONS

This case highlights the importance of adapting treatment plans based on patient-specific anatomical and pathological factors. In situations in which traditional surgery poses risks to sensitive structures such as the venous system, alternative approaches like radiosurgery offer safer yet effective options. Comprehensive risk-benefit evaluations are crucial for such decisions.

Open access

Management of recurrent giant hemangiopericytoma: illustrative cases

Joshua Vignolles-Jeong, Guilherme Finger, Ben G McGahan, Thomas L Beaumont, Matthieu D Weber, Kyle C Wu, and Daniel M Prevedello

BACKGROUND

Hemangiopericytoma (HPC) is a rare malignancy accounting for 0.4% of intracranial tumors. HPCs are characterized by local aggressiveness, high rates of recurrence, and a tendency to metastasize to extracranial sites. These features make management of HPCs challenging, often requiring a combination of radical resection and radiation. Given their rarity, optimal treatment algorithms remain undefined.

OBSERVATIONS

The authors report a series of four patients who underwent resection of intracranial HPC. Mean age at presentation was 49.3 years. Three patients had reoperation for progression of residual tumor, and one patient was surgically retreated for recurrence. One patient received adjuvant radiotherapy following initial resection, and three patients received adjuvant radiotherapy following resection of recurrent or residual disease. There was one death in the series. Average progression-free survival and overall survival following the index procedure were 32.8 and 82 months, respectively. Progression occurred locally in all patients, with metastatic recurrence in one patient.

LESSONS

The current gold-standard treatment for intracranial HPC consists of gross-total resection followed by radiation therapy. This approach allows satisfactory local control; however, given the tendency for these tumors to recur either locally or distally within or outside of the central nervous system, there is a need for salvage therapies to improve long-term outcomes for patients.

Open access

Role of stereotactic radiosurgery for recurrent skull base acinic cell carcinoma: illustrative case

Tomohiro Yoshihira, Motoyuki Umekawa, Yuki Shinya, Hirotaka Hasegawa, Masahiro Shin, Yodai Kikuchi, Yuki Saito, Kenji Kondo, Atsuto Katano, Aya Shinozaki-Ushiku, and Nobuhito Saito

BACKGROUND

Acinic cell carcinomas (AcCCs), rare malignancies of the salivary glands, often recur and metastasize, particularly in the skull base. Conventional radical resection can be invasive for skull base AcCCs adjacent to cranial nerves and major vasculature, and the effectiveness of stereotactic radiosurgery (SRS) as an alternative is not well established.

OBSERVATIONS

This case report details the application of SRS for recurrent skull base AcCCs. A 71-year-old male with a history of resection for a right mandibular AcCC 23 years earlier experienced tumor recurrence involving the right cavernous sinus and nasal cavity. He underwent endoscopic transnasal surgery followed by SRS targeting different tumor locations—the cavernous sinus to the pterygopalatine fossa, maxillary sinus, and clivus—each with a prescribed dose of 20 Gy to the 40% to 50% isodose line. After the first skull base metastasis, additional sessions of localized SRS after endoscopic surgery led to a 12-year survival without sequela.

LESSONS

This is a report indicating that SRS for skull base AcCCs can achieve favorable local control, functional preservation, and long-term survival. SRS may be suitable for skull base AcCC given the lesion’s tendency toward multiple local recurrences. Further investigation is needed to validate the treatment’s efficacy.

Open access

Salvage pemetrexed for brain metastases from ALK-positive lung cancer after Gamma Knife radiosurgery: illustrative case

Ryuichi Noda, Atsuya Akabane, Mariko Kawashima, Masafumi Segawa, Sho Tsunoda, and Tomohiro Inoue

BACKGROUND

Systemic therapy for cancer treatment has improved, and therapeutic options for intracranial lesions are increasing. Combinations of treatment modalities are required in certain difficult cases. Gamma Knife radiosurgery (GKS) is effective for the treatment of brain metastases, especially for lesions that are inoperable because of their anatomical or functional location.

OBSERVATIONS

The authors report a case of brain metastases in anaplastic lymphoma kinase (ALK)-positive lung adenocarcinoma initially treated with GKS followed by the combination of repeat GKS and ALK tyrosine kinase inhibitors (ALK-TKIs) for tumor recurrence. During the clinical course, acquired resistance to ALK-TKIs due to the long exposure period was suspected. After a great deal of thought and discussion with the oncologist responsible for the treatment of the pulmonary lesions, the authors successfully controlled the lesion for the next 17 months by salvage pemetrexed administration.

