Congenital tumors of the central nervous system: an institutional review of 64 cases with emphasis on tumors with unique histologic and molecular characteristics

Congenital brain tumors are rare accounting for 0.5%-1.9% of all pediatric brain tumors. While different criteria have been used to classify a tumor as congenital, those diagnosed prior to 6 months of age are considered to be "probably" congenital in origin. We performed an institutional review of all central nervous system (CNS) tumors (surgical and autopsy specimens from 1990 to 2019) in patients less than 6 months old. Sixty-four unique cases were identified, and these accounted for 2.0% of all CNS tumor specimens at our institution. The most common tumor types were high-grade gliomas, low-grade gliomas and medulloblastomas. Atypical teratoid rhabdoid tumors, choroid plexus tumors and germ cell tumors also accounted for a significant portion of the cohort. Seven tumors were diagnosed prenatally. The most common clinical presentation at diagnosis was increased head circumference. At the conclusion of the study, over half of the patients were alive including all patients with WHO grade I and II tumors. Ninety-two percent of cases were classifiable using the 2016 WHO system, and when available, molecular findings supported the histologic diagnoses. However, several gliomas had unusual histologic features and did not correspond to a well-defined entity. Molecular testing was essential for accurate classification of a subset of these tumors, and several high-grade gliomas exhibited fusions considered unique to infantile gliomas, including those involving the MET, ALK and NTRK genes. To our knowledge, this cohort represents the largest single-institution study of congenital CNS tumors and highlights many ways in which congenital CNS tumors are distinct from CNS tumors of older pediatric patients and adults.

Prenatal diagnosis of pericallosal curvilinear lipoma: specific imaging pattern and diagnostic pitfalls

We report the first series of cases of pericallosal curvilinear lipoma (CL) diagnosed prenatally and highlight the limitations in identifying a specific prenatal imaging pattern using ultrasound and magnetic resonance imaging (MRI). In all five of our cases, on ultrasound, the main feature leading to referral was a short corpus callosum. This subtle callosal dysgenesis was associated with a band of hyperechogenicity surrounding the corpus callosum, mimicking the pericallosal sulcus, which increased in size during the third trimester in three of the four cases in which sonographic follow-up was performed. On T2-weighted MRI, this band showed typical hypointensity in all cases; in contrast, on T1-weighted imaging, in only one case was there hyperintensity, suggestive of fat, as seen typically in the postnatal period. For appropriate prenatal counseling regarding outcome, it is important to identify or rule out CL when mild corpus callosal dysgenesis is observed. One should be aware of subtle diagnostic findings, such as a thin band of echogenicity surrounding the corpus callosum that is seen as a band of hypointensity on T2-weighted fetal MRI, and which may increase in size during gestation. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Surgical treatment of brain tumors in infants younger than six months of age and review of the literature

OBJECTIVE

Brain tumors are rare in infants who are younger than six months of age. These tumors can be challenging to treat surgically. We analyzed a modern series of patients treated by a multidisciplinary team at a tertiary care center and performed a literature review of this unique population.

METHODS

Retrospective clinical data were collected for patients surgically treated for intracranial mass lesions at The Children's Hospital of Philadelphia from 1998 to 2007. Dermoid cysts and other skull-based lesions were excluded from the analysis.

RESULTS

Sixteen patients younger than six months of age underwent surgery for primary intracranial mass lesions. The median age of the patients at surgery was 5.2 months (range, 1.4-6 months of age). Children most often presented with a bulging fontanelle, hydrocephalus, or macrocephaly (seven patients). Vomiting was seen in five patients, cranial nerve palsies in one patient, and seizures in three patients. All patients had tumor resections and postoperatively were monitored in the intensive care unit. The final pathology consisted of atypical teratoid/rhabdoid tumor (three patients), primitive neuroectodermal tumor/medulloblastoma (three patients), choroid plexus papilloma (two patients), astrocytoma (two patients), ganglioglioma (two patients), desmoplastic infantile ganglioglioma (two patients), glioblastoma multiforme (one patient), and choroid plexus carcinoma (one patient). Two intraoperative deaths occurred. Of the surviving 14, a gross total resection was achieved in four. Adjuvant therapy was determined by a multidisciplinary team composed of neuro-oncology, neurosurgery, and radiation oncology. Seven patients were treated with chemotherapy, and one patient had proton beam therapy. Five-year overall survival was 45%. The eight surviving patients had neurological sequelae, and developmental outcome was variable.

