Surgical Management of Intracranial Neuroenteric Cysts: The UCSF Experience

Supratentorial Neurenteric Cysts: Systematic Literature Review and Case Report

BACKGROUND

Neurenteric cysts (NC) are uncommon, congenital lesions with histopathologic properties derived from the gastrointestinal or respiratory tract. They are typically located in the intradural extramedullary compartment but rarely seen in the supratentorial region. The occurrence of supratentorial NCs (S-NC) presents an interesting quandary regarding their embryopathogenesis.

METHODS

We present a case report and systematic literature review on S-NCs following PRISMA guidelines.

RESULTS

A 57-year-old woman presented with a seizure and paresthesias of the face, hands, and feet. MRI revealed a right temporo-occipital cystic lesion, which was managed with surgical resection. Histologically the cyst was Type A. The patient is without recurrence at 10 months. Including this case, 88 S-NCs are reported in the literature. Common presenting symptoms are headaches and seizures. They were mostly treated with craniotomy, preferably with gross total resection (GTR), although sub-total resection (STR) may be necessary due to adhesions. Resection usually led to symptom improvement (61%). Malignant transformation was seen in 3%. Recurrence was seen in 17%, with a mean time to recurrence of 4.2 years, and was significantly more common after STR than GTR.

CONCLUSIONS

If surgically resected, the cyst wall specimen should be sent for pathology review, because of the potential risk for malignancy. If conservatively managed, serial imaging is warranted to track for changes that may indicate transformation. The embryopathogenesis of these rare congenital lesions remains incompletely understood, but the most comprehensive theory involves enteric cell migration to the neuroectoderm during embryogenesis.

Pediatric intracranial neurenteric cyst of the oculomotor nerve: a case-based review

BACKGROUND

Neurenteric cysts (NECs) of the central nervous system (CNS) are uncommon congenital entities arising from embryonal elements. Intracranial NECs in the pediatric population are rare.

METHODS

The authors describe the presentation, radiographic imaging, and pathologic findings of an 11-year-old boy with a right oculomotor nerve NEC. A literature review was performed to identify additional cases of pediatric intracranial NECs published in the English language, over the past 30 years (1990-2020). The authors discuss the presentation, investigations, management, and prognosis of this interesting entity.

RESULTS

We describe an 11-year-old boy who presented to neurosurgical attention with disconjugate gaze, anisocoria, and ptosis. Magnetic resonance imaging (MRI) demonstrated a lobulated, cystic, and peripherally enhancing mass involving the right oculomotor nerve. The patient underwent pterional craniotomy for drainage of the cyst and subtotal resection of the cyst wall. The tan-colored mass was displacing the basilar artery, compressing the cerebral peduncle, and adherent to the inferior surface of the tentorium. The lesion was within the oculomotor nerve and splitting the fibers, and the cystic contents were thick and mucinous. Histopathological examination of the specimen demonstrated a thin fibrous cyst wall with scattered inflammatory cells and lined by simple columnar epithelium containing mucin. The lining cells were immunoreactive with epithelial membrane antigen (EMA) and pan-keratin AE1/AE3. The diagnosis of a NEC was rendered. A comprehensive literature review of pediatric intracranial NECs yielded 46 additional lesions published in the literature, involving the skull base, posterior fossa, cerebral convexity, and cranial nerves. NECs present with local mass effect and less commonly, with aseptic meningitis or intracystic hemorrhage. Maximal safe GTR remains the mainstay management, although cyst drainage and marsupialization, cyst shunting, and fenestration of cystic contents into the ventricle or basal cisterns have been reported with variable success.

CONCLUSION

CNS NECs are rare congenital entities; although they occur less frequently in the intracranial components compared to the spine, their diagnosis and management should be considered for intracranial cystic lesions. Maximal safe GTR is the mainstay treatment and frequently yields favorable outcomes.

Intracranial neurenteric cyst with post-operative chemical meningitis and vagal nerve palsy

Intracranial neurenteric cysts are rare congenital lesions that, though benign, are difficult to diagnose radiologically given their similar imaging appearance to other intracranial cystic lesions. We present a case of a 21-year-old female with a pathologically proven, symptomatic neurenteric cyst in the premedullary cistern. Superimposed on this uncommon diagnosis were also rare post-operative complications of chemical meningitis and vagal nerve injury. We review the current literature surrounding intracranial neurenteric cysts, their imaging characteristics, differential diagnosis, therapeutic options, and potential complications related to their resection.

Intra-axial Neurenteric Cyst of Medulla: Case Report and Literature Review

Neurenteric cysts (NCs) are rare congenital lesions that are thought to result from the persistence of the neurenteric canal connecting primitive gut and neural tube. Despite the congenital nature, NCs can be diagnosed at any age and at a similar frequency in women and men. To our knowledge, 140 intracranial NCs, confirmed by histology, including the patient presented in this review, have been reported since 1952. Parenchymal NCs are extremely rare, and there are no publications describing the intra-axial NCs of the brainstem at the moment.

A 19-year-old female presented to the clinic with the following complaints: moderate dysphagia (two to three times per day) for and liquids and solids, dysphonia, vertigo, spontaneous nystagmus, imbalance, and numbness in the left side of the body, including the face. The magnetic resonance imaging (MRI) of the brain showed a well-defined lesion centered in the medulla. The patient underwent a small right-sided keyhole retro-sigmoid craniotomy. Just under the sulcus, a cyst containing pathological amorphous gray-yellow liquid was evacuated. Accessible parts of the capsule were resected without brain injury. Residual particles of the capsule were coagulated.

