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Open access

BRAF-mutated suprasellar glioblastoma mimicking craniopharyngioma: illustrative case

Bryan Zheng, Belinda Shao, Jennifer Mingrino, Jonathan Poggi, Richard S Dowd, Douglas C Anthony, John E Donahue, and Curtis E Doberstein

BACKGROUND

Suprasellar masses commonly include craniopharyngiomas and pituitary adenomas. Suprasellar glioblastoma is exceedingly rare with only a few prior case reports in the literature. Suprasellar glioblastoma can mimic craniopharyngioma or other more common suprasellar etiologies preoperatively.

OBSERVATIONS

A 65-year-old male with no significant history presented to the emergency department with a subacute decline in mental status. Work-up revealed a large suprasellar mass with extension to the right inferior medial frontal lobe and right lateral ventricle, associated with significant vasogenic edema. The patient underwent an interhemispheric transcallosal approach subtotal resection of the interventricular portion of the mass. Pathological analysis revealed glioblastoma, MGMT partially methylated, with a BRAF V600E mutation.

LESSONS

Malignant glioblastomas can mimic benign suprasellar masses and should remain on the differential for a diverse set of brain masses with a broad range of radiological and clinical features. For complex cases accessible from the ventricle where the pituitary complex cannot be confidently preserved via a transsphenoidal approach, an interhemispheric approach is also a practical initial surgical option. In addition to providing diagnostic value, molecular profiling may also reveal therapeutically significant gene alterations such as BRAF mutations.

Open access

The infundibulochiasmatic angle and the favorability of an endoscopic endonasal approach in type IV craniopharyngioma: illustrative case

Guilherme Finger, Maria Jose C Ruiz, Eman H Salem, Matthew D Marquardt, Kyle C Wu, Lucas P Carlstrom, Ricardo L Carrau, Luciano M Prevedello, and Daniel M Prevedello

BACKGROUND

Lesions located in the floor of the third ventricle are among the most difficult to access in neurosurgery. The neurovascular structures can limit transcranial exposure, whereas tumor extension into the third ventricle can limit visualization and access. The midline transsphenoidal route is an alternative approach to tumor invading the third ventricle if the tumor is localized at its anterior half and a working space between the optic apparatus and the pituitary infundibulum exists. The authors introduce the “infundibulochiasmatic angle,” a valuable measurement supporting the feasibility of the translamina terminalis endoscopic endonasal approach (EEA) for resection of type IV craniopharyngiomas.

OBSERVATIONS

Due to a favorable infundibulochiasmatic angle measurement on preoperative magnetic resonance imaging (MRI), an endoscopic endonasal transsellar transtubercular approach was performed to resect a type IV craniopharyngioma. At 2-month follow-up, the patient’s neurological exam was unremarkable, with improvement in bitemporal hemianopsia. Postoperative MRI confirmed gross-total tumor resection.

LESSONS

The infundibulochiasmatic angle is a radiological tool for evaluating the feasibility of EEA when resecting tumors in the anterior half of the third ventricle. Advantages include reduced brain retraction and excellent rates of resection, with minimal postoperative risks of cerebrospinal fluid leakage and permanent pituitary dysfunction.

Open access

Surgical management of metastatic Hürthle cell carcinoma to the skull base, cortex, and spine: illustrative case

N. U. Farrukh Hameed, Meagan M Hoppe, Ahmed Habib, Jeffrey Head, Regan Shanahan, Bradley A Gross, Sandra Narayanan, Georgios Zenonos, and Pascal Zinn

BACKGROUND

Hürthle cell carcinoma (HCC) is an unusual and aggressive variant of the follicular type of differentiated thyroid cancer (DTC), accounting for less than 3% of DTCs but posing the highest risk of metastasis. Brain metastases are uncommonly reported in the literature but pose a poor prognosis. The low rate of brain metastases from HCC coupled with ambiguous treatment protocols for the extracranial disease complicate successful disease management and definitive treatment strategy. The authors present the case of a patient with HCC metastasis to the skull base, cortex, and spine with recent tibial metastasis.

OBSERVATIONS

Despite the presence of metastasis to the cortex, skull base, and spine, the patient responded very well to radiation therapy, sellar mass resection, and cervical spine decompression and fixation and has made a remarkable recovery.

LESSONS

The authors’ multidisciplinary approach to the patient’s care, including a diverse team of specialists from oncology, neurosurgery, orthopedic surgery, radiology, endocrinology, and collaboration with clinical trial researchers, was fundamental to her successful outcome, demonstrating the utility of intersecting specialties in successful outcomes in neuro-oncological patient care.

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

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

Endoscopic endonasal resection of a primary intraosseous clival myxoma: illustrative case

Riley Young, Brandon Laing, Benjamin Best, Gillian L. Harrison, and Nathan Zwagerman

BACKGROUND

An intraosseous myxoma is a rare, benign mesenchymal tumor that penetrates the bone. The occurrence of an intraosseous myxoma in the clivus is a unique presentation of the disease.

OBSERVATIONS

The authors discuss the case of a 15-year-old male with a new diagnosis of a primary clival intraosseous myxoma presenting with cranial nerve VI palsy. This is the third documented case of this pathology occurring in the clivus. This patient was successfully treated with endoscopic endonasal resection of the tumor.

LESSONS

Primary clival intraosseous myxomas are extremely rare, but nonetheless it is important to add it to the differential diagnosis of clival masses. This mass has a high risk of recurrence, and prior literature suggests gross total resection may improve chances of progression-free survival. However, further larger studies are needed to provide guidelines regarding proper management of this pathology.

Open access

Primary isolated skull base eosinophilic granuloma confined to the anterior clinoid process: illustrative case

Ahmad Pour-Rashidi, Payam Asem, Kazem Abbasioun, and Abbas Amirjamshidi

BACKGROUND

Solitary eosinophilic granuloma (EG) occurs anecdotally in the skull base region, and it has been described in only three previous publications. The authors report the first case of EG of the anterior clinoid process (ACP), which was confined to the ACP and presented with decreased vision.

OBSERVATIONS

A 38-year-old woman presented with decreased vision of the left eye of 5 months’ duration. Her visual acuity was 3/10, other neurological examinations were intact, and there were no other osseous or soft tissue lesions. The lesion was excised using a left-sided craniotomy and transdural clinoidectomy, decompressing the optic nerve both intra- and extradurally. The lesion was characteristic for EG, and no recurrence was detected after 2 years.

LESSONS

EG can be confined to the ACP and impair vision. Imaging studies are sensitive but not specific, and surgical decompression is both diagnostic and treatment oriented. Close observation and even adjuvant therapy may be indicated in similar cases.