Cervicomedullary junction mature teratoma with pulmonary differentiation and diastematomyelia in an adult - A rare case

Background

Intradural extramedullary teratomas in the cervical or cervicomedullary region are rare in adults.

Case Description

We report a symptomatic, mature teratoma at the cervicomedullary junction in a 52-year-old Hispanic female who also has a type I diastematomyelia in the thoracolumbar spine. The patient underwent surgical resection of the lesion with the resolution of presenting symptoms. Histopathology of the lesion revealed a mature cystic teratoma with pulmonary differentiation.

Conclusion

We discuss the case along with a review of pertinent literature and considerations with regard to the diagnosis, etiology, prognosis