Pediatric cerebellar pilocytic astrocytoma presenting with spontaneous intratumoral hemorrhage

Pilocytic astrocytoma: A rare case report

Pilocytic astrocytoma (PA) is a rare, low-grade glioma predominantly affecting children and young adults, with a favorable prognosis and a high survival rate. Despite its' slow growth, PA often presents with significant symptoms at diagnosis due to its tendency to reach a large size, especially in pediatric patients, where compensatory mechanisms can delay detection. This case report describes a 7-year-old girl with progressive vision loss, headache, and balance disturbance. The imaging result revealed a right cerebellar mass that was in accordance with pilocytic astrocytoma and obstructive hydrocephalus. Histopathologic analysis confirmed the diagnosis with the typical features of PA such as Rosenthal fibers and eosinophilic granular bodies. This case report highlights the critical role of radiologic and histopathologic evaluations for PA diagnosis and management; also the unique presentation and challenges in managing PA, emphasizing the importance of timely intervention to optimize neurological outcomes.

Detecting Tumor-Associated Intracranial Hemorrhage Using Proton Magnetic Resonance Spectroscopy

Intracranial hemorrhage associated with primary or metastatic brain tumors is a critical condition that requires urgent intervention, often through open surgery. Nevertheless, surgical interventions may not always be feasible due to two main reasons: (1) extensive hemorrhage can obscure the underlying tumor mass, limiting radiological assessment; and (2) intracranial hemorrhage may occasionally present as the first symptom of a brain tumor without prior knowledge of its existence. The current review of case studies suggests that advanced radiological imaging techniques can improve diagnostic power for tumoral hemorrhage. Adding proton magnetic resonance spectroscopy (1H-MRS), which profiles biochemical composition of mass lesions could be valuable: it provides unique information about tumor states distinct from hemorrhagic lesions bypassing the structural obliteration caused by the hemorrhage. Recent advances in 1H-MRS techniques may enhance the modality's reliability in clinical practice. This perspective proposes that 1H-MRS can be utilized in clinical settings to enhance diagnostic power in identifying tumors underlying intracranial hemorrhage.

Imaging of Hemorrhagic Stroke in Children

Hemorrhagic stroke (HS) is an important cause of neurologic morbidity and mortality in children and is more common than ischemic stroke between the ages of 1 and 14 years, a notable contradistinction relative to adult stroke epidemiology. Rapid neuroimaging is of the utmost importance in making the diagnosis of HS, identifying a likely etiology, and directing acute care. Computed tomography and MR imaging with flow-sensitive MR imaging and other noninvasive vascular imaging studies play a primary role in the initial diagnostic evaluation. Catheter-directed digital subtraction angiography is critical for definitive diagnosis and treatment planning.

Clinical features and treatment of apoplectic intratumoral hemorrhage of glioma

OBJECTIVE

The primary objective of this study was to explore the clinical characteristics of apoplectic intratumoral hemorrhage in gliomas and offer insights for improving the diagnosis and treatment of this disease.

METHODS

We analyzed the clinical data of 35 patients with glioma and hemorrhage. There were eight cases of multiple cerebral lobe involvement, and 22 cases involved a single lobe. Twenty-one patients had a preoperative Glasgow Coma Scale (GCS) score of ≥ 9 and had a craniotomy with tumor resection and hematoma evacuation after undergoing preoperative preparation. A total of 14 patients with GCS < 9, including one with thalamic hemorrhage breaking into the ventricles and acute obstructive hydrocephalus, underwent craniotomy for tumor resection after external ventricular drainage (EVD). One patient had combined thrombocytopenia, which was surgically treated after platelet levels were normalized through transfusion. The remaining 12 patients received immediate intervention in the form of craniotomy hematoma evacuation and tumor resection.

RESULTS

We performed subtotal resection on three tumors of thalamic origin and two tumors of corpus callosum origin, but we were able to successfully resect all the tumors in other locations that were gross total resection Pathology results showed that 71.43% of cases accounted for WHO-grade 4 tumors. Among the 21 patients with a GCS score of ≥ 9, two died perioperatively. Fourteen patients had a GCS score < 9, of which eight patients died perioperatively.