Two months after the operation, the patient presented with similar symptoms. We used the previous craniotomy during the second surgery. After the evacuation of the cyst, a silicone stent was set for connecting with the cerebellopontine cistern and preventing new synechiae formation. As surely as after the first surgery, all neurological symptoms gradually regressed. In two months after surgery, deglutition and sensations recovered, and hemiparesis and imbalance decreased. Postoperative MRI examination two months after surgery showed no evidence of cyst recurrence.

Intra-axial NCs are a rare group of congenital pathological lesions with a favorable prognosis. There are no publications of brainstem NCs with intra-axial localization to date. The treatment of choice in this group of patients is complete microsurgical excision followed by long-term observation.

Resection of a Posterior Fossa Endodermal Cyst With Exoscopic Assistance: 2-Dimensional Operative Video

Neurenteric cysts are rare benign congenital tumors of endodermal origin that most commonly occur in the cervical and upper thoracic spine, with only about 10% to 18% of the reported cases occurring intracranially.1 A definitive preoperative diagnosis is complicated by the variable appearance of neurenteric cysts on magnetic resonance (MR) imaging.2 The recommended treatment of neurenteric cysts is complete surgical resection when possible.3,4 We present a case of a posterior fossa neurenteric cyst. A 33-yr-old man without medical history presented with left-sided headache and mild left-sided facial numbness and weakness. Admission MR imaging revealed a nonenhancing mass, which was hyperintense on T1-weighted MR images, compressing the brainstem anteriorly. The lesion was isointense on T2 FLAIR images and hypointense on diffusion-weighted imaging, initially read as possible epidermoid cyst. The patient underwent a left-sided retrosigmoid craniotomy via far lateral transcondylar approach. The tumor was adjacent to both vertebral arteries, the left PICA, and cranial nerves (CN) VII-XII with superior extension to CN V. The cyst was encased in a thin capsule, and its contents were yellowish in color and ranged from thick liquid to colloidal and caseous consistency. The cyst also contained heavily calcified portions, which were excised using sharp dissection. Images of the cyst wall show that it is focally lined with ciliated columnar epithelium with intracellular mucin confirming an endodermal or neurenteric cyst. After the operation, the patient's symptoms resolved, and he was discharged on postoperative day 4. Postoperative MR images confirmed gross total resection. The patient consented to video production.

Supratentorial neuroenteric cyst in children: a case report and brief literature review

Neurenteric cysts are rare developmental lesions typically found outside the central nervous system but when they do, we most likely find them in a spinal (cervical or dorsal) intradural extramedular location, often associated with dysraphism. The more unusual intracranial cases have been published because of its rarity, occurring mostly as a posterior fossa extra-axial cyst, in adults. Supratentorial cases are distinctly infrequent, especially in children, resulting in few case reports and even fewer case reviews. We describe a case of a child with a supratentorial neurenteric cyst and present a brief review of the literature about these cysts in children, a noticeable gap in the literature.

Single-Center Clinical Characteristics and Treatment Experience of Foramen Magnum Neurenteric Cyst: Report of 6 Cases and Brief Review of the Literature

OBJECTIVE

To retrospectively analyze the clinical data of 6 patients with foramen magnum (FM) neurenteric (NE) cysts, and summarize the clinical characteristics and treatment experience for this rare disease in our single center.

METHODS

Between January 2011 and December 2015, 6 patients with FM NE cyst were surgically treated at Xuan Wu Hospital of Capital Medical University. We summarize the treatment experience of these patients through a retrospective review of the clinical information, imaging features, surgical details, and follow-up outcomes.

RESULTS

All 6 patients were female, ranging in age from 15 to 54 years (mean age, 36.8 ± 12.9 years). Occipital headache along with cranial nerve injury were the most common symptoms. Preoperative brain magnetic resonance imaging identified all lesions in the FM region, with an oblong or lobulated shape. The surgical approach was far lateral in 4 patients and suboccipital midline in 2 patients. Total lesion removal was completed in 4 patients, and subtotal excision was performed in the other 2 patients, in whom the cyst wall was intensely adherent to surrounding structures. In all 6 patients, the preoperative symptoms were significantly relieved after surgery. No recurrence was seen after a mean follow-up of 27.3 months (range, 3-70 months).

CONCLUSIONS

Our present study identified a female predominance among patients with intracranial FM NE cyst. Surgical excision is the optimum treatment strategy for this rare disease. Our findings indicate that subtotal removal of an FM NE cyst may be associated with favorable outcomes, but strict long-term follow up is needed.

Intracranial neurenteric cyst mimicking an ependymoma: imaging features, pathologic correlation and review of literature

We present a case of a 57-year-old female with four-months of diplopia and vertigo. MRI revealed a mixed cystic and solid partially enhancing lesion of the 4th ventricle, foramen of Luschka and cerebellopontine angle. Preoperative differential diagnosis favored ependymoma. Biopsy revealed a neurenteric cyst, a benign developmental lesion that rarely occurs intracranially. This case highlights several atypical manifestations of intracranial neurenteric cyst, with regions of histologically benign solid enhancement, multicompartmental extra-axial location mimicking an ependymoma, and rapid recurrence without evidence of underlying malignancy.