Abrupt foramen magnum syndrome due to shunt malfunction in a previously asymptomatic chiari I malformation: the hidden predictable risk in long-lasting shunted patients

Sixth Cranial Nerve Palsy as the Presenting Sign of Metastatic Cholangiocarcinoma

Background

Cholangiocarcinoma is a locally invasive, poorly treatable malignancy of the biliary tract that uncommonly metastasizes to the brain and rarely causes neuro-ophthalmologic complications.

Case Presentation

A 34-year-old woman with an isolated sixth cranial nerve palsy underwent brain neuroimaging and was found to have a large sellar/suprasellar mass invading the cavernous sinus. Gross total resection was performed with improvement in the sixth cranial nerve nerve palsy. Next-generation sequencing and histology studies revealed an adenocarcinoma with a fibroblast growth factor receptor (FGFR)2-BICC1 gene mutation. Positron emission tomography/computed tomography scan demonstrated a large hypermetabolic partially necrotic hepatic mass with local invasion, and liver biopsy confirmed a diagnosis of cholangiocarcinoma. At three weeks after resection, the brain lesion recurred and the patient developed worsening diplopia. The patient then received stereotactic radiotherapy applied to the brain lesion and began treatment with gemcitabine and cisplatin. The patient was transitioned to FGFR-targeted therapy with pemigatinib, and the patient was alive at last follow-up, 49 weeks after diagnosis.

Conclusion

To our knowledge, this is the first report of cholangiocarcinoma presenting as a neuro-ophthalmologic finding, consisting of an isolated sixth cranial nerve palsy, which was the harbinger of a brain metastatic sellar/suprasellar mass. The case highlights the importance of prompt neuroimaging in isolated cranial nerve palsies, particularly in younger patients, and consideration of rare aggressive metastasis to the sellar region, where prompt surgery and pathology are critical in identifying the primary carcinoma and to instituting expedited therapy.

Complete Regression of a Solitary Cholangiocarcinoma Brain Metastasis Following Laser Interstitial Thermal Therapy

BACKGROUND

To our knowledge, we report the first case of a cholangiocarcinoma brain metastasis successfully treated with magnetic resonance imaging (MRI)-guided laser interstitial thermal therapy.

CASE DESCRIPTION

In 2017, a 71-year-old man was diagnosed with unresectable intrahepatic cholangiocarcinoma. In August 2018, a brain MRI scan was performed after a transient episode of altered mental status and revealed a subcentimeter enhancing lesion in the deep white matter of the right cerebellum. Due to lack of symptoms and the small size of the lesion, it was initially observed. However, a follow-up MRI scan at 2.5 months demonstrated increased lesion size with worsening perilesional edema. Given the rarity of cholangiocarcinoma brain metastases and the deep location, the patient underwent stereotactic needle biopsy to confirm the diagnosis followed by laser ablation as a primary treatment for the metastasis. The patient tolerated the surgery well with no complications, and the postoperative course was uneventful. At 16 months postablation, there has been no recurrence or disease progression.

CONCLUSIONS

Although prognosis for these tumors is poor, our result suggests that laser ablation can be an effective treatment for this rare entity and is a representative example of the expanding indications for laser interstitial thermal therapy.