CONCLUSIONS

Patients with a preoperative GCS score ≥ 9 who underwent subemergency surgery and received aggressive treatment showed a reasonable prognosis. We found their long-term outcomes to be correlated with the pathology findings. On the other hand, patients with a preoperative GCS score < 9 required emergency treatment and had a high perioperative mortality rate.

Intrasellar Dermoid Cyst: Case Report of a Rare Lesion and Systematic Literature Review Comparing Intrasellar, Suprasellar, and Parasellar Locations

OBJECTIVE

Intracranial dermoid cyst (DC) is a rare benign, slow-growing lesion, most commonly arising along the midline. They can occur in the supratentorial compartment, very rarely involve the sellar region and only exceptionally are intrasellar. The aim of our study is to address the challenges in the diagnosis and management of sellar DCs.

METHODS

We performed a systematic review of sellar DCs, in keeping with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and described an intrasellar DC in a 32-year-old female who presented with bilateral blurring vision.

RESULTS

The review identified 4 intrasellar, 29 suprasellar, and 28 parasellar cases. Intrasellar DCs more likely present with progressive visual impairment and pituitary hormone dysfunctions during the fifth decade of life. Suprasellar and parasellar DCs are typically diagnosed during the third decade of life because of diplopia, ptosis, trigeminal hypoaesthesia/para-esthesia or cyst's rupture. Sellar DCs are typically hypodense on computed tomography scans and contain calcifications. Magnetic resonance imaging features include T1 hyperintensity, T2 heterogeneous intensity, no restriction on diffusion-weighted images, and no contrast enhancement. Surgery is the treatment of choice. Gross total resection is achieved in 60% of intrasellar and 61.9% of suprasellar and parasellar DCs. Early postoperative complications are reported in 40.0%, 16.7%, and 23.8% of intrasellar, suprasellar, and parasellar DCs, respectively.

CONCLUSIONS

Intrasellar DCs are rare lesions typically diagnosed later than suprasellar and parasellar DCs due to their different clinical presentations. However, they should be considered in the differential diagnosis of cystic lesions of the sella, including epidermoid cysts, craniopharyngiomas, Rathke's cleft cysts, and teratomas.

The type II RAF inhibitor tovorafenib in relapsed/refractory pediatric low-grade glioma: the phase 2 FIREFLY-1 trial

BRAF genomic alterations are the most common oncogenic drivers in pediatric low-grade glioma (pLGG). Arm 1 (n = 77) of the ongoing phase 2 FIREFLY-1 (PNOC026) trial investigated the efficacy of the oral, selective, central nervous system-penetrant, type II RAF inhibitor tovorafenib (420 mg m-2 once weekly; 600 mg maximum) in patients with BRAF-altered, relapsed/refractory pLGG. Arm 2 (n = 60) is an extension cohort, which provided treatment access for patients with RAF-altered pLGG after arm 1 closure. Based on independent review, according to Response Assessment in Neuro-Oncology High-Grade Glioma (RANO-HGG) criteria, the overall response rate (ORR) of 67% met the arm 1 prespecified primary endpoint; median duration of response (DOR) was 16.6 months; and median time to response (TTR) was 3.0 months (secondary endpoints). Other select arm 1 secondary endpoints included ORR, DOR and TTR as assessed by Response Assessment in Pediatric Neuro-Oncology Low-Grade Glioma (RAPNO) criteria and safety (assessed in all treated patients and the primary endpoint for arm 2, n = 137). The ORR according to RAPNO criteria (including minor responses) was 51%; median DOR was 13.8 months; and median TTR was 5.3 months. The most common treatment-related adverse events (TRAEs) were hair color changes (76%), elevated creatine phosphokinase (56%) and anemia (49%). Grade ≥3 TRAEs occurred in 42% of patients. Nine (7%) patients had TRAEs leading to discontinuation of tovorafenib. These data indicate that tovorafenib could be an effective therapy for BRAF-altered, relapsed/refractory pLGG. ClinicalTrials.gov registration: NCT04775485 .