CONCLUSIONS

Brain tumors are uncommon in children younger than six months of age. Patients present with a variety of tumor pathologies. Children who survive have neurological sequelae. More studies are necessary to understand the impact that different treatment options, tumor pathology, and tumor location have on neurological outcome.

Congenital brain tumors: diagnostic pitfalls and therapeutic interventions

Congenital brain tumors are rare, accounting for 0.5% to 4% of all pediatric brain tumors. A 10-year retrospective study based on autopsy and neurosurgical clinical reports with a diagnosis of congenital/fetal/neonatal brain tumor identified 6 cases. Four cases were diagnosed antenatally by neuroradiology. Clinical outcomes in 5 cases resulted in death; 1 patient with choroid plexus papilloma underwent successful resection of the tumor and is still alive. Tumor pathologies consisted of 2 teratomas, 2 choroid plexus papillomas, 1 gemistocytic astrocytoma, and 1 glioblastoma multiforme. A literature review of all fetal cases specific to the pathologies presented in this series was also performed. Relative to the literature, this series contains a rare case of congenital gemistocytic astrocytoma. This series further sheds light on the diagnostic, histological, prognostic, and therapeutic differences between congenital brain tumors and tumors of the same pathology in older pediatric and adult populations.

In vivo detection of inducible nitric oxide synthase in rodent gliomas

Increased iNOS expression is often found in brain tumors, such as gliomas. The goal of this study was to develop and assess a novel molecular MRI (mMRI) probe for in vivo detection of iNOS in rodent models for gliomas (intracerebral implantation of rat C6 or RG2 cells or ethyl nitrosourea-induced glioma). The probe we used incorporated a Gd-DTPA (gadolinium(III) complex of diethylenetriamine-N,N,N',N'',N''-pentaacetate) backbone with albumin and biotin moieties and covalent binding of an anti-iNOS antibody (Ab) to albumin (anti-iNOS probe). We used mMRI with the anti-iNOS probe to detect in vivo iNOS levels in gliomas. Nonimmune normal rat IgG coupled to albumin-Gd-DTPA-biotin was used as a control nonspecific contrast agent. By targeting the biotin component of the anti-iNOS probe with streptavidin Cy3, fluorescence imaging confirmed the specificity of the probe for iNOS in glioma tissue. iNOS levels in glioma tumors were also confirmed via Western blots and immunohistochemistry. The presence of plasma membrane-associated iNOS in glioma cells was established by transmission electron microscopy and gold-labeled anti-iNOS Ab. The more aggressive RG2 glioma was not found to have higher levels of iNOS compared to C6. Differences in glioma vascularization and blood-brain barrier permeability between the C6 and the RG2 gliomas are discussed. In vivo assessment of iNOS levels associated with tumor development is quite feasible in heterogeneous tissues with mMRI.

Cranio-orbital teratoma

A new-born baby presented with a large, rapidly growing tumour. The tumour involved the right orbit, the anterior half of the right intracranial space and extended through the skull of the temporal region. The proptotic eye ruptured due to exposure. The tumour was extirpated when the patient was 12 days old. A large recurrence was extirpated two months later. The tumour was firmly bound to the medial aspect of the superior orbital fissure which probably was the location of origin of the tumour. Based on the size of the intracranial-and the orbital part of the tumour, it was classified as a secondary orbital teratoma. The tumour was macroscopically composed of cystic and solid areas. Microscopically it was seen to be a benign teratoma with tissue from all three germinal layers.

Early second-trimester diagnosis of intracranial teratoma

Congenital brain tumors are rare and, whether diagnosed prenatally or postnatally, the most frequent type is teratoma. Prenatal diagnosis relies on sonography and magnetic resonance imaging, and is usually achieved during the second or third trimester. We report a case of an intracranial tumor diagnosed in the early second trimester. The diagnosis had been suspected at first-trimester routine sonography, which showed a compressive intracranial mass with mild vascularization. Because of the poor prognosis, termination of pregnancy was discussed with the parents and was carried out at 14 weeks of gestation. Postmortem examination provided a diagnosis of right frontal immature teratoma.

