Fusiform dilation of the internal carotid artery (FDICA) is an infrequent vascular complication following resection of suprasellar lesions in the pediatric population, and its course appears to be benign without apparent clinical symptoms. However, data correlating symptomatic FDICA with bypass surgery are scarce. The authors here report 2 symptomatic cases that were treated using internal maxillary artery bypass more than 5 years after total removal of a craniopharyngioma at an outside institution. Both cases of FDICA were resected to relieve the mass effect and to expose the craniopharyngioma. The postoperative course was uneventful, and radiological imaging revealed graft conduit patency. To the authors' knowledge, this is the first reported use of extracranial to intracranial bypass to treat FDICA following removal of a suprasellar lesion. Their findings suggest that bypass surgery is a useful therapeutic approach for symptomatic cases of FDICA and total removal of recurrent craniopharyngioma. Moreover, the indications for surgical intervention and treatment modalities are discussed in the context of previous relevant cases.
Long Wang, Xiang'en Shi, Fangjun Liu and Hai Qian
Zhiwei Tang, Xiang'en Shi, K. I. Singh Khatri Chhetri and Xueling Qi
The primary intracranial endodermal sinus tumor (EST) is regarded as a rare histological subtype that is often associated with components of other germ cell tumors, and there are no reports on the onset of intracranial ESTs after growth hormone (GH) replacement therapy. The authors report an extremely rare case of pure primary EST associated with GH replacement therapy. A 15-year-old girl with GH deficiency experienced headache, nausea, and vomiting after GH replacement therapy for a 17-month period. Magnetic resonance imaging showed 2 tumor masses located in the pineal region and frontal horn of the right lateral ventricle, respectively. Before surgery, the authors administered 1 cycle of neoadjuvant chemotherapy, which shrank the tumor and facilitated surgical intervention. The larger mass located in the pineal region was removed via a right occipital transtentorial approach, and postoperative histopathological analysis revealed a pure EST. While there is a clear association between the initiation of GH replacement therapy and the development of the EST in this case, the causal effect cannot be specified. Nevertheless, this case demonstrates that GH replacement therapy must be used cautiously.
Qing Liu, Ran Liu, Meghana V. Kashyap, Rajnee Agarwal, Xiang'en Shi, Chung-cheng Wang and Shao-Hua Yang
Brainstem gliomas are common in children and have the worst prognosis of any brain tumor in this age group. On the other hand, brainstem gliomas are rare in adults, and the authors of some clinical studies have suggested that this lesion behaves differently in adults than in children. In the present study, the authors test an orthotopic C6 brainstem glioma model in juvenile and adult rats, and investigate the biological behavior of this lesion in the 2 age groups.
The C6 glioma cells were stereotactically implanted into the pons of juvenile or adult male rats. Neurological presentation and survival time were recorded. Tumor proliferation and the number of apoptotic cells in brainstem gliomas of young and adult rats were determined by immunohistochemical staining with Ki 67 and terminal deoxynucleotidyl transferase 2′-deoxyuridine 5′-triphosphate-mediated nick-end labeling assay.
Striking differences in the onset of neurological signs, duration of symptoms, survival time, tumor growth pattern, tumor proliferation, and number of apoptotic cells were found between the gliomas in the 2 groups of rats. The lesions were relatively focal in adult rats but more diffuse in young rats. Furthermore, brainstem gliomas in adult rats were less proliferative and had more apoptotic cells than those in young rats.
The authors found that the C6 brainstem glioma model in young and adult rats closely imitates the course of brainstem glioma in humans both in neurological findings and histopathological characteristics. Their findings also suggest that the different growth pattern and invasiveness of these lesions in children compared with that in adults could be due to different cellular environments in the 2 age groups, and warrants further investigation into the difference in the host response to brainstem gliomas in children and adults.
Long Wang, Shuaibin Lu, Li Cai, Hai Qian, Rokuya Tanikawa and Xiang’en Shi
The rapid innovation of the endovascular armamentarium results in a decreased number of indications for a classic surgical approach. However, a middle cerebral artery (MCA) aneurysm remains the best example of one for which results have favored microsurgery over endovascular intervention. In this study, the authors aimed to evaluate the experience and efficacy regarding surgical outcomes after applying internal maxillary artery (IMA) bypass for complex MCA aneurysms (CMCAAs).
All IMA bypasses performed between January 2010 and July 2018 in a single-center, single-surgeon practice were screened.
In total, 12 patients (9 males, 3 females) with CMCAAs managed by high-flow IMA bypass were identified. The mean size of CMCAAs was 23.7 mm (range 10–37 mm), and the patients had a mean age of 31.7 years (range 14–56 years). The aneurysms were proximally occluded in 8 cases, completely trapped in 3 cases, and completely resected in 1 case. The radial artery was used as the graft vessel in all cases. At discharge, the graft patency rate was 83.3% (n = 10), and all aneurysms were completely eliminated (83.3%, n = 10) or greatly diminished (16.7%, n = 2) from the circulation. Postoperative ischemia was detected in 2 patients as a result of graft occlusion, and 1 patient presenting with subarachnoid hemorrhage achieved improved modified Rankin Scale scores compared to the preoperative status but retained some neurological deficits. Therefore, neurological assessment at discharge showed that 9 of the 12 patients experienced unremarkable outcomes. The mean interval time from bypass to angiographic and clinical follow-up was 28.7 months (range 2–74 months) and 53.1 months (range 19–82 months), respectively. Although 2 grafts remained occluded, all aneurysms were isolated from the circulation, and no patient had an unfavorable outcome.
The satisfactory result in the present study demonstrated that IMA bypass is a promising method for the treatment of CMCAAs and should be maintained in the neurosurgical armamentarium. However, cases with intraoperative radical resection or inappropriate bypass recipient selection such as aneurysmal wall should be meticulously chosen with respect to the subtype of MCA aneurysm.