Long-term outcome after management of pilocytic astrocytoma in the posterior fossa in a pediatric population

Background and purpose

To assess the impact of posterior fossa pilocytic astrocytoma (PA) removal in pediatric patients, with special focus on postoperative neurological outcome after repeated surgery for tumor remnants.

Methods

Our institutional database was screened for patients with PA treated between 2000 and 2019. Patients ≤ 18 years of age with complete clinical records, preoperative contrast enhanced magnetic resonance imaging (MRI) and postoperative follow-up time of ≥ 6 months were suitable for study inclusion. Functional outcome was quantified with the modified Ranking Scale (mRS) score and assessed at admission, at discharge and at every follow-up investigation. Predictors of hydrocephalus, cranial nerve deficits and tumor recurrence were evaluated.

Results

A total of 57 pediatric patients with a mean age of 7.7 ± 4.8 years were included in the analysis. 27 (47.3%) children suffered from hydrocephalus at diagnosis, out of which 19 (33.3%) required a subsequent VP-Shunt. 22 (39.3%) patients had a partial resection, of which 9 (40.9%) went through second-look surgery. 2 patients with initially radiological confirmation of complete resection, had a tumor recurrence at FU and needed second-look surgery. Among the children requiring second-look surgery, 7 (63.6%) had a complete resection. Favorable outcome (mRS≤2) after initial and second-look surgery was observed in 52 patients (91.2%). Univariate analysis identified tumor location in the floor of the 4th ventricle (p = 0.030), and repeated surgery for tumor remnant removal (p = 0.043) as predictors for post-operative cranial nerve deficits. Multivariate analysis confirmed this independent association. The incidence of tumor recurrence occurred more often in patients with previous partial resection (p = 0.009) as well as in lesions located in the cerebellar peduncles (p = 0.043). Partial resection remained an independent predictor after multivariate logistic regression analysis (p = 0.045).

Conclusions

Incomplete resection of posterior fossa PA is a risk factor for tumor recurrence and repeated surgery to remove tumor remnants increases the risk of new postoperative deficits. Thus, the risk of iatrogenic deterioration due to second look surgery should be implemented in the primary pre- and intraoperative decision-making.

Endoscope-Assisted Extreme Lateral Supracerebellar Infratentorial Approach for Resection of Superior Cerebellar Peduncle Pilocytic Astrocytoma: Technical Note

(1) Background: Superior cerebellar peduncle (SCP) lesions are sparsely reported in the literature. The surgical approaches to the cerebello-mesencephalic region remain challenging. In this article, we present the extreme lateral supracerebellar infratentorial (ELSI) approach to treat a large hemorrhagic pilocytic astrocytoma of the SCP. (2) Methods: An 11-year-old boy, known for neurofibromatosis Type I, presented to the emergency department of our institution with symptoms and signs of intracranial hypertension. The cerebral magnetic resonance imaging (MRI) revealed a large hemorrhagic lesion centered on the SCP provoking obstructive hydrocephalus. Following an emergency endoscopic third ventriculocisternostomy (ETV), he underwent a tumor resection via an endoscope-assisted ELSI approach. (3) Results: ELSI approach allows for a wide exposure with direct access to lesions of the SCP. The post-operative course was uneventful, and the patient was discharged home on post-operative day 5. Post-operative MRI revealed a near total resection with a small residual tumor within the mesencephalon. (4) Conclusion: ELSI approach offers an excellent exposure with the surgical angles necessary for median and paramedian lesions. The park-bench position with appropriate head flexion and rotation offers a gravity-assisted relaxation of the tentorial and petrosal cerebellar surfaces. The endoscope can be an adjunct to illuminate the blind areas of the surgical corridor for an improved tumor resection without significant cerebellar retraction.

