Intracranial Location Research Articles

Clinical variety and prognosis of intracranial arachnoid cysts in children.

Arachnoid cysts (AC) occur in different intracranial locations. Management and prognosis depend on the clinical presentation and treatment guidelines do not exist. With this study, we want to demonstrate the clinical variety of arachnoid cysts in children and place a focus on outcome factors in operated cases. This retrospective study of a consecutive single unit series of children, who underwent AC surgery between January 2010 and September 2019, provides demographic, clinical, imaging data, and information about surgical treatment and outcome. Overall, 63 patients (71.4 male) underwent surgery. Mean age was 50months (0-191). Mean follow-up was 40months (0-121). Eighty-one percent of patients presented with symptoms/signs of raised ICP. Focal neurological deficits were present in 15.9%, headache in 11.1% of children. Galassi cysts represented the predominant type (30.2%), followed by suprasellar (14.3%), quadrigeminal (12.7%), retrocerebellar, CPA and midline (each 11.1%), and hemispheric cysts (7.9%). Endoscopic and microsurgical fenestrations were performed in 27% and 58.7%, stent or shunt insertion in 6.3%/57.9% of the cases. In 33.3% of the cases one and in 12.7%, a second reintervention became necessary. Reoperation rate was significantly higher in children < 1year (p = 0.003). Cyst volume decreased in 85.7%. Seventy percent of the patients were symptom free, 5% suffered from headache, and 22% from developmental disorders. All focal neurological symptoms resolved. Complication rate and outcome are depending on age and cyst location. Recurrence and revision rates are significantly higher in young infants (p = 0.003). Midline cysts with CCA are associated with developmental disorders.

Survival in patients with surgically treated dural based metastases: A single-center retrospective study

PurposeDural-based metastases (DBM) are present in 4% of all patients diagnosed with metastatic cancer. DBM most commonly arise from primary cancers of the lung, breast, and prostate. While diagnostic challenges are relatively well studied, the epidemiology, common intracranial locations, and therapeutic outcomes of DBM remain poorly understood. Our current study aims to define the epidemiological characteristics of patients presenting with DBM, the most common locations of metastasis within the dura, and clinical outcomes after surgery and radiation therapy. MethodsPatients presenting to the Montreal Neurological Institute for intracranial metastasis between the years 2010 and 2016 were reviewed, and patients with DBM were identified based on radiological characteristics. Data were extracted from patient charts and MRIs. ResultsA total of 46 patients met inclusion criteria and were included in the study. The mean age at DBM diagnosis was 57 years old. Lung cancer was the most common origin (57%), while breast cancer was the second most common (22%). DBM were more likely to present in patients with active systemic disease (63%) and were found within 1 cm of a major venous sinus in 52% of cases. 87% of patients underwent gross total resection of their tumors. In these patients, adjuvant SRS was associated with a 2-fold increase in mean survival time (p = 0.013). ConclusionAlthough DBM are a marker of advanced systemic cancer, surgical resection with adjuvant radiotherapy may play a role in control of intracranial disease and overall patient survival.

Comparing treatment outcomes of various intracranial bifurcation aneurysms locations using the Woven EndoBridge (WEB) device

BackgroundThe Woven EndoBridge (WEB) device has Food and Drug Administration approval for treatment of wide-necked intracranial bifurcation aneurysms. The WEB device has been shown to result in adequate occlusion in...

Identification and Management of Aggressive Meningiomas.

Meningiomas are common primary central nervous system tumors derived from the meninges, with management most frequently entailing serial monitoring or a combination of surgery and/or radiation therapy. Although often considered benign lesions, meningiomas can not only be surgically inaccessible but also exhibit aggressive growth and recurrence. In such cases, adjuvant radiation and systemic therapy may be required for tumor control. In this review, we briefly describe the current WHO grading scale for meningioma and provide demonstrative cases of treatment-resistant meningiomas. We also summarize frequently observed molecular abnormalities and their correlation with intracranial location and recurrence rate. We then describe how genetic and epigenetic features might supplement or even replace histopathologic features for improved identification of aggressive lesions. Finally, we describe the role of surgery, radiotherapy, and ongoing systemic therapy as well as precision medicine clinical trials for the treatment of recurrent meningioma.

