Occipital Craniotomy Research Articles

Intracranial Solitary Fibrous Tumor with Concurrent Meningioma: Case Report and Review of the Literature

Abstract Introduction The present study describes a case of an intracranial solitary fibrous tumor (iSFT) concurrent with meningioma in different anatomical regions. Case Description A female patient, 64-years-old, presented with an 18-month history of progressive vision impairment in the right eye and no other neurological symptoms. The magnetic resonance imaging (MRI) revealed two solid and expansive lesions: one with right interhemispheric occipital location and dependent on the falx cerebri, and another located in the anterior skull base. We opted for a right frontotemporal craniotomy for the first tumor, and a right occipital craniotomy, 41-days later, for the second one, showing no postoperative complications. Histological and immunohistochemical findings confirmed the diagnosis of a grade-I fibrous meningioma and a grade-III SFT. After 9 months of follow-up, the patient showed vision improvement and no signs of neurological compromise or tumor recurrence in the last MRI. Conclusions The present study describes the first reported case of a patient with an intracranial SFT associated with a meningioma in different anatomical locations. The involved pathogenesis and evolution of both coexisting tumors are still unknown, which highlights the need for more case reports on them.

Brain and lung metastasis of uterine leiomyosarcoma: illustrative case.

Uterine leiomyosarcoma is a rare, extremely aggressive tumor with a high rate of metastasis. Five-year survival for individuals with metastatic disease is only 10%-15%. Metastases to the brain are exceptionally rare and are associated with poor survival. The authors report a case of uterine leiomyosarcoma that metastasized to the brain in a 51-year-old woman. A single lesion on magnetic resonance imaging was discovered in the right posterior temporo-occipital region 44 months after resection of the primary uterine tumor. The patient underwent a right occipital craniotomy with gross-total resection of the tumor and is receiving adjuvant stereotactic radiosurgery and chemotherapy with gemcitabine and docetaxel. At 8 months postresection, the patient remains alive and asymptomatic with no sign of recurrence. A literature review of prior reported cases was conducted to analyze patterns of approach to patient treatment and survival. The authors found an apparent survival benefit in patients receiving adjuvant radiation therapy.

Patient assessment of cosmetic outcome after craniotomy for intracranial tumor surgery

BackgroundIntracranial tumors are commonly approached through a craniotomy, and the bone flap is later reattached with plates and screws. The gap created around the bone flap may cause the skin to submerge, potentially influencing the facial and head aesthetic appearance. The aim of this study was to examine patient satisfaction with cosmetic outcome after craniotomy for intracranial tumor resection. MethodsIn a prospective questionnaire-based study, patients were asked to report their degree of satisfaction with the scar and overall cosmetic appearance, and the extent of change to their facial appearance using 0–10 rating scales. The questionnaire was sent six months after surgery to patients undergoing first-time craniotomy for tumor resection at either of two neurosurgical departments. ResultsOf the 70 patients included in the study, 49 (70%) completed the questionnaire. Median scores were 9.3 for satisfaction with the scar and 9.0 for overall cosmetic satisfaction (a score of 10 reflected highest satisfaction). The median score was 1.7 for degree of change in facial appearance (a score of 0 reflected no change). However, 24.5% of patients reported major alterations to facial appearance. Satisfaction levels were similar by age, sex, and tumor type, but patients with occipital craniotomies were less satisfied with the overall cosmetic result than those with temporal craniotomies. ConclusionMost patients were satisfied with the cosmetic outcome of the craniotomy, but a considerable proportion reported major facial alterations. While the level of overall cosmetic satisfaction did not differ according to age, sex, or tumor type, the location of the craniotomy seemed to be a factor in satisfaction with the aesthetic outcome. Further studies are needed to investigate how the cosmetic result from craniotomy could be improved from the patient's perspective.

Primary cerebral epithelioid angiosarcoma: a case report

BackgroundPrimary cerebral epithelioid angiosarcoma (PCEA) is a rare malignant tumor of the central nervous system. To the best of our knowledge, only three cases have been reported in the English language literature thus far.Case presentationHere, we report a fourth case in a 73-year-old man admitted for headache. Radiological examination revealed a mass in the right occipital lobe, which was removed by right occipital craniotomy. Histopathological examination revealed epithelioid angiosarcoma. The patient received radiotherapy after resection but survived for only nine months due to recurrence of the tumor and his declining further surgery.ConclusionsIn this report, we add to the knowledge base on this exceedingly rare tumor, review the small number of relevant cases published previously, and analyze and summarize the clinical and pathological characteristics, treatment options and prognosis of this cancer.