LESSONS

This is the first report on the effectiveness of pemetrexed for recurrent brain metastasis from ALK-positive lung adenocarcinoma resistant to both radiosurgery and ALK inhibitors. Salvage pemetrexed showed a favorable therapeutic effect in this specific case.

Open access

Stereotactic radiosurgery for the treatment of a distant recurrence of ependymoma on the optic nerve: illustrative case

Eduardo Orrego González, M. Beatriz Lopes, Gabriel Anibal Ramos, and Jason P Sheehan

BACKGROUND

Ependymomas rarely disseminate to other central nervous system areas distant from the original site. Stereotactic radiosurgery (SRS) provides high control rates for recurring ependymomas. The treatment of optic nerve tumors carries high morbidity, but SRS is an acceptable option to manage these cases to reduce risks.

OBSERVATIONS

The authors report the case of a 31-year-old male with a cervical spinal ependymoma who had a disseminated pattern of recurrence including the optic nerve after initial resection of the cervical lesion. The optic nerve tumor was treated with SRS, and the authors discuss the technical aspects of the treatment and its outcomes. At the last follow-up, the optic nerve tumor was controlled with SRS, and visual function was preserved.

LESSONS

High-grade ependymomas such as the one in the presented case can have unpredictable patterns of recurrence. SRS provides excellent control of the distant recurring ependymoma with a low complication profile given the location of the tumor in this case.

Open access

Novel combination of GammaTile cesium-131 brachytherapy with 5-aminolevulinic acid fluorescence–guided resection in the re-irradiation of pediatric recurrent high-grade glioma: illustrative case

Julian A. Gordon, Melisa Pasli, Cathleen M. Cook, Rainor Connor, Philip J. Boyer, Andrew W. Ju, K. Stuart Lee, Kathleen E. Knudson, and M. Sean Peach

BACKGROUND

Herein, the authors describe the successful utilization of 5-aminolevulinic acid (5-ALA) and the first case of GammaTile cesium-131 therapy in a pediatric patient with recurrent high-grade glioma. 5-ALA was utilized to optimize gross-total resection prior to GammaTile implantation. After conversion to an equivalent dose in 2-Gy fractions (EQD2), a composite was made of the GammaTile dose with the initial external beam radiotherapy. Two hypothetical plans consisting of a standard hypofractionated strategy for glioma reirradiation and a CyberKnife plan using GammaTile’s planning target volume were developed and likewise underwent EQD2 conversion and composite plan generation with the initial radiotherapy.

OBSERVATIONS

5-ALA was useful in achieving gross-total resection with no acute toxicity from the surgery or GammaTile irradiation. When compared with the hypothetical composite doses, GammaTile’s composite, axium point dose (D0.03cc) to the brainstem was 32.9 Gy less than the hypofractionated and the CyberKnife composite plans at 38.7 Gy and 40.2 Gy, respectively. The right hippocampus demonstrated a substantially reduced composite plan dose with GammaTile with a D0.03cc of 62.4 Gy versus 71.7 and 80.7 Gy for the hypofractionated and CyberKnife composite plans, respectively.

LESSONS

Utilization of 5-ALA and GammaTile therapy yielded clinically superior tumor debulking and effective radiotherapy dose localization with sparing of organs at risk, respectively.

Open access

Symptomatic radionecrosis after postoperative but not preoperative stereotactic radiosurgery in a single patient: illustrative case

Bryce J Laurin, Michael Straza, George Noid, Jennifer M Connelly, Wade M Mueller, Joseph Bovi, and Max O Krucoff

BACKGROUND

Standard of care for brain metastases involves stereotactic radiosurgery (SRS). For cases that also require surgery because of lesion size, edema, or neurological symptoms, whether to provide pre- or postoperative SRS has become a prevalent debate.

OBSERVATIONS

Herein, the unique case of a patient with brain metastases of the same pathology and similar size in two different brain locations at two different times is described. The patient underwent surgery with preoperative SRS for the first lesion and surgery with postoperative SRS for the second lesion. Although both treatments resulted in successful local control, the location that received postoperative SRS developed symptomatic and rapidly progressive radiation necrosis (RN) requiring a third craniotomy.