Rosette-forming glioneuronal tumours are midline, FGFR1-mutated tumours.

Rosette-forming glioneuronal tumour (RGNT) is a rare central nervous system (CNS) World Health Organization (WHO) grade 1 brain neoplasm. According to the WHO 2021, essential diagnostic criteria are a 'biphasic histomorphology with neurocytic and a glial component, and uniform neurocytes forming rosettes and/or perivascular pseudorosettes associated with synaptophysin expression' and/or DNA methylation profile of RGNT whereas 'FGFR1 mutation with co-occurring PIK3CA and/or NF1 mutation' are desirable criteria. We report a series of 46 cases fulfilling the essential pathological diagnostic criteria for RGNT. FGFR1 and PIK3CA hotspot mutations were searched for by multiplexed digital PCR in all cases, whereas DNA methylation profiling and/or PIK3R1 and NF1 alterations were analysed in a subset of cases. Three groups were observed. The first one included 21 intracranial midline tumours demonstrating FGFR1 mutation associated with PIK3CA or PIK3R1 (n =19) or NF1 (n =1) or PIK3CA and NF1 (n =1) mutation. By DNA methylation profiling, eight cases were classified as RGNT (they demonstrated FGFR1 and PIK3CA or PIK3R1 mutations). Group 2 comprised 11 cases associated with one single FGFR1 mutation. Group 3 included six cases classified as low-grade glioma (LGG) other than RGNT (one-sixth showed FGFR1 mutation and one a FGFR1 and NF1 mutation) and eight cases without FGFR1 mutation. Groups 2 and 3 were enriched in lateral and spinal cases. We suggest adding FGFR1 mutation and intracranial midline location as essential diagnostic criteria. When DNA methylation profiling is not available, a RGNT diagnosis remains certain in cases demonstrating characteristic pathological features and FGFR1 mutation associated with either PIK3CA or PIK3R1 mutation.

Malignant gastrointestinal neuroectodermal tumor in head and neck: two challenging cases with diverse morphology and different considerations for differential diagnosis.

Malignant gastrointestinal neuroectodermal tumor (MGNET) is a sarcoma typically involving the gastrointestinal tract with neuroectodermal differentiation and EWSR1-ATF1/CREB1 fusions. Recently, rare MGNET cases were reported in extragastrointestinal sites. We identified 2 cases of MGNET arising in unprecedented laryngeal and intracranial locations, respectively. Both cases showed spindle and epithelioid tumor cells with amphophilic to clear cytoplasm and occasionally prominent nucleoli, arranged in solid, fascicular, and pseudoalveolar patterns. Case 1 exhibited moderate to marked nuclear atypia and focal intraepithelial component. In contrast, case 2 comprised predominantly low-grade epithelioid cells with extensive pseudopapillary structures. Both tumors showed an S100/SOX10-positive and HMB45/melan-A-negative immunoprofile as well as EWSR1-ATF1 fusion. A chief obstacle in diagnosing case 1 was the histologic and immunophenotypic resemblance to melanoma. The striking pseudopapillary architecture and the intracranial location of case 2 rendered differential diagnoses including meningioma and ependymoma. With the peculiar locations and morphology, these cases posed great diagnostic challenge.

Anomalous location of intracranial vessels in adults

Anomalous intracranial vessels are not uncommon, and this finding is not always associated with arteriovenous malformations. Other conditions such as anomalous connections between arteries or phlebitc patterns can also present as vessels with abnormal intracranial locations. Noninvasive diagnosis is important to determine whether to do more invasive tests such as cerebral digital subtraction angiography or to estimate the risk of bleeding in arteriovenous malformations and therefore to evaluate the need for endovascular/surgical treatment. In this paper, we present an algorithm for the differential diagnosis of anomalous intracranial vessels according to their location (intra/extra-axial) and function (whether the vessels are arterialized). Moreover, we analyze the important points of the angioarchitecture of the principal arteriovenous malformations with risk of intracranial bleeding, such as pial arteriovenous malformations and dural fistulas.