NCMP-01. CEREBRAL ANGIOSARCOMA AND DISTANT RADIATION THERAPY

Abstract Angiosarcoma is a rare malignant tumor originating from vascular endothelial cells. Typically, the diagnosis of angiosarcomas carry poor prognosis. Radiation exposure is one of the most common risk factors for angiosarcomas. Due to the rarity of angiosarcoma, there is sparse literature, hence it is mostly seen in case reports. We describe a case of cerebral angiosarcoma with an unknown primary malignancy in a patient with distant history of non-Hodgkin’s lymphoma treated with chemotherapy and radiation therapy to the thorax. A 54 year old male with a history of Non-Hodgkin’s Lymphoma was treated with ABVD chemotherapy and thoracic radiation therapy in 1995,presented for bilateral vision loss. Neurologic examination revealed a left homonymous hemianopia .Further investigation with brain Magnetic Resonance Imaging revealed hemorrhagic lesions in the bilateral frontal and in the right parietal-occipital lobes. Computed tomography of the chest, abdomen, and pelvis was negative for malignancy. The patient underwent a right occipital craniotomy with resection of right parietal occipital lesion. Histopathology revealed metastatic angiosarcoma. It has been acknowledged that exposure to external beam radiotherapy puts patients at risk for angiosarcoma in the future. It is believed that radiation may induce the development of AS by several mechanisms. One mechanism is the direct oncogenic effect of ionizing radiation, which can damage DNA, leading to genome instability and mutation of cancer-related genes. A prior literature review noted twenty cases of angiosarcoma developing following therapeutic irradiation. Our particular patient’s prior exposure to irridation did not include a brain radiation field, so it is unlikely this patient had radiation induced angiosarcoma.Furthermore, it does not appear that his prior radiation exposure explains the location of his angiosarcoma as his radiation field was localized to chest. Although angiosarcoma is rare, it deserves further investigation to increase the knowledge base on etiology of metastasis.

Individualized combination therapies based on whole-exome sequencing displayed significant clinical benefits in a glioblastoma patient with secondary osteosarcoma: case report and genetic characterization

BackgroundThe incidence of osteosarcoma as a secondary neoplasm in glioblastoma patient is extremely rare. The genetic characteristic still remains unclear until now.Case descriptionWe reported a 47-year-old female patient with multiple intracranial disseminations and infiltrations (splenium of the corpus callosum and lateral ventricular wall) of a rapid progressive glioblastoma underwent occipital craniotomy and total resection of all the enhancing lesions. Whole-exome sequencing and pathological examination revealed glioblastoma, IDH1 wild type, PTEN deficient, TERT mutated, NF1mutated, MGMT unmethylated. After surgery, the patient received combined therapeutic regimen of TTFields (tumor-treating fields) plus pembrolizumab plus temozolomide and TTFields plus everolimus, which displayed significant clinical benefits. During the combined therapeutic course, an extremely rare secondary malignant neoplasm occurred, femur MR and pathological detection of biopsy tissue demonstrated osteosarcoma. The result of whole-exome sequencing revealed 7 germline mutated genes (EPAS1, SETD2, MSH3, BMPR1A, ERCC4, CDH1, AR). Bioinformatic analysis showed the two germline mutations (MSH3 and ERCC4) induced deficiency in the DNA repair machinery, which resulting in the accumulation of mutations and may generate neoantigens contributing to the development of a secondary osteosarcoma in this case.ConclusionIndividualized combination therapies based on whole-exome sequencing displayed significant clinical benefits in this case. Germline MSH3 and ERCC4 mutation may induce a secondary osteosarcoma in glioblastoma patients.