The impact of imposed delay in elective pediatric neurosurgery: an informed hierarchy of need in the time of mass casualty crisis

SARS-CoV-2 COVID-19, coronavirus, has created unique challenges for the medical community after national guidelines called for the cancellation of all elective surgery. While there are clear cases of elective surgery (benign cranial cosmetic defect) and emergency surgery (hemorrhage, fracture, trauma, etc.), there is an unchartered middle ground in pediatric neurosurgery. Children, unlike adults, have dynamic anatomy and are still developing neural networks. Delaying seemingly elective surgery can affect a child's already vulnerable health state by further impacting their neurocognitive development, neurologic functioning, and potential long-term health states. The purpose of this paper is to demonstrate that "elective" pediatric neurosurgery should be risk-stratified, and multi-institutional informed guidelines established.

Multiple Lesions Accompanied by Postoperative Spontaneous Intracystic Hemorrhage in a Pediatric Patient with Pilocytic Astrocytoma

Pilocytic astrocytoma is the most common primary brain tumor in the pediatric population and has a classic imaging manifestation of a solitary, cyst-like mass with a strong contrast-enhancing mural nodule. Here, we report a case of multiple lesions in pilocytic astrocytoma in a pediatric patient accompanied by postoperative spontaneous intracystic hemorrhage. We describe the case of a 14-year-old female patient with a history of surgery for right cerebellar tumor 6 years ago. Computed tomography (CT) and magnetic resonance imaging showed cystic lesion with a mural nodule in the cerebellum and right retrothalamic area, suggesting a pilocytic astrocytoma. Emergency surgery was done. Pathology confirmed a pilocytic astrocytoma World Health Organization Grade 1. During postoperative course, clinical outcomes of the patient did not improve. Follow-up CT showed cystic remnant compressing the brain stem with spontaneous intracystic hemorrhage. The second surgery was done to evacuate the hemorrhage and to remove the cyst. Serial CT was made after the second surgery with no cyst growth nor hemorrhage present. Only three other pediatric multiple pilocytic astrocytomas have been reported previously, and there were only 11 publications about spontaneous intracystic hemorrhage in pediatric pilocytic astrocytoma. Our review of all previously reported cases found that the patients were predominantly male, and some had a history of neurofibromatosis type 1.

Advantages of gross total resection in patients with astrocytoma: A population-based study

The present study aimed to investigate the association between surgical methods and survival outcomes in patients with astrocytoma. Patients diagnosed with astrocytoma between January 2004 and December 2015 were identified using the Surveillance, Epidemiology and End Results database. Kaplan-Meier curves and Cox regression were used to analyze the effects of surgical methods on overall survival (OS) and cancer-specific survival (CSS). Among 42,224 eligible patients with astrocytoma, 11,427 (27.1%) patients did not receive surgery, 7,661 (18.1%) received excisional biopsy (EB), 5,520 (13.1%) received a subtotal resection (STR), 6,037 (14.3%) received a gross resection (GR), 5,314 (12.6%) received a partial resection (PR) and 6,265 (14.8%) received a gross total resection (GTR). Patients who underwent GR had the longest survival time (17.00 months). However, over time, the proportion of patients who underwent STR or GR increased, whereas the proportion of patients who did not undergo surgery, PR or GTR decreased. Furthermore, surgical method was an independent prognostic factor for OS and CSS for the patients with astrocytoma. Multivariate Cox regression showed that GTR was associated with the more favorable OS [hazard ratio (HR), 0.80; 95% confidence interval (CI), 0.77-0.83; P<0.001] and CSS (HR, 0.80; 95% CI, 0.77-0.83; P<0.001) times compared with EB. Moreover, similar results were observed in subgroup analyses based on summary stage and grade. In the present study, it was demonstrated that GTR was one of the effective surgical methods for improved OS and CSS time in patients with astrocytoma. However, among the American astrocytoma population, the proportion of patients who underwent GTR decreased. It is necessary to further advocate for the efficacy of GTR.