Vasos intracraneales en localización anómala en adultos

Anomalous intracranial vessels are not uncommon, and this finding is not always associated with arteriovenous malformations. Other conditions such as anomalous connections between arteries or phlebitc patterns can also present as vessels with abnormal intracranial locations. Noninvasive diagnosis is important to determine whether to do more invasive tests such as cerebral digital subtraction angiography or to estimate the risk of bleeding in arteriovenous malformations and therefore to evaluate the need for endovascular/surgical treatment. In this paper, we present an algorithm for the differential diagnosis of anomalous intracranial vessels according to their location (intra/extra-axial) and function (whether the vessels are arterialized). Moreover, we analyze the important points of the angioarchitecture of the principal arteriovenous malformations with risk of intracranial bleeding, such as pial arteriovenous malformations and dural fistulas.

The development of a new, ultra-fine, and flexible neuroendoscope for intracranial observation.

A neuroendoscope is a technical advance that allows surgeons to visualize certain regions of the brain that was previously inaccessible through the use of a surgical microscope. Several neuroendoscope designs have been implemented by other neurosurgeons over the past 5 years. The advantage of a neuroendoscope is the addition of a flexible and narrow tip that allows for safe entry into intracranial structures for clinical observation. However, there are some limitations to this approach. Here, we report the use of a modified angioscope as a newly developed neuroendoscope to be employed in observing intracranial structures. We report the use of an angioscope that is 1.8 mm in diameter and has both a thin and flexible tip. In this study, the angioscope was inserted into the lumen of an aspirator tube, and the tip of the device was placed at the intracranial area of intended observation area. Image findings were evaluated using an established in vivo goat brain model. The angioscope was light in weight and maneuverable and could be reached and observed in the blind spot using a surgical microscope. From the cerebellopontine angle, the lower cranial nerves and trigeminal nerve could be observed, and from the cisterna magna, the floor of the fourth ventricle and the aqueduct could be seen. The angioscope is a useful instrument to observe intracranial locations safely and effectively even within a limited surgical field. Further modifications will be required to use the angioscope in various craniotomy procedures.

Unexpected intracranial location of a Cephenemyia stimulator larva in a roe deer, Capreolus capreolus, revealed by computed tomography

In this study we describe the finding of a Cephenemyia stimulator larva in the brain of a roe deer (Capreolus capreolus) after performing a computed tomography (CT) scan of its head. Despite this anatomical location of oestrid larvae could be relatively frequent in other genera, such as Oestrus, to our knowledge, this is the first reported case involving the genus Cephenemyia. Concretely, a second-instar C. stimulator larva was found in the basis of the cranium. The location of a macroscopic hemorrhagic lesion involving the brain parenchyma peripheral to the location of the larva suggests that tissue colonization occurred before the animal was hunted. Since no detectable alterations or damage to the cranial bones were observed, we suggest a possible larval migration route drilling the skull bones. Finally, we propose the use of the term “neuromyiasis” to be referred to the invasion of the central nervous system by dipteran larvae, particularly oestrids.

T-DM1 Increases the Risk of SRS-Induced Radiation Necrosis in Her2+ Breast Cancer

Stereotactic radiosurgery (SRS) is an important treatment modality in the management of breast cancer-related brain metastases (BrM). Recent research has found Trastuzumab emtansine (T-DM1) to be effective against Her2+ BrM. However, the risk of radionecrosis (RN) with T-DM1 in combination with SRS is unclear. The objective of this study was to investigate factors associated with RN post-SRS in patients with Her2+ BrM.Patients with Her2+ BrM treated with SRS at the Sunnybrook Odette Cancer Centre between 2010 and 2020 were retrospectively identified. The incidence of RN was determined on a lesion-by-lesion basis using serial brain imaging with or without histological confirmation. Clinical factors associated with RN, such as age, RT dose, lesion volume, intracranial location, total number of BrM, along with history of whole brain RT, and T-DM1 treatment were investigated with univariable and multivariable competing risks regression (MVR) using death from any cause as a competing risk factor. A P-value of < 0.05 in MVR following backward selection was considered statistically significant.67 patients with Her2+ BrM (223 lesions) treated with SRS were identified; among them, 21 (31.3%) were treated with T-DM1 post-SRS, including 14 (20.9%) who received T-DM1 within 12 months of SRS. The median follow-up was 15.6 (IQR 5.4-35.3) months. The 1-year, and 2-year risk of RN post-SRS was 6.7% (95% CI 2.7-10.7%), and 15.2% (95% CI 9.2-21.3%), respectively. MVR identified T-DM1 treatment post-SRS (HR 2.5, 95% CI 1.2-5.3, P = 0.02) and RT dose with a biologically effective dose (BED) > 50.4 Gy (HR 2.4, 95% CI 1.1-5.1, P = 0.02) as independent risk factors of RN. Patients treated with T-DM1 and SRS had a 25.2% (95% CI 12.8-37.6%) risk of RN at both 1- and 2-years post-T-DM1. The median time to RN after T-DM1 among the affected was 4.8 (95% CI: 3.8-25.6) months with 80% of all RN cases occurring within 12 months of T-DM1 treatment.This study demonstrates that T-DM1 exposure post-SRS was independently associated with a higher risk of RN in Her2+ BrM patients. The potential side effects of brain-penetrating agents post-SRS merit greater awareness.B. Id Said: None. H. Chen: None. K. Jerzak: Research Grant; Astra Zeneca, Eli Lilly. Consultant; Amgen, AstraZeneca, Apo Biologix, Eli Lilly, Esai, Genomic Health, Knight Therapeutics, Merck, Myriad Genetics Inc, Pfizer, Roche, Novartis, Purdue Pharma. S.D. Myrehaug: Advisory Board; Novartis AG.C. Tseng: Consultant; Sanofi. Travel Expenses; Elekta. Member; Elekta MR-LINAC.J. Detsky: None. Z.A. Husain: None. A. Sahgal: Research Grant; Elekta AB. Honoraria; Elekta AB, Varian, BrainLAB, Medtronic Kyphon. Consultant; Varian. Travel Expenses; Elekta AB, Varian. H. Soliman: None.

Consideration of Time From Planning to Treatment for Frameless Fractionated Stereotactic Radiosurgery in Patients With Intact Large Brain Metastases

Patients with large brain metastases may receive fractionated stereotactic radiosurgery (FSRS) if they are not surgical candidates yet still pursuing cancer-directed therapy. FSRS with limited margins can allow for optimal sparing of uninvolved regional brain tissue. However, due to required treatment planning process, there is often elapsed time between MRI brain and treatment start which may contribute to marginal misses. Growth rates of large brain metastases and implications for optimal margin to account for growth rate and time interval between planning MRI and FSRS are incompletely characterized.Patients treated at a single institution from 2018-2020 who received frameless FSRS on a Cobalt-60 treatment unit for large (> 2cm diameter) brain metastases were identified. Patients with a prior diagnostic brain MRI scan with technically similar parameters to a second MRI obtained for treatment planning were included. Resection cavities and lesions undergoing re-treatment after prior SRS were excluded. Brain metastasis volumes were obtained by contouring on both diagnostic and planning MRIs. Patient characteristics and treatment details were also collected. Analysis was conducted using paired Student's t test and Pearson's R and growth rate was determined using a linear model.Thirty-six patients with 54 brain metastases met inclusion criteria. The most common primary cancer sites were lung (36%), colorectal (14%), and skin (14%), and most common histologies were adenocarcinoma (53%) and melanoma (17%). Nearly half (47%) of patients were on systemic therapy at the time of FSRS and the majority (85%) received steroids prior to starting FSRS. Treatment dose ranged from 24-32.5 Gy in 3-5 fractions, with median of 30 Gy in 5 fractions with zero margin. Median time from diagnostic to planning MRI was 15 days (IQR: 11-21) and planning MRI to FSRS was 1 day (IQR 1-3). The median size of included brain metastases on planning MRI was 7.38cc (IQR: 5.09-11.55) compared to 6.03cc (IQR: 3.87-8.95) on prior diagnostic MRI (P < 0.001). Eight metastases (15%) decreased in size in the context of concurrent central nervous system-penetrant systemic therapy or steroids. Median calculated daily growth was 0.10cc (2.37%) per day (IQR: 0.02-0.21cc, 0.41-3.78%). There was no significant association between lesion growth rate and histology, intracranial location, steroid use, and baseline tumor size. A 1.0 mm, 1.5 mm, 2.0 mm, and 2.5 mm margin would have covered anticipated growth in > 90% of lesions over 3, 7, 10, and 14 days between planning and treatment, respectively.In the absence of expedited planning, FSRT for intact large brain metastases with limited margins may result in geometric under treatment. An adaptive margin strategy based upon initial tumor size, and time between planning imaging and treatment delivery may be afforded to maintain ideal conformity, properly targeting a growing target lesion while maximally sparing uninvolved regional brain.J. Chew: None. S. Sinha: None. S.J. Liu: None. S.E. Fogh: Independent Contractor; Accuray. L. Boreta: None. D. Raleigh: None. L. Ma: Patent/License Fees/Copyright; University of California Regents. S.E. Braunstein: Advisory Board; Radiation Oncology Questions, LLC.

Extraskeletal Intracranial Mesenchymal Chondrosarcoma: A Case Report

Mesenchymal chondrosarcoma (MCS) is a rare high-grade malignant tumor that affect young adults. The intracranial location is extremely exceptional. It is characterized by an undifferentiated mesenchymal cell, with islands of hyaline cartilage. This is a case of a 23-year-old young patient suffering from a generalized tonic-clonic seizures. The cerebral scanner objectified a hemorrhagic frontotemporal pass of 6x5x5 cm. The immunohistochemical and anatomopathological of the surgical specimen was in favor extraskeletal intracranial mesenchymal. The patient's progress was unfavorable due to tumor recurrence postoperatively. In this article, we discuss the clinical presentation, the diagnostic assessment, the therapeutic strategy as well as the prognosis of this rare pathology.

Pathologic Characteristics of Pregnancy-Related Meningiomas.

Simple SummaryMeningiomas are the most common primary intracranial tumor in adults. Meningiomas are usually benign and slow growing. Treatment is surgical resection in the case of symptomatic growth. Dramatic growth can occur during pregnancy, complicating clinical management and entailing a risk to the well-being of the mother and fetus. Authors of a previous review paper raised the hypothesis that prolactin may be a key contributor to the sudden growth seen in pregnancy-related meningiomas. We set out to investigate the presence of prolactin receptors/prolactin, as well as other female hormones and histopathological characteristics of pregnancy-related meningiomas in Denmark, compared to meningiomas from female controls within the same age group. No differences in hormone receptor distribution were found between the groups and very few meningiomas expressed prolactin receptors, which contradicts the above-mentioned hypothesis. Interestingly, we observed above cut-point proliferative indices of the meningiomas for the entire study population of females in the reproductive age.Meningiomas are the most common intracranial tumor. During pregnancy, explosive growth of a known meningioma occasionally occurs, but the underlying reasons remain unknown. Prolactin has been suggested as a possible key contributor to pregnancy-related meningioma growth. This study sets out to investigate prolactin and prolactin receptor status in 29 patients with pregnancy-related meningiomas in Denmark, from January 1972 to December 2016, as compared to 68 controls aged 20–45 years, also undergoing resection of a meningioma. Furthermore, we investigated potential differences in the progesterone and estrogen receptor statuses, WHO grade, Ki-67 labeling indices, and locations of the resected meningiomas between the cases and controls. Immunohistochemical analyses were performed, and histopathology and intracranial location were assessed with the investigator blinded for the case–control status. None of the samples stained positive for prolactin and very few samples stained positive for prolactin receptors, equally distributed among cases and controls. Estrogen and progesterone receptors generally followed the same distributional pattern between groups, whereas above cut-point Ki-67 labeling indices for both groups were observed. In conclusion, our results did not support the notion of prolactin as a key contributor to pregnancy-related meningioma growth. Rather, the similarities between the cases and controls suggest that meningiomas early in life may comprise a distinct biological entity.

Assessing the management of major bleeding events in patients treated by direct oral anticoagulant in an emergency department.

Since direct oral anticoagulants have been marketed, the management of major bleeding in emergency departments has become more challenging. In 2013 and 2016, the Working Group in Perioperative Haemostasis made several proposals for this. The objective of the present study was to evaluate conformity with these proposals in daily clinical practice. We performed a retrospective single-center cohort study addressing the management of major bleeding in patients treated by direct oral anticoagulant in an emergency department. Patients were included between January 1, 2015 and November 30, 2017. Among 3,365patients admitted to the emergency department for bleeding, a total of 191 were treated by direct oral anticoagulant and 55 (28.8%) with major bleeding were included in the present study. The majority of patients received rivaroxaban (n =44, 80.0%) and were treated for atrial fibrillation (n =47, 85.0%). Bleeding concerned gastrointestinal (n =30, 54.6%) and (n =14, 25.5%) intracranial location. Twenty-one patients (38.2%) were treated by prothrombin complex concentrate, and 31patients (56.4%) were transfused. Intervention for hemostatic control was performed for 30patients (54.6%). Thirty-three patients (60.0%) presented a deviation from protocol. There is no significant difference for mortality at 3months according to whether or not there was a deviation from protocol. Nearly two-thirds of patients with major bleeding associated with direct oral anticoagulant administration had protocol deviation, but there was no effect on mortality.

Rosai-Dorfman-Destombes disease: isolated intracranial without nodal involvement presentation. Illustrative case

BACKGROUNDRosai-Dorfman-Destombes disease is a rare and heterogeneous entity that has been associated with autoimmune, hereditary, and malignant diseases. There is controversy about its etiopathogenesis, clinical course, and therapeutic management.OBSERVATIONSThe authors report a case of a 61-year-old man with a history of progressive headache without any other symptoms. Magnetic resonance imaging of the brain revealed multiple irregular lesions with an initial diagnostic impression of meningiomatosis. An excisional biopsy was performed, and the pathology report stated the finding was Rosai-Dorfman-Destombes disease.LESSONSThe uniqueness of this case is its rarity. The isolated intracranial location presents many diagnostic and therapeutic challenges, with radiological and clinical characteristics similar to those of other central nervous system tumors. There is currently no clear evidence of the pathogenesis and therapeutic management of this condition. Follow-up of these patients will help elucidate the natural history of this condition and the benefits of various treatment modalities.

Sensitivity of prehospital stroke scales for different intracranial large vessel occlusion locations.

IntroductionPrehospital stroke scales have been proposed to identify stroke patients with a large vessel occlusion to allow direct transport to an intervention centre capable of endovascular treatment (EVT). It is unclear whether these scales are able to detect not only proximal, but also more distal treatable occlusions. Our aim was to assess the sensitivity of prehospital stroke scales for different EVT-eligible occlusion locations in the anterior circulation.Patients and methodsThe MR CLEAN Registry is a prospective, observational study in all centres that perform EVT in the Netherlands. We included adult patients with an anterior circulation stroke treated between March 2014 and November 2017. We used National Institutes of Health Stroke Scale scores at admission to reconstruct previously published prehospital stroke scales. We compared the sensitivity of each scale for different occlusion locations. Occlusions were assessed with CT angiography by an imaging core laboratory blinded to clinical findings.ResultsWe included 3021 patients for the analysis of 14 scales. All scales had the highest sensitivity to detect internal carotid artery terminus occlusions (ranging from 0.21 to 0.97) and lowest for occlusions of the M2 segment (0.08 to 0.84, p-values < 0.001).Discussion and conclusion: Although prehospital stroke scales are generally sensitive for proximal large vessel occlusions, they are less sensitive to detect more distal occlusions.

Neuroimaging Features of Ectopic Cerebellar Tissue: A Case Series Study of a Rare Entity.

Ectopic cerebellar tissue is a rare entity likely secondary to multiple, interacting, developmental errors during embryogenesis. Multiple sites of ectopic cerebellar tissue have been reported, including extracranial locations; however, an intracranial location is most common. We report on the MR imaging findings of a multi-institutional series of 7 ectopic cerebellar tissue cases (2 males, 4 females, 1 fetal) ranging from 22 weeks 5 days' gestational age to 18 years of age. All cases of ectopic cerebellar tissue were diagnosed incidentally, while imaging was performed for other causes. Ectopic cerebellar tissue was infratentorial in 6/7 patients and supratentorial in 1/7 patients. All infratentorial ectopic cerebellar tissue was connected with the brain stem or cerebellum. MR imaging signal intensity was identical to the cerebellar gray and white matter signal intensity on all MR imaging sequences in all cases. Ectopic cerebellar tissue should be considered in the differential diagnoses of extra-axial masses with signal characteristics similar to those of the cerebellum. Surgical biopsy or resection is rarely necessary, and in most cases, MR imaging is diagnostic.

Chordoma and meningioma arising as a collision tumor in the petroclival region: Case report and literature review

The co-existence of two independent brain tumors at the same anatomical site is rare and occurs as a "collision tumor" or "tumor-to-tumor metastasis." In intracranial location, meningioma is the most common neoplasm in such coincidences. We present a case involving a 31-year-old woman with a complex tumor consisting of chordoma and meningioma in the petroclival region. The patient presented with left facial numbness, ataxia, and left-sided hemiparesis. Computed tomography and magnetic resonance imaging showed a well-demarcated, intradural, extra-axial tumor mass in the petroclival region. After complete total resection, histopathological examination revealed two different parts of the tumor, consisting of chordoma and meningioma. Therefore, additional radiation therapy and adjuvant chemotherapy were given. To the best of our knowledge, this is the first description of the simultaneous occurrence of chordoma and meningioma in the same anatomical location. In such a scenario, differential diagnosis of choroid meningioma and chordoma is required. The correct recognition of both components is important for treating this complex tumor, and its separate elements may require independent approaches.

Our experience in treating meningiomas with radiosurgery

Introduction: Radiosurgery is ionizing radiation treatment. Concentration of a large amount of radiation in an area of ​​the brain results in ablation of the lesion. The technique was designed and perfected by Dr. Lars Lexell, Swedish neurosurgeon, in 1951. Meningiomas are usually benign and slow-growing tumors, derived from the leptomeninges. First line treatment for meningiomas is surgery. They occasionally are difficult to treat surgically because of their location, the associated vascular and nerve structures and patient comorbidities. Stereotactic Radiosurgery (SRS) is an option to manage these cases. Objective: This studi is retrospective, from Novembner 2013 to January 2018 (4 years), SRS for meningioma in X-Knife Unit, Neurosurgery Service prof. Kurti UC, Mother Theresa,, Tirana. During this period we evaluated the long term effect of SRS on tumor control. Material and Methods: We analyzed data from 17 Meningiomas in 14 patinets (4 meningiomatosis) to these variables: age, presenting symptoms, intracranial location of meningiomas, surgery prior to SRS, extension of tumor resection, the radiation dose, tumor volume coverage, pre-SRS tumor volume, tumor volume on latest follow up MR biopsy results, Assessment of tumor control was based on VOLUMETRIC criteria and RECIST criteria. Results: 14 patients in a total (17 meningiomas, 4 of them was meningiomatosis), (Male 4 (23%), Female 13 (77%), Age 45-75 years (average 59.5 Median 62.0). Follow up from (23 months), (Range 59.9-99 99.5), intracranial localization of meningiomas: Medial sphenoid crystal – 8, Convection – 7, Falx/Parasagittal – 2. Residual 4 - (24%), Recurence 5 - (29%), New 8 – (47%), WHO I – 8 (47%), WHO II – 4 (23%), WHO III – 1 (7%). With out biopsy – 4. Prescripted dose – 14-16 Gy, tumor coverage – 59 – 100%, (91.70), median 95.40, tumor volume – 0.27 – 10.36 cc (3.84), 1-isocenter – 9 cases, 2-isocenter – 8 cases. Number for arcs for isocenter – 1-5. Tumor volume, controlled - 12 (70%), reduced – 22 (48%) – 5 (PR), unchanged – 7 (SD), adult (WHO 2 and 3) – 5 (PD), side effects - 0. Follow up from 2-51 months (23 months) Mean tumor volume on follow up MRI was 0.31 cm3 and maximum Diameter over 4.83 cm. According to Volumetric criteria and RECIST criteria (adapted version), remained stable disease and excellent control - 70% total, 100% grade 1 WHO). Conclusions: SRS is one of the safest and most effective strategies to keep meningiomas under control and management in different patients, both those with primary tumors and those with relapses or those left over from previous interventions. Doing the comparative analysis shows an improved analysis and long-term effects with SRS. The criteria used during the evaluation and standardization of these criteria make possible the effect on the duration of treatment of meningiomas with SRS.