Microsurgical Management of Posterior Circulation Aneurysms: A Retrospective Study on Epidemiology, Outcomes, and Surgical Approaches

Posterior circulation aneurysms have been regarded as the most challenging for endovascular coiling and microsurgical occlusion. The role of microsurgical treatment is gradually being overlooked and diminishing in the trend of endovascular treatment. As microsurgical occlusion of posterior circulation aneurysms is decreasing, we present our relevant experience to evaluate treatment options and surgical approaches. A retrospective study was conducted in the Department of Neurosurgery of the First Affiliated Hospital of Soochow University between 2016 and 2021. Patients with posterior circulation aneurysms treated by clipping, bypass, and trapping were enrolled and followed up for at least six months. We included 50 patients carrying 53 posterior circulation aneurysms, 43 of whom had aneurysm ruptures. The posterior cerebral artery and posterior inferior cerebellar artery were the most common aneurysm locations. Direct clipping was performed in 43 patients, while bypass and trapping was performed in six patients. The retrosigmoid, far-lateral, and midline or paramedian suboccipital approaches were performed for those aneurysms in the middle and lower thirds. Aneurysms in the upper third required the lateral supraorbital approach, pterional approach, subtemporal approach, and occipital craniotomy. The lateral supraorbital approach was utilized in seven patients for aneurysms above the posterior clinoid process. Thirty-four patients recovered well with modified Rankin score 0–3 at discharge. No patient experienced aneurysm recurrence during the mean follow-up period of 3.57 years. Microsurgery clipping and bypass should be considered in conjunction with endovascular treatment as a treatment option in posterior circulation aneurysms. The lateral supraorbital approach is a feasible, safe, and simple surgical approach for aneurysms above the posterior clinoid process.

Resection of bilateral occipital lobe lesions during a single operation as a treatment for bilateral occipital lobe epilepsy.

BACKGROUNDNeurosurgical treatment of severe bilateral occipital lobe epilepsy usually involves two operations several mos apart. AIMTo evaluate surgical resection of bilateral occipital lobe lesions during a single operation as a treatment for bilateral occipital lobe epilepsy. METHODSThis retrospective case series included patients with drug-refractory bilateral occipital lobe epilepsy treated surgically between March 2006 and November 2015.RESULTSPreoperative evaluation included scalp video-electroencephalography (EEG), magnetic resonance imaging, and PET-CT. During surgery (bilateral occipital craniotomy), epileptic foci and important functional areas were identified by EEG (intracranial cortical electrodes) and cortical functional mapping, respectively. Patients were followed up for at least 5 years to evaluate treatment outcome (Engel grade) and visual function. The 20 patients (12 males) were aged 4-30 years (median age, 12 years). Time since onset was 3-20 years (median, 8 years), and episode frequency was 4-270/mo (median, 15/mo). Common manifestations were elementary visual hallucinations (65.0%), flashing lights (30.0%), blurred vision (20.0%) and visual field defects (20.0%). Most patients were free of disabling seizures (Engel grade I) postoperatively (18/20, 90.0%) and at 1 year (18/20, 90.0%), 3 years (17/20, 85.0%) and ≥ 5 years (17/20, 85.0%). No patients were classified Engel grade IV (no worthwhile improvement). After surgery, there was no change in visual function in 13/20 (65.0%), development of a new visual field defect in 3/20 (15.0%), and worsening of a preexisting defect in 4/20 (20.0%). CONCLUSIONResection of bilateral occipital lobe lesions during a single operation may be applicable in bilateral occipital lobe epilepsy.

Intra-diploic epidermoid cyst: An iceberg lesion

Introduction: Intraosseous epithelial inclusion cysts of the skull, presenting as lytic defects, constitute a very small percentage of the primary intracranial tumours. The case is presented by virtue of not only the rarity of the variant but also to highlight the importance of timely intervention by a neurosurgeon after adequate investigation and in a tertiary care setting. Case Report: A 45 year old female patient presented to the local Primary Healthcare Centre(PHC) with a small scalp swelling in the occipital region. . Intraoperative identification of intracranial extension was made by the surgeon as inferior margin of the swelling couldn’t be reached and also by palpation of the huge bone defect following which the procedure was abandoned midway and patient was referred to our centre for further management. Imaging: Contrast Enhanced Computerised Tomograhy(CECT) revealed a well defined, mixed density lesion with hypodense and an isodense component in right occipital region. Lesion was measuring 4.2(Cranio caudal) x 3.3(Antero posterior) x 3.6( transverse) cm. A sharp marginated bone defect was noted involving both the outer and inner tables of the occipital bone. Operative management: Lesion was approached through a right occipital craniotomy wherein the margins of bone defect were nibbled away to gain a wide access to the lesion. Pearly white, flaky contents of the lesion along with capsule were identified and excised completely. Discussuion: Intradiploic epidermoid cysts are very rare, accounting for <3% of all intracranial epidermoid cysts.(5) These cysts grow very slowly and usually present as painless bony swelling under the scalp. Conclusion: Cranial epidermoid is a fairly common entity and intradiploic variant of the same isnot uncommonly seen in neurosurgical practise. These lesions may present as a small scalp lesion which should not be judged based on its apparent size as these lesions are not infrequently known to have a bigger intracranial extension