A rare brain developmental anomaly in a patient with Usher's syndrome

We report a rare brain developmental anomaly in Usher's syndrome. We present a 43-year-old male with visual disturbance, hearing loss, and headache. Retinitis pigmentosa and sensorineural hearing loss were determined and he was diagnosed with Usher's syndrome according to the clinical findings. Magnetic resonance imaging showed an arachnoid cyst on the left temporal lobe, cavum septum pellucidum et vergae. Uneventful cataract surgery was performed in both eyes. He was suggested to be followed up periodically for the arachnoid cyst and to use a hearing device. Although auditory and visual disturbances are the typical findings of this syndrome, it may affect other parts of the central nervous system as well. Morphological abnormalities of central nervous system and related disorders can be seen in patients with Usher's syndrome.

[A relationship of congenital brain malformations and tumor growth]

The peritumor-like areas of 12 cerebral hemispheric tumors were examined. Histological study revealed vascular malformations and/or congenital tissue dysplasias in all cases: cortical disorganization, neuronal heterotopy into the white matter, neural location in the molecular cortical layer, and persistence of a subpial granular cell layer. Immunohistochemical study using Ki-67 antibodies in the peritumor-like tissue dysplasias revealed proliferative activity in a number of cases. The associations of the origin of brain tumors and congenital malformations are discussed.

Neonatal macrocephaly: cerebral primitive neuroectodermal tumor or neuroblastoma as an infrequent cause--a case report and review of the literature

We report a male term newborn presenting with a congenital macrocephaly 3.5 standard deviations above the median, with a wide and tense anterior fontanel, splayed calvarial sutures, and muscular hypotonia. Antenatal head circumferences were repeatedly below the median. A postnatal head ultrasound showed a large right intracerebral mass with right lateral ventricle compression, right temporal horn dilation, and right frontal horn enlargement with lateral displacement. Additional imaging by computed tomography scan and magnetic resonance imaging was performed. A decompression was performed and histology, immunohistochemistry, and molecular biology supported the diagnosis of a primitive neuroectodermal tumor. A MYCN gene amplification assay remained negative. The incidence of neonatal brain tumors is between 1.4 and 4.1/100,000 live births. Their most common presentation is macrocephaly, hydrocephalus, stillbirth, or diagnosis by pre- or postnatal imaging. Although hydrocephaly and intra- or extracranial hemorrhage are the most frequent causes of congenital macrocephaly, this should be initially investigated by head ultrasound. A suspected malignancy will be confirmed by histopathology, immunohistochemistry, and molecular biology.

Congenital and acquired lesions of the septum pellucidum

The septum pellicidum is a thin midline brain structure the function of which is poorly understood. Despite its small size, it is the site of a considerable number of anatomical variants, congenital anomalies, and acquired lesions. The review presents the imaging appearances of some of the more common congenital and acquired lesions of the septum pellucidum.

Giant intracranial teratoma with epignathus in a neonate. Case report and review of the literature

Epignathus, a congenital oropharyngeal teratoma, is a rare clinical entity with variable clinical outcomes described in the literature. Even fewer cases of epignathus with intracranial extension have been reported, all with poor outcomes. In this manuscript, the authors present a case of epignathus with intracranial extension, emphasizing clinical presentation, imaging findings, a staged surgical approach, multidisciplinary management, and outcome.

Neonatal subependymal giant cell astrocytoma: new case and review of literature

Subependymal giant cell astrocytomas are one of the three major intracranial lesions found in tuberous sclerosis complex. Subependymal giant cell astrocytomas are typically slow-growing tumors of mixed glioneuronal lineage which can become aggressive and cause obstructive hydrocephalus usually in older children and adolescents. Neonatal subependymal giant cell astrocytomas are extremely rare, and their natural history and prognosis are poorly understood. This report investigates an extremely large neonatal subependymal giant cell astrocytoma which was initially identified in utero at 19 weeks of gestation in a high-risk pregnancy with no family history of tuberous sclerosis complex.

