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Open access

Posterior fossa Hodgkin’s lymphoma radiographically mimicking an arteriovenous malformation: illustrative case

Joshua D McBriar, Kyriakos Papadimitriou, Danielle Golub, Hayley Donaldson, Jian Y Li, Pallavi Khattar, Samuel Singer, Karen S Black, and Thomas W Link

BACKGROUND

Intracranial Hodgkin’s lymphoma (HL) is an exceedingly rare condition that is at an increased risk of misdiagnosis and mismanagement, especially when initial radiographic evidence points to an alternative pathology.

OBSERVATIONS

The authors describe the case of a 75-year-old female who presented with a posterior fossa lesion initially concerning for a vascular malformation on computed tomography imaging due to perilesional hypervascularity. Subsequent angiography revealed a developmental venous anomaly (DVA) but no arteriovenous shunting. The patient’s clinical history combined with magnetic resonance imaging findings prompted a tissue biopsy, which demonstrated a rare case of central nervous system (CNS) HL. The neoangiogenesis of this CNS HL with an adjacent DVA contributed to the original radiographic misdiagnosis of an arteriovenous malformation. HL’s angiogenic potential, coupled with the proangiogenic environment induced around DVAs, may have contributed to this rare CNS HL metastasis to the cerebellum. The potential misdiagnosis of posterior fossa CNS HL has also been seen in several prior cases reviewed herein.

LESSONS

Hypervascular tumors, especially when associated with an adjacent DVA, should also be considered when first evaluating suspected intracranial vascular lesions. Although rare, CNS HL should be included in the differential diagnosis for patients with a prior history of HL.

https://thejns.org/doi/10.3171/CASE24238

Open access

Revealing subependymal giant cell astrocytoma with multimodal positron emission tomography: illustrative cases

Nobuhiko Kawai, Daisuke Ogawa, Tomono Fuke, Masaki Tatano, Momo Ishikawa, Takahiro Kanda, Kenta Suzuki, Takeshi Fujimori, Yasunori Toyota, Tetsuhiro Hatakeyama, Masanobu Okauchi, Masahiko Kawanishi, Reiji Haba, Akira Kurose, Yo Nida, and Keisuke Miyake

BACKGROUND

There is limited literature on the use of positron emission tomography (PET) for benign tumors originating in the brain ventricles, and the use of multiple tracers for subependymal giant cell astrocytoma (SEGA) has not been reported. The authors compared the PET findings in two SEGA cases with past reports and literature, exploring the distinctive characteristics of SEGA on PET.

OBSERVATIONS

In a 21-year-old female with SEGA, the authors utilized 18F-fluorodeoxyglucose (18F-FDG), 11C-methionine (11C-MET), 18F-fluorothymidine (18F-FLT), 18F-fluoromisonidazole, and 18F-THK5351 tracers. Additionally, in a 6-year-old girl, the authors performed 11C-MET PET.

LESSONS

The results indicated the accumulation of all tracers except 18F-FDG, with particularly intense accumulation noted with 18F-FLT. In particular, 18F-FLT demonstrated accumulation comparable to that observed in malignant tumors. This study suggests that multiple PET tracers can provide valuable insights into the characterization of SEGA, with 18F-FLT showing particular promise as a distinctive marker of blood-brain barrier disruption. Further research in larger cohorts may enhance our understanding of metabolic patterns in SEGA and aid in its diagnosis and treatment.

https://thejns.org/doi/10.3171/CASE24111

Open access

Enlarging neurenteric cyst at the craniocervical junction with a fluid-fluid level on magnetic resonance imaging: illustrative case

Toshihide Takahashi, Kiyoyuki Yanaka, Hitoshi Aiyama, Minami Saura, Michihide Kajita, Nobuyuki Takahashi, Kuniyuki Onuma, and Eiichi Ishikawa

BACKGROUND

Neurenteric cysts are relatively rare benign congenital intracranial cystic lesions that enlarge rarely and very slowly. The authors present a case of an enlarging neurenteric cyst at the craniocervical junction with a fluid-fluid level on magnetic resonance imaging (MRI).

OBSERVATIONS

A 34-year-old man with no significant medical history underwent head MRI to investigate mild headaches. An incidental cystic lesion, approximately 8 mm in diameter, was revealed at the craniocervical junction. Serial follow-up MRI showed cyst enlargement with a fluid-fluid level. Four years later, the cyst reached a size of 15 mm and was surgically removed. The cyst contained cloudy fluid with a high protein concentration, without any bleeding or tissue fragments. Pathological examination confirmed the diagnosis of a neurenteric cyst. The patient recovered well, was discharged home, and has remained recurrence free for 2 years.