Indocyanine green illuminates the way to cut the tentorium in occipital transtentorial approach: technical note

Background and importance The occipital transtentorial approach is used to address lesions at the posterior incisural space or upper cerebellum. This approach is rarely used, making standardization of the surgical procedure challenging. Here we describe the effectiveness of indocyanine green (ICG) and dye markings before tentorial incision in charting a safe and bloodless surgical trajectory for improved manoeuvrability. Clinical presentation The first case was a 40-year-old man with a residual pineal mass after chemoradiation therapy for pathologically-proven germinoma. Surgical resection was performed via left occipital craniotomy. Incision of the left cerebellar tentorium by a radiofrequency knife was preceded by visualization of the straight sinus and venous lake, which were marked with dye, enabling safe entry into the quadrigeminal cistern. Finally, total-resection of the mature teratoma was achieved. The second case was a 50-year-old man with an enhancing mass at the cerebellar vermis and left hemisphere. Left occipital craniotomy was followed by ICG administration, illuminating the straight sinus and a complex structure of dural venous channels, which were marked with dye. This visualization maximized the tentorial incision by carefully avoiding venous structures and widely exposed the upper cerebellum. Subtotal-resection of the tumor was achieved, with a diagnosis of glioblastoma. Conclusion ICG administration and dye marking are feasible and useful methods for precise identification/visualization of venous structures. They enable maximization as well as safe and appropriate tentorial incision to provide a sufficient surgical corridor for the occipital transtentorial approach.

Metastatic malignant PEComa of the brain: An unusual entity with rare presentation

Perivascular epithelioid cell tumor (PEComa) is an unusual mesenchymal tumor comprised histological and immunohistochemically distinctive perivascular epithelioid cells exhibiting myomelanocytic phenotype. We hereby report the case of a 59-year-old female who presented with sudden headache, vomiting, and transient decreased vision with contrast MRI suggestive of the right occipital mass. Biopsy from the right occipital craniotomy mass was reported as metastatic malignant melanoma. The case was referred to our hospital for review. We considered a differential diagnosis of metastasis from malignant melanoma, poorly differentiated carcinoma, high-grade glioma, PEComa, hemangioblastoma, and high-grade sarcoma. A post-operative whole-body PET/CT scan revealed a metabolically active lesion in the endometrium that seems to be primary. It is suggested to consider PEComa as a differential diagnosis in poorly differentiated malignancy and to evaluate accordingly with appropriate immunohistochemistry markers. This is the third reported case of metastatic malignant PEComa to the brain as per the English literature.

SURG-28. PRESENTATION OF A POSTERIOR FOSSA TUMOR AT A HOSPITAL IN WESTERN JAMAICA

Abstract The posterior cranial fossa is part of the cranial cavity, located between the foramen magnum and tentorium cerebelli that houses the cerebellum, pons and medulla oblongata. Commonly, tumors arising from this region in adults are cerebellar metastases or schwannomas of the vestibular nerve – the incidence of primary neoplasms is uncommon and more reserved for the pediatric population. A 28 year old female was in her usual state of health until last year when she started experiencing recurrent headaches with associated vomiting and intermittent loss of consciousness. A CT brain was done upon presentation to the hospital that revealed a 4th ventricle mass with obstructive hydrocephalus. A ventriculoperitoneal (VP) shunt was done thereafter to decompress the ventricular system, in anticipation for further surgical intervention for mass. Occipital craniotomy and resection of tumor was done and patient managed in a multidisciplinary manner in the intensive care unit. Post-operative course was marked by occipital pseudomeningocele with an associated CSF leak; a lumbar drain was placed in situ until complete resolution of leak. Histological analysis showed WHO Grade II Astrocytoma. Adult primary posterior fossa tumors are rare and can present with a constellation of symptoms. Although patient presented with findings in keeping with the diagnosis of an ependymoma, close clinical follow up will be required henceforth due to the refractory nature of such a low grade astrocytoma post-resection. Radiotherapy can also be considered in further management of case.