Congenital glioblastoma multiforme. Case report and review of the literature

Congenital intracranial tumors are rare. If such a lesion is detected before birth, it is usually an incidental finding on fetal ultrasonography. The definition of a "congenital" tumor is controversial. The authors report the case of a "definite" congenital glioblastoma multiforme (GBM) diagnosed with the aid of ultrasonography and fetal magnetic resonance (MR) imaging in the 37th week of gestation. Postnatal MR imaging revealed a massive tumor occupying the patient's left temporoparietooccipital area. Angiography was performed to assess vascularity and embolize the main feeding arteries. Surgery was performed, and the tumor was successfully excised completely. The histopathological diagnosis of the tumor was GBM. An examination of the tumor cells revealed no p53 accumulation, a high MIB-1 index (87.5%), and no staining for epidermal growth factor receptor (EGFR). Adjuvant chemotherapy was administered, and the patient is doing well at 23 months of age. Congenital GBM should be considered in the differential diagnosis in cases in which a fetal ultrasonography study or fetal MR image reveals a tumor, especially in the presence of intratumoral hemorrhage. Radical tumor removal, administration of adjuvant therapy, and biological findings (such as a lack of the overexpression of p53 and EGFR in the tumor cells) all point to a longer survival time.

[Malignant solid tumors in neonates: a study of 71 cases]

Malignant neonatal tumors are rare and comprise 2% of childhood malignancies. Clinical features, histologic types, prognosis were very different from those seen in older children, facing oncologists with diagnostic, therapeutic and ethical problems.

PATIENTS AND METHODS

In a retrospective study from January 1987 to January 2004, we reviewed the management of neonates treated at the Institute Gustave Roussy for a malignant solid tumor for whom symptoms started in the first month of life.

RESULTS

Seventy-one neonates were treated, comprising 1,2% of the overall patients treated during the same period of time. Of these 71 patients, 42 (59%) presented with neuroblastomas, 12 (17%) with mesenchymal tumors, 6(8%) with cerebral tumors and 11 with various other types of tumors. Fifty-nine patients underwent surgical resection. Thirty-eight neonates received chemotherapy, administered at a 30 to 50% reduced dose. Hematologic toxicities and infections were the main therapeutic complications. Very small doses of radiotherapy were used in only 5 children. There has been no therapy-related mortality. Twenty-two of the 57 survivors have sequelae, especially patients with intraspinal neuroblastoma. The 5 year overall survival was 79%.

CONCLUSIONS

Neonatal malignant solid tumors, except for cerebral tumors, have a good prognosis. The young age of patients resulted in problems of treatment tolerance. The therapeutic regimen should take into account the risk of acute iatrogenic toxicity and long term sequelae. Surgery remains the treatment of choice but chemotherapy, with dose reduction, managed by expert teams, is essential and safer in a lot of case.

A report of nine newborns with congenital brain tumours

BACKGROUND

Although rare, brain tumours represent one of the relatively larger groups of congenital neoplasias. Most studies on congenital neoplastic disease deal with several types of neoplasms and are dominated by leukaemias, retinoblastomas and systemic solid tumours. Few studies are dedicated to congenital brain tumours. We present nine newborns (four boys and five girls) who were diagnosed with congenital brain tumours during the 8-year period 1 January 1992-31 December 1999 at our institution, which covers all paediatric neuro-oncology cases for Eastern Denmark.

EPIDEMIOLOGY

Two of the cases were referred from Western Denmark for surgery, and were therefore excluded from the calculation of incidence. During the same period, a total of 172 children below the age of 15 years were diagnosed as having primary central nervous system tumours. The seven remaining congenital cases thus represent 4% of all paediatric brain tumour cases in the area (95% confidence interval 1.7-8.3%). The population of the referral area is 2.383x10(6), and based on the total number of living births, the incidence of congenital brain tumour was calculated to be 2.9 per 100,000 live births. The ages of the mothers were 28-33 years, corresponding to the present mean age of 31 years for Danish primipara. The gestational age varied between 35 and 42 weeks, and the birth weights were 3,044-4,790 g.

RISK FACTORS

Two patients with p53-related glioblastoma multiforme (GBM) had relatives with p53-related neoplasms. In one case, the mother was treated for cancer of the ovary with surgery and chemotherapy 2 months before conception.

CLINICAL FEATURES

In five of the cases, brain abnormality was suspected antenatally. The clinical features of the newborns were limited to enlarged head circumferences, associated hydrocephalus, and asymmetric skull growth.

DIAGNOSIS AND TREATMENT

Three babies were treated with complete tumour resection. In the remaining six cases, a guided or open biopsy to obtain histology was made after CT/MRI imaging. The histological diagnoses were teratoma in four cases, GBM in two cases, anaplastic astrocytoma in two cases and, finally, haemangioma capillare in one case.

OUTCOME

Four of the patients (44%) are still alive, including two patients with totally resected combined orbital/intracranial teratomas, one patient with a totally resected haemangioma and one patient with anaplastic astrocytoma who did not receive any treatment apart from supportive care. The survival lengths of the five neonates who died varied between 1 day and 51 days.

Is language lateralization in temporal lobe epilepsy patients related to the nature of the epileptogenic lesion?

PURPOSE

Early acquired lesions are considered to be a risk factor for atypical language lateralization in epilepsy, whereas developmental lesions are not. Hippocampal sclerosis (HS) can be understood as an early, acquired lesion, whereas developmental tumors (DT) are thought to originate in utero. We assessed whether language lateralization differs between these groups of temporal lobe epilepsy patients.

METHODS

We used 3-Tesla functional MRI (fMRI) to assess 41 patients (16 DT, 25 HS) and 50 controls, performing a noun-verb-generation task. fMRI data were processed by using SPM2. A laterality index (LI) was calculated based on the number of activated voxels in left- and right-sided frontal lobe language areas. Atypical lateralization was considered if the index was < or = 0.2.

RESULTS

Patients had a lower LI (0.42 +/- 0.5) than controls (0.6 +/- 0.3; p < or = 0.05), but the LI was not different between DT (0.44 +/- 0.5) and HS patients (0.43 +/- 0.4; p = 0.9). The frequency of atypical lateralization was increased in patients (27%) compared with controls (8%) but was similar in both patient groups (DT, 31%; HS, 24%). HS patients had an earlier onset and longer duration of epilepsy and a higher frequency of significant antecedent events (p < or = 0.05).

CONCLUSIONS

Patients with TLE demonstrate a deviation toward atypical language lateralization. However, language lateralization was not different between patients with presumably acquired lesions compared with patients with developmental pathology. This suggests that the nature of the temporal lobe lesion does not influence overall language lateralization.

Surgical treatment of a neonate with refractory seizures secondary to congenital giant cell astrocytoma: case report and literature review

Congenital brain tumours are rare. They account for 0.5% to 1.9% of intracranial tumours in childhood and have an incidence of 0.34 per million live births. Most congenital brain tumours are neuro-ectodermal tumours and medulloblastomas; giant cell astrocytoma and other tuberous sclerosis-related tumours are rare. We report on a neonate who developed seizures that were refractory to medical treatment. Imaging studies revealed a right frontal calcified tumour. Surgical resection was performed successfully and pathology revealed the tumour to be a giant cell astrocytoma. The child was seizure-free afterwards.

Successful chemotherapy for congenital malignant gliomas: a report of two cases

We describe the cases of 2 patients with a congenital malignant glioma that responded to chemotherapy. In the first case, a 2-month-old boy had a conjugate deviation to the right side and nystagmus. A T(1)-weighted gadolinium-enhanced magnetic resonance image showed a large tumor in his right frontal lobe. The tumor was partially resected, and the histological diagnosis was malignant ganglioglioma. The child then underwent 6 cycles of chemotherapy (mainly carboplatin and etoposide), and the residual tumor shrank. The tumor was then partially resected during a second operation, after which the patient underwent 5 cycles of chemotherapy (a combination of carboplatin, etoposide, vincristine, ifosfamide, cisplatin and cyclophosphamide). The tumor has not recurred in more than 8.5 years. In the second case, a 2-month-old boy had bulging of the anterior fontanel. The T(1)-weighted gadolinium-enhanced magnetic resonance image showed a large suprasellar tumor. The tumor was partially resected, and the histological diagnosis was anaplastic astrocytoma. The patient underwent 8 cycles of chemotherapy (MCNU, carboplatin and etoposide) and the tumor has not recurred in more than 7.5 years. Our experience indicates that, if surgical removal and chemotherapy are done aggressively for malignant gliomas in neonates and infants, long-term survival is possible.

A congenital brain tumor associated with assisted in vitro fertilization. Case report

In this report the authors describe the clinical features of a rare neonatal anaplastic astrocytoma in the setting of in vitro fertilization (IVF). The infant had been conceived using IVF and was born full term to a 29-year-old prima gravida mother. At birth, the baby boy was irritable and demonstrated poor feeding. Cranial ultrasonography and magnetic resonance imaging revealed an echogenic mass in the left hemisphere with midline shift and hydrocephalus. Grosstotal resection of an anaplastic astrocytoma was followed by chemotherapy with temozolomide and vincristine. Previous cases of neonatal brain tumors occurring in the setting of assisted reproduction are reviewed. A possible association between IVF and congenital neuroepithelial tumors is highlighted.

Occurrence of fetal choroid plexus cysts in siblings: Concerns regarding recurrence and chromosomal abnormality

Choroid plexus cysts (CPC) are a well-known ultrasound aneuploidy marker easily detectable at second-trimester ultrasound examination. However, their genetic etiology is totally unknown. We report two cases of Japanese mothers who carried two and three siblings respectively; all the fetuses that had CPC were noticed at second trimester. Genetic amniocentesis revealed that each fetus had different karyotypes, that is, trisomy 18 and 46,XX in the case of one mother, and trisomy 18, 46,XY and trisomy 21 in the case of the other. These observations indicate that the genetic basis of the cysts is not linked to abnormal chromosomes. We propose that careful ultrasound observation and genetic counseling of the siblings should be offered to patients who have previously had a baby with CPC, despite that baby having a normal karyotype.

RNA expression analysis of a congenital intracranial teratoma

Congenital intracranial tumors are extremely rare and account only for 0.5%-1.5% of brain tumors in children. We report a large intrauterine congenital teratoma in a female fetus at gestation weeks 37, which was diagnosed by detecting the tumor and associated craniomegaly with ultrasonography (US) and magnetic resonance (MR) imaging. The tumor had replaced the cerebral hemispheres and produced prenatal manifestations. Pathologic examination showed an immature teratoma, which was differentiated from all three germ layers. Microarray analysis revealed upregulation of ten genes and downregulation of three genes, as well as upregulation of 41 genes of ribosomal proteins in teratoma cells, compared to normal brain tissue of the patient. The data from the microarray analysis offer not only the potential to help define disease pathogenesis but may also provide clues to identify potential molecular therapeutic targets.

[Congenital brain tumor in neonate--case report and review of literature]

The paper describes a case of prenatally diagnosed congenital brain tumor of an extremely rare histological type--oligodendrocytoma. The intrauterine ultrasound scans were interpreted as intracranial hemorrhage. The initial physical examination of the newborn revealed symptoms of mild increase of intracranial pressure. The diagnosis of brain tumor was based on computed tomography of the head performed on the 4th day of life. The tumor was totally (as histological and radiological test indicated) removed on the 9th day of life. At the age of 2 months, relapse of tumor was diagnosed. Reoperation and subsequent chemiotheraphy were introduced. At present, the child is 9 months old and no neurological impairment is visible. The discussion presents data on congenital brain tumor epidemiology and differences in location, histology and outcome between neonates and older children. Moreover, recent surgical and medical management is described.

Parietal Lipomeningocele-Case Report-

A 2-month-old female infant had had a parietal mass since birth. Neuroimaging revealed a lipoma under the splenium of the corpus callosum that was connected to the subcutaneous lipoma via a bone defect in the cranium bifidum of the parietal region. At the age of 5 months, partial resection of only the extracranial mass was carried out. The histological diagnosis was lipoma. She grew up normally without neurological disorders during follow up for 12 years after the surgery. In the present case, the intracranial lipoma was associated with the cranium bifidum, and dysraphism was possibly involved in the pathogenesis. Resection of only the extracranial subcutaneous tumor can be performed for cosmetic reasons.

Massive congenital intracranial teratoma: perioperative coagulation impairment

Massive congenital intracranial teratoma is a rare neoplasm with a poor prognosis. Surgery may be curative only if complete resection can ben obtained. Several single case reports have been published in the pediatric literature, mostly focusing on prenatal diagnosis. The authors describe six patients with congenital intracranial teratoma treated at their institution in the past decade. Perioperatively, a marked hemostatic derangement was observed in three of them undergoing surgery: the pathophysiology of this complication is discussed. The surgical indication itself represents an ethical dilemma when treating a large intracranial tumor with partial destruction and replacement of brain structures.

Posterior pericallosal lipoma extending through the interhemispheric fissure into the scalp via the anterior fontanelle

We report an unusual pericallosal lipoma presenting as scalp mass at birth. The patient had no obvious neurological deficit, but CT and MRI revealed a striking lipoma extending extracranially into the scalp from the interhemispheric fissure via the anterior fontanelle. The corpus callosum was distorted but not dysplastic.

Congenital cavernous angioma exhibits a progressive decrease in size after birth

CASE REPORT

We report a case of congenital intracranial cavernous angioma, which was initially found at a gestational age of 34 weeks in utero as a mass lesion associated with hydrocephalus. After birth, the patient was treated for hydrocephalus first by external drainage and then by ventricular peritoneal shunt. The natural course of the mass lesion was observed until the age of 8 months when the histopathological diagnosis confirmed the cavernous angioma after tissue was obtained by surgery. CT scans repeated monthly during this period demonstrated that the angioma continuously decreased in size. There was no evidence of hemorrhage in the angioma on serial CT scans. The histopathology revealed thrombosis of cavernous vessels with hyaloid changes in the angioma.

DISCUSSION

The mechanisms of the decreasing size of the cavernous angioma have often been discussed in relation to spontaneous hemorrhages and resolution. The present case suggests a mechanism in which the spontaneous formation of a thrombus might be the dominant factor for the decrease in size. Thrombus formation may result from low perfusion due to the large size of the angioma.

Teratomas of the head and neck region

BACKGROUND

Teratomas are exceptionally rare malformations in the head and neck region. They are mostly benign but as a direct result of their rarity, most clinician's experience of these tumours is very limited, and consequently most of the associated literature consists of single case reports. In this paper, however, all the cases managed by a major Craniofacial Unit (the Australian Craniofacial Unit) were reviewed to attempt to identify common problems encountered in their management.

MATERIAL AND METHODS

All cases managed by the Australian Craniofacial Unit over the last 25 years were reviewed. In total a series of nine cases was identified, but two were seen and operated on in overseas centres and the data in these cases were incomplete, and have been excluded from the study. Case note, radiology and pathology review was undertaken to collect data.

RESULTS

In total a series of seven cases was identified as suitable for inclusion in this study. Six of these have had a minimum of 9 years follow-up, three having completed growth.

CONCLUSION

The initial and subsequent management demonstrates that these tumours when benign can be successfully removed, but depending on the affected site may require continued multidisciplinary management until growth has finished.

A case of definitely congenital glioblastoma manifested by intratumoral hemorrhage

BACKGROUND

A female infant was born with a left-sided glioblastoma that manifested clinically with weakened crying and feeding on day 1 of life, fever and bulging anterior fontanel on day 4, and right hemiparesis by day 10.

METHODS

Preoperative magnetic resonance imaging showed hemosiderin intensity indicating that hemorrhage had occurred during the prenatal period. Radical surgical removal of the tumor was performed on the 22nd postnatal day.

RESULTS

Postoperatively, the right hemiparesis did not worsen and the patient did not have any new neurological deficits. The right hemiparesis gradually improved after her initial surgery, and she was able to stand by herself at 18 months of age. Adjuvant chemotherapy and radiation were administered. This patient survived for 27 months following birth, which is a relatively long time for glioblastoma cases. Radical removal at the first operation with reliance on the plasticity of infant cerebral function was the key point in the long survival.

Congenital mixed malignant germ cell tumor involving cerebrum and orbit

Congenital intracranial tumors are rare and only account for 0.5 to 1.5% of all pediatric brain tumors. Teratoma is the most frequently encountered intracranial tumor at birth. Cephalomegaly and hydrocephalus are the usual clinical presentations. Advances in imaging techniques have improved diagnostic accuracy in congenital brain tumors. But the prognosis of a massive intracranial teratoma is always dismal. We report a congenital mixed malignant germ cell tumor in a male fetus at 27 weeks of gestation, with massive involvement of cerebrum and orbit. According to histological and immunohistochemical studies, the tumor was made up of predominantly immature teratoma combined with a yolk sac tumor. To our knowledge, such a combination has not been well documented in the literature.

Skew ocular deviation: a catastrophic sign on MRI of fetal glioblastoma

CASE REPORT

We report the prenatal observation of fetal ocular skew deviation in a case of a glioblastoma found prenatally at 33 weeks' gestation by MRI. The fetal MRI, obtained by half-Fourier single-shot turbo spin echo (HASTE) pulse sequences, showed a tumor (80 mm in maximum diameter) in the right deep cerebral hemisphere with extension to the mid-cranial fossa and tentorial hiatus in addition to severe hydrocephalus. On coronal MR images a vertical dysconjugated gaze was recognized. One week after the MRI, frequent delayed deceleration prompted an emergency cesarean section. The baby was born with left hemiparesis and central neurogenic hyperventilation, which evolved into decerebrate rigidity and apneustic breathing within 2 h. Post-mortem examination revealed a glioblastoma in the right deep hemisphere, a tumor with brain stem involvement, and transtentorial herniation.

CONCLUSIONS

We suggest, therefore, that recognition of ocular skew deviation on fetal MR images would indicate brain stem involvement and poor postnatal prognosis. Early recognition of the catastrophic sign would lead to proper management.

Fast magnetic resonance imaging in steady-state precession (true FISP) in the prenatal diagnosis of a congenital brain teratoma

Teratomas are the most common congenital intracranial tumor. Although fetal magnetic resonance (MR) imaging is becoming more popular for prenatal diagnosis, only 2 cases of congenital intracranial teratoma have been reported, and these cases relied on half-Fourier single-shot turbo spin echo (HASTE) imaging. We report the first known case of congenital intracranial teratoma diagnosed by means of a fast imaging in steady-state precession (true FISP) MR sequence. True FISP can be obtained in almost 20 seconds and provides superior contrast resolution compared with HASTE.

Prenatal imaging of congenital cerebral primitive neuroectodermal tumor

A case of fetal brain tumor, which appeared after 32 weeks' gestation, is presented. Prenatal ultrasonography and magnetic resonance imaging demonstrated a large heterogeneous mass in the right supratentorial region and left enlarged ventricle. A male fetus weighing 2,616 g was delivered at 34 weeks' gestation by cesarean section and died on the 37th day of life due to rapid growth of the tumor. Following autopsy, the pathohistological examination revealed primitive neuroectodermal tumor. Magnetic resonance imaging in the prenatal management of the congenital brain tumor is efficient in evaluating the expansion and margin of the tumor and intratumoral bleeding, which are not demonstrated by ultrasonography.

Congenital bilateral plexiform neurofibromas of the cavernous sinuses

We report the CT and MRI findings of congenital bilateral plexiform neurofibromas of the cavernous sinuses in a 2-month-old girl. Contrast-enhanced CT showed enhancement of masses in both cavernous sinuses and enlargement of both superior orbital fissures. On MRI the masses were isointense with muscle on T1-weighted images, hypointense on T2-weighted images and showed strong homogeneous enhancement on contrast-enhanced T1-weighted images. A dural tail sign was observed. The diagnosis was proven by biopsy.

[Congenital brain tumors: nine cases and review of the literature]

OBJECTIVE

To review congenital brain tumors patients younger than 2 months diagnosed in our Department.

PATIENTS AND METHODS

Nine congenital brain tumors were diagnosed between 1983 and 2001 among a consecutive serie of 484 paediatric cerebral tumors (patients less than 15 years). Clinical and radiological findings and prognostic factors are analyzed.

RESULTS

There were two teratomas, two glioblastomas, one xanthogranuloma affecting cavernous sinus, one supratentorial PNET and one medulloblastoma and one oligodendroglioma. In one case histological diagnosis was not possible. In four cases antenatal diagnosis was done by means of ultrasonography and MRI. Seven patients were operated on, with one intraoperative exitus. Five patients died due to tumoral progression in the first two months after surgery. Another case was considered not amenable for surgical resection, and thus was not operated. He died in the fifth day of life. Three patients are alive 14, 36 and 72 months after surgery, one with severe psicomotor delay, another one with normal mental status but dependent on seizures medication and the last one with mild mental delay. In the last case of our serie intrauterine death happened by 33(rd )week and histological diagnosis was not possible.

CONCLUSIONS

Prognosis for congenital brain tumors depends on the operative morbidity and tumor histology. However final prognosis in these patients is still discouraging, despite early surgery and operative and anaesthetic improvements.