LESSONS

The growth dynamics of the relatively rapidly expanding neurenteric cyst at the craniocervical junction were monitored over time using MRI. This cyst exhibited the distinctive feature of a fluid-fluid level as it enlarged. Investigating the mechanisms underlying fluid-fluid level formation may offer novel insights into the pathogenesis of cyst enlargement.

https://thejns.org/doi/10.3171/CASE24180

Open access

Facilitating complete resection of intrinsic motor cortex glioma with titration of high-frequency cortico-subcortical mapping train count informed by navigated transcranial magnetic stimulation: illustrative case

Ryan P Hamer and Adrian J Praeger

BACKGROUND

The dilemma of neuro-oncological surgery involving suspected eloquent cortex is to maximize the extent of resection while minimizing neurological morbidity, referred to as the “onco-functional balance.” Diffuse lower-grade gliomas are capable of infiltrating or displacing neural function within cortical regions and subcortical white matter tracts, which can render classical anatomic associations of eloquent function misleading.

OBSERVATIONS

This study employed presurgical navigated transcranial magnetic stimulation (nTMS) to determine the motor eloquence of a diffuse lower-grade glioma at the superior frontal gyrus extending and intrinsic to the primary motor cortex in a 45-year-old female. Positive nTMS findings were confirmed intraoperatively with high-frequency direct cortico-subcortical stimulation (HF-DCS). Modification of the HF-DCS train count from train-of-five to train-of-two permitted resection beyond classic anatomical boundaries and conventional HF-DCS safe stopping criteria.

LESSONS

Anatomical correlates of function can inaccurately inform the surgical management of diffuse lower-grade glioma, which represents the utmost opportunity for progression-free survival. Integrating an individually tailored nTMS-DCS surgical strategy contributed to complete resection, negating the requirement for adjuvant therapy. Serial nTMS follow-up may assist with the characterization of tumor-induced functional reorganization.

https://thejns.org/doi/10.3171/CASE24197

Open access

Pituitary germinoma after resection of a mature third ventricular teratoma: illustrative case

Tim J Hallenberger, Emma von Seth, Michel Roethlisberger, Raphael Guzman, and Jehuda Soleman

BACKGROUND

Metachronous intracranial germ cell tumors (iGCTs)—unrelated, histologically different iGCTs occurring at different time points—occurring within the same patient remain a rarity. Herein, the authors report such a case and discuss the literature and potential pathophysiological mechanisms leading to this phenomenon.

OBSERVATIONS

A 9-year-old boy presented with new-onset impaired balance, headaches, nausea, visual disturbances, and left facial paresis. Magnetic resonance imaging (MRI) scans revealed a suspected pineal region teratoma originating from the pineal gland with consecutive obstructive hydrocephalus. A mature teratoma was diagnosed and resected. Postoperative recovery was good, and the patient could return to his normal daily activities. However, a new, slowly progressive lesion in the sellar region with an enlarged infundibular stalk was detected on follow-up MRI 3.5 years after initial pineal region teratoma resection. Biopsy revealed a newly developed pure germinoma. The patient was treated with radiotherapy plus chemotherapy and remained relapse free at the last follow-up. Sixteen other cases have reported a surgically resected primary mature teratoma, wherein patients developed metachronous germinomas during follow-up. Different theories try to elaborate this phenomenon, yet none can completely account for it.

LESSONS

Although rare, metachronous iGCT is a phenomenon neurosurgeons should be aware of. In patients treated for iGCT, close long-term clinical, imaging, and laboratory follow-up is recommended.

https://thejns.org/doi/10.3171/CASE2443

Open access

Rare case of tentorial cavernous malformation mimicking a meningioma: illustrative case

Michael Reinert, Danijela Kolenc, Elisabeth Rushing, Arne Fischmann, and Valentina Reinert

BACKGROUND

Cavernous malformations of the dura, especially of the tentorium, are exceedingly rare. In the available literature, only 10 cases have been described to date.

OBSERVATIONS

The authors present the case of a 46-year-old male patient with a 1-cm infratentorial lesion suspicious for meningioma that was found on routine magnetic resonance imaging (MRI) performed for vertigo. The lesion was followed for 1.5 years with no change in signal and size. Nevertheless, the patient was concerned about the lesion and requested removal. The removal was successful and without any neurological sequelae. However, histological evaluation demonstrated a cavernous malformation. Postoperative computed tomography and MRI showed complete removal. Preoperative MRI characteristics, intraoperative images, and a video, as well as histological evaluation, are shown. The case is discussed with respect to the literature.

LESSONS

Cavernous malformations of the tentorium are extremely rare and mimic meningiomas; thus, they need to be taken into account. DOTATOC positron emission tomography may help to differentiate in these cases. Considering the cases reported in the literature, in cases of large tumors, preoperative angiography and possibly embolization may be helpful.

https://thejns.org/doi/10.3171/CASE24168

Open access

Recurrent choroid plexus carcinoma treated with CyberKnife radiosurgery: illustrative case

Lorenzo Yuan, David J Park, Amit R. L Persad, Yusuke S Hori, Armine Tayag, Louisa Ustrzynski, Sara C Emrich, and Steven D Chang

BACKGROUND

Choroid plexus carcinomas (CPCs) are rare malignant brain tumors primarily affecting children younger than 2 years old. These tumors originate from the choroid plexus epithelium and are a subtype of choroid plexus tumors, which account for 1%–4% of pediatric brain tumors. Although CPCs often show a notably high recurrence rate after surgery, the standard treatment approach remains gross-total resection (GTR) of the tumor, given the lack of clinical data supporting the effectiveness of adjunct treatment options such as radiotherapy or chemotherapy.