Unique Case Series of Occipital Sinus and Its Thrombosis- A Radiological Marvel

Background: Variations of the dural venous sinuses may result in inaccurate imaging interpretation or complications during surgical approaches. One of these variations reported infrequently is the occipital sinus with an overall incidence of under 10%.When present, it may get thrombosed or become source of intracranial bleeds or pose difficulty during occipital craniotomies. Our review suggests that the thrombosis of this unique venous sinus variant is a rare condition as there are very few case reports of the same. Herein, we present a case series of persistent occipital sinus and the unusual combination of a persistent occipital sinus and its thrombosis. Subjects and Methods: The study included 4 paediatric cases that presented with neonatal seizuressecondary to different underlying aetiologies and in retrospect had either persistent andpatent occipital sinus or a thrombosed occipital sinus. A descriptive study of the aforementioned cases was carried out. MRI scanner PHILIPS Achieva 1.5 Tesla was used for diagnosis. Results: One case had thrombosis of bilateral persistent occipital sinuses and superficial cortical veins with minimal intraventricular haemorrhage in bilateral lateral ventricles.Second case had persistent and thrombosed right occipital sinus; while two other cases had persistent but patent occipital sinuses. Conclusion: A comprehensive knowledge of cerebral venous anatomy and meticulous recognition of venous variations essentially helps when dealing with a pathology, which presents along with a particular venous variation, no matter how rare this combination is.

Management of Transorbital Penetrating Intracranial Injury by a Homemade Metal Arrow: Serials Case Report

BACKGROUND: Transorbital penetrating intracranial injury (TOPI) is rare lesions, representing about 0.4% of traumatic brain injury. This uncommon injury has potentially severe and fatalities brain damage with high mortality rate if not promptly treated.
 CASE REPORT: We presented three patients with TOPI following penetration by a homemade metal arrow; unfortunately, two patients (cases 1 and 2) death on arrival at our hospital. As a survival patient (case 3), a 15-year-old boy presented with a homemade metal arrow entered through a right superior orbital fissure into the right cerebral hemisphere. Plain skull radiograph showed that the tip of the shaft was located in the right of the posterior cerebral hemisphere and confirmed by computerized tomography (CT) and three-dimensional CT of his brain. Injury to the right middle cerebral arteries was apparent on non-contrast CT angiography. Using a right occipital craniotomy approach with C-arm radiography fluoroscopy guidance, we successfully removed the arrow. Follow-up studies confirmed an excellent outcome.
 CONCLUSIONS: Pre-operative imaging is mandatory to evaluate the trajectory, brain, and vascular injury for appropriate surgical planning and post-operative care of patients with TOPI.

Tailored Surgical Approaches for Foramem Magnum Tumors

Objective To describe our surgical techniques, analyze their safety and their postoperative outcomes for foramen magnum tumors (FMTs). Methods From 1986 to 2014, 34 patients with FMTs underwent surgeries using either the lateral suboccipital approach, standard midline suboccipital craniotomy, or the far lateral approach, depending on the anatomic location of the lesions. Results In the present series, there were 22 (64.7%) female and 12 (35.2%) male patients. The age of the patients ranged from 12 to 63 years old. We observed 1 operative mortality (2.9%). A total of 28 patients (82.3%) achieved a score of 4 or 5 in the Glasgow Outcome Scale (GOS). Gross total resection (GTR) was obtained in 22 (64.7%) patients. After the surgery, 9 (26%) patients developed lower cranial nerve dysfunction (LCNd) weakness. The follow-up varied from 1 to 24 years (mean: 13.2 years). Conclusion The majority of tumors located in the FM can be safely and efficiently removed using either the lateral sub occipital approach, standard middle line sub occipital craniotomy, or the far lateral approach, depending on the anatomic location of the lesions.