LESSONS

Large randomized controlled trials are ongoing to compare pre- versus postoperative SRS for the treatment of symptomatic brain metastases (e.g., study NRG-BN012). Recent interest in preoperative SRS has emerged from its theoretical potential to decrease rates of postoperative RN and leptomeningeal disease. This valuable case in which both therapies were applied in a single patient with a single pathology and similar lesions provides evidence supportive of preoperative SRS.

Open access

Rubrospinal activation during asleep subthalamic nucleus deep brain stimulation: a false localizing sign. Illustrative case

Devon L. Mitchell, John Pearce, Patrick King, and Sepehr Sani

BACKGROUND

Deep brain stimulation (DBS) can be a life-changing intervention for patients with Parkinson’s disease (PD), but its success is largely dependent on precise lead placement. The subthalamic nucleus (STN) is one of the most common surgical targets of DBS, but the close anatomical and physiological resemblance of the STN to the mediocaudal red nucleus renders these landmarks difficult to distinguish.

OBSERVATIONS

We present an atypical case in which targeted localization of the STN resulted in symptoms pathognomonic of rubrospinal tract (RST) stimulation. A 79-year-old female with a 12-year history of right-hand resting tremor due to medically refractory PD presented for asleep bilateral STN-DBS surgery. Right STN intraoperative testing revealed left hand and elbow flexion contractures, initially suggestive of corticospinal tract activation, despite imaging studies demonstrating reasonable lead placement in the central dorsolateral STN. The lead was moved anteromedially near the medial border of the STN, but stimulation at this location revealed similar but more robust flexor hand and arm contractures, without any extraocular muscle involvement. Thus, activation of the RST was suspected.

LESSONS

Isolated activation of the RST is possible during STN-DBS surgery. Its identification can help avoid false localization and suboptimal lead placement.

Open access

Rare clival localization of an eosinophilic granuloma: illustrative case

Martin E. Weidemeier, Steffen Fleck, Werner Hosemann, Silke Vogelgesang, Karoline Ehlert, Holger N. Lode, and Henry W. S. Schroeder

BACKGROUND

Eosinophilic granuloma (EG) belongs to the family of Langerhans cell histiocytosis (LCH) and is considered to be a benign disease typically found in children younger than 15 years of age. Here, the authors describe an EG of unusual localization and clinical presentation.

OBSERVATIONS

The authors report a 9-year-old girl with an EG presenting as an osteolytic lesion of the clivus. After transsphenoidal resection and histological confirmation, adjuvant chemotherapy was initiated. Presenting signs and symptoms were weight loss, episodic grimacing, and moderate ballism-like movements. After a follow-up-period of 32 months, the patient presented with a total resolution of initial symptoms and no further tumor growth.

LESSONS

Although these lesions are rare, one should consider EG as a differential diagnosis when confronted with osteolytic lesions of the clivus.

Open access

White epidermoid cyst transformation after stereotactic radiosurgery: illustrative case

Hideki Matsumoto, Yuki Shinya, Satoru Miyawaki, Masahiro Shin, Satoshi Koizumi, Daisuke Sato, Munetoshi Hinata, Masako Ikemura, Satoshi Kiyofuji, Taich Kin, Mototaro Iwanaga, Masahiro Shimizu, Hirofumi Nakatomi, and Nobuhito Saito

BACKGROUND

White epidermoid cysts (WECs) are a rare type of epidermoid cyst with atypical radiological features. The epidemiological aspects and mechanisms of their onset remain unknown. Herein, the authors report a unique case of WEC transformation from a typical epidermoid cyst after stereotactic radiosurgery (SRS), confirmed by radiological and pathological findings.

OBSERVATIONS

The case involved a 78-year-old man with a history of 2 surgeries for a left cerebellopontine angle typical epidermoid cyst 23 years earlier and SRS using the CyberKnife for recurrent trigeminal neuralgia (TN) 14 years earlier. The tumor with high intensity on T1-weighted imaging, low intensity on T2-weighted imaging, without restriction on diffusion-weighted imaging had gradually enlarged after SRS. Therefore, a salvage surgery was performed via a left suboccipital craniotomy, and the intraoperative findings showed a cyst with a brown, viscous liquid component, consistent with those of WECs. Histopathologically, keratin calcification and hemorrhage were identified, leading to a diagnosis of WEC. The postoperative course was uneventful, and the TN resolved. No tumor recurrence was recorded at 2 years postoperatively.

LESSONS

To the best of the authors’ knowledge, this is the first world case of WEC transformation from a typical epidermoid cyst after SRS, confirmed by radiological and pathological findings. Radiation effects could have been involved in this transformation.