OBSERVATIONS

A 16-year-old female with a history of a recurrent cranial CPC resistant to surgery and radiotherapy was treated with CyberKnife stereotactic radiosurgery (SRS), following resection. The procedures successfully maintained local disease control for 41 months; however, there was a subsequent recurrence, ultimately leading to the death of the patient.

LESSONS

CPC treatment remains challenging. SRS can be used as a viable adjunct to surgery, which remains the gold standard, although it can also be considered for nonsurgical candidates or when GTR cannot be achieved. Nevertheless, it is crucial to conduct additional research to explore diverse approaches for radiosurgery, including its role as the primary treatment modality versus its combination with surgery, radiotherapy, or chemotherapy.

https://thejns.org/doi/10.3171/CASE23748

Open access

Spinal extramedullary hematopoiesis mimicking an epidural tumor in a patient with high-risk polycythemia vera: illustrative case

Ashlee N Hawkins, Jeffrey M Breton, Akrita Bhatnagar, Nitika Paudel, and Jean-Marc Voyadzis

BACKGROUND

Here the authors present the case of a 43-year-old male with a history of T-cell lymphoma, which was treated with azacitidine plus cyclophosphamide, doxorubicin, vincristine, and prednisone and autologous hematopoietic cell transplant, and high-risk polycythemia vera (PCV) presenting with severe lower-back pain radiating to the bilateral legs with associated lower-extremity weakness and splenomegaly.

OBSERVATIONS

T2-weighted magnetic resonance imaging revealed multilevel epidural lesions involving T1–10 and S1–2. Because of severe spinal canal stenosis, the patient underwent surgical decompression of T5–7, with immediate postoperative alleviation of the lower-extremity pain and complete resolution of the lower-leg weakness. Biopsy results revealed extramedullary hematopoiesis (EMH) mimicking a spinal epidural tumor. EMH is radiosensitive and displays a rapid response to low dosages, so the patient was further treated with palliative radiation therapy for residual tumors and symptom alleviation, as well as hydroxyurea and corticosteroids as indicated for cytoreduction.

LESSONS

EMH associated with PCV or myeloproliferative conditions occurring within the spine is a rare phenomenon without a standard treatment approach.

https://thejns.org/doi/10.3171/CASE23659

Open access

Surgical cavity dilatation after resection of IDH-mutated astrocytoma of the mesial temporal lobe: illustrative cases

Yohan Caudron, Juan Martino, Sébastien Froelich, and Emmanuel Mandonnet

BACKGROUND

Space-occupying tumor bed cysts may exceptionally happen after the resection of diffuse low-grade glioma. Their mechanism and management remain debated. The authors report two cases of tumor bed cysts occurring after the resection of a left temporal diffuse low-grade glioma with two different evolutions.

OBSERVATIONS

The first patient showed a spontaneous decrease in the cyst volume and did not report any symptoms. In contrast, the second patient showed a progressive increase in the cyst volume and reported headaches and difficulties in finding words. Endoscopic cyst fenestration was performed and led to symptom relief and normalization of the surgical cavity.

LESSONS

A tumor bed cyst is a rare complication of temporal low-grade glioma resection. Its formation is due to entrapment of the choroid plexus in the temporal horn widely opened into the surgical cavity. Endoscopic cyst fenestration should be offered only in symptomatic cases.

https://thejns.org/doi/10.3171/CASE23674

Open access

Systemic Candida abscess after hypofractionated radiotherapy with temozolomide for glioblastoma in an older patient: illustrative case

Kosuke Nambu, Masashi Kinoshita, Yasunori Sato, Sho Tamai, Riho Nakajima, Kenichi Harada, and Mitsutoshi Nakada

BACKGROUND

Hypofractionated radiotherapy with temozolomide is recommended for older patients with glioblastoma. Nevertheless, a potential complication of treatment is opportunistic infections with immunosuppression.

OBSERVATIONS

An 86-year-old man presented with hemiparesis, prompting an investigation that revealed a right frontotemporal glioblastoma, isocitrate dehydrogenase wildtype. After the diagnostic biopsy, hypofractionated radiotherapy with temozolomide was administered. Lymphocytopenia was observed before the start of chemoradiotherapy and gradually worsened until 2 months later, possibly as a side effect of the treatment. One month after the completion of the initial treatment, the patient developed septic shock, leading to death within 2 days. Postmortem examination with autopsy revealed evidence of an invasive Candida infection possibly originating from the urinary catheter.

LESSONS

Immunodeficiency, which is a side effect of radiation therapy with temozolomide, can cause rare and potentially fatal invasive Candida infections, especially in older and frail patients with newly diagnosed glioblastoma, even with short-term hypofractionated chemoradiotherapy.

https://thejns.org/doi/10.3171/CASE24175