Case Report: Concurrent primary CNS lymphoma and meningothelial meningioma - nuances of diagnosis and management

Background: The incidence of two distinct primary intracranial pathologies is an exceedingly rare phenomenon. Although meningiomas are well known to coexist with other primary intracranial malignancies there are only nine reported cases of a meningioma occurring simultaneously with primary CNS lymphoma in the literature. We report a case of a woman who sustained multiple injuries due to two distinct intracranial pathologies, however, lateralizing signs were unrecognized for two weeks prior to her final diagnosis. Case Description: A 64-year-old female with history of diabetes mellitus type 2 initially presented to the Emergency Department, two weeks prior, following a mechanical fall at home resulting in a left bimalleolar fracture. CT imaging revealed a right occipital mass with significant vasogenic edema causing 12mm of midline shift. MRI revealed two distinct homogeneously contrast-enhancing lesions: a right occipital mass with dural-based attachment, as well as a homogenously contrast-enhancing lesion adjacent to the right posterolateral ventricle. FLAIR signal changes were also appreciated and were noted to extend across the corpus callosum, raising concerns for a high-grade glial process. She underwent a right occipital craniotomy with gross total resection of the right occipital mass as well as subtotal resection and biopsy of the second lesion. Final pathology of the extra-axial lesion was found to be meningothelial meningioma and the deep lesion was found to be diffuse large B-cell lymphoma. Discussion: We describe a rare instance of simultaneous meningioma and primary CNS lymphoma that was found to be the underlying cause of a traumatic injury several weeks after the incident. We review the current diagnosis and management nuances in the setting of multiple intracranial oncologic processes.

Clinical importance of the occipital artery in vascular lesions: A review of the literature.

The occipital artery (OA) is a critical artery in vascular lesions. However, a comprehensive review of the importance of the OA is currently lacking. In this study, we used the PubMed database to perform a review of the literature on the OA to increase our understanding of its role in vascular lesions. We also provided our typical cases to illustrate the importance of the OA. The OA has several variations. For example, it may arise from the internal carotid artery or anastomose with the vertebral artery. Therefore, the OA may provide a crucial collateral vascular supply source and should be preserved in these cases. The OA is a good donor artery. Consequently, it is used in extra- to intracranial bypasses for moyamoya disease (MMD) or aneurysms. The OA can be involved in dural arteriovenous fistula (DAVF) and is a feasible artery for the embolisation of DAVF. True aneurysms and pseudoaneurysms can occur in the OA; surgical resection and embolisation are the effective treatment approaches. Direct high-flow AVF can occur in the OA; embolisation treatment is a good option in such cases. The OA can also be involved in MMD and brain arteriovenous malformation (AVM) by forming transdural collaterals. For a patient in the prone position, if occipital and suboccipital craniotomies are performed, the OA can also be used for intraoperative angiography. In brief, the OA is a very important artery in vascular lesions.

Postoperative analgesia for pediatric craniotomy patients: a randomized controlled trial

BackgroundPain is often observed in pediatric patients after craniotomy procedures, which could lead to some serious postoperative complications. However, the optimal formula for postoperative analgesia for pediatric neurosurgery has not been well established. This study aimed to explore the optimal options and formulas for postoperative analgesia in pediatric neurosurgery.MethodsThree hundred and twenty patients aged 1 to 12-years old who underwent craniotomy were randomly assigned to receive 4 different regimens of patient-controlled analgesia. The formulas used were as follows: Control group included normal saline 100 ml, with a background infusion of 2 ml/h, bolus 0.5 ml; Fentanyl group was used with a background infusion of 0.1–0.2 μg/k·h, bolus 0.1–0.2 μg/kg; Morphine group was used with a background infusion of 10–20 μg/kg·h, bolus 10–20 μg/kg; while Tramadol group was used with a background infusion of 100–400 μg/kg·h, bolus 100–200 μg/kg. Postoperative pain scores and analgesia-related complication were recorded respectively. Comparative analysis was performed between the four groups.ResultsIn comparison of all groups with each other, lower pain scores were shown at 1 h and 8 h after surgery in Morphine group versus Tramadol, Fentanyl and Control groups (P < 0.05). Both Tramadol and Fentanyl groups showed lower pain scores in comparison to Control group (P < 0.05). Nausea and vomiting were observed more in Tramadol group in comparison to all other groups during the 48 h of PCIA usage after operation (P = 0.020). Much more rescue medicines including ibuprofen and morphine were used in Control group (CI = 0.000–0.019). Changes in consciousness and respiratory depression were not observed in study groups. Moderate-to-severe pain was observed in a total of 56 (17.5%) of the study population. Multiple regression analysis for identifying risk factors for moderate-to-severe pain revealed that, younger children (OR = 1.161, 1.027–1.312, P = 0.017), occipital craniotomy (OR = 0.374, 0.155–0.905, P = 0.029), and morphine treatment (OR = 0.077, 0.021–0.281, P < 0.001) are the relevant factors.ConclusionsCompared with other analgesic projects, PCIA or NCIA analgesia with morphine appears to be the safest and most effective postoperative analgesia program for pediatric patients who underwent neurosurgical operations.Trial registrationChinese Clinical Trial Registry. No: ChiCTR-IOC-15007676. Prospective registration. http://www.chictr.org.cn/index.aspx.

Case Report: Concurrent primary CNS lymphoma and meningothelial meningioma - nuances of diagnosis and management

Background: The incidence of two distinct primary intracranial pathologies is an exceedingly rare phenomenon. Although meningiomas are well known to coexist with other primary intracranial malignancies there are only nine reported cases of a meningioma occurring simultaneously with primary CNS lymphoma in the literature. We report a case of a woman who sustained multiple injuries due to two distinct intracranial pathologies, however, lateralizing signs were unrecognized for two weeks prior to her final diagnosis. Case Description: A 64-year-old female with history of diabetes mellitus type 2 initially presented to the Emergency Department, two weeks prior, following a mechanical fall at home resulting in a left bimalleolar fracture. CT imaging revealed a right occipital mass with significant vasogenic edema causing 12mm of midline shift. MRI revealed two distinct homogeneously contrast-enhancing lesions: a right occipital mass with dural-based attachment, as well as a homogenously contrast-enhancing lesion adjacent to the right posterolateral ventricle. FLAIR signal changes were also appreciated and were noted to extend across the corpus callosum, raising concerns for a high-grade glial process. She underwent a right occipital craniotomy with gross total resection of the right occipital mass as well as subtotal resection and biopsy of the second lesion. Final pathology of the extra-axial lesion was found to be meningothelial meningioma and the deep lesion was found to be diffuse large B-cell lymphoma. Discussion: We describe a rare instance of simultaneous meningioma and primary CNS lymphoma that was found to be the underlying cause of a traumatic injury several weeks after the incident. We review the current diagnosis and management nuances in the setting of multiple intracranial oncologic processes.

Houdini Tumor: Case Report and Literature Review of Pregnancy-Associated Meningioma

Meningiomas are common intracranial neoplasms of undetermined etiology. Accelerated growth during episodes of elevated serum estrogen and progesterone have been demonstrated in pregnant patients, as exhibited by an overexpression of estrogen or progesterone on immunohistochemical analysis. This case report and literature review describe a case of complete meningioma regression in a postpartum patient. A 23-year-old female presented at 37 weeks of pregnancy with 1-month history of fluctuating severe left-sided headaches, periodic blurry vision, nausea, and vomiting. She had 2 previous pregnancies without complication. Magnetic resonance imaging revealed a dural-based, heterogeneously enhancing mass along the left tentorium, just posterior to the transverse sinus, with supratentorial extension and surrounding edema. Differential diagnoses included meningioma versus hemangioma versus hemangiopericytoma. The patient followed up with neurosurgery 1 month after delivery. She had continued left-sided headaches but no longer complained of visual changes. A postpartum surgical resection via left occipital and suboccipital craniotomy was planned. Approximately 1 month later (now about 3 months after delivery) a repeat magnetic resonance imaging demonstrated a marked decrease in meningioma size, and the previously seen edema had resolved. In light of the sudden disappearance of the meningioma, no further surgical intervention was pursued. Because meningioma shrinkage or disappearance may occur after pregnancy, repeat imaging is advised as part of a preoperative evaluation. In addition, it is possible that an undetermined amount of meningioma removal surgeries may be avoided with further research into monitoring hormone levels connected to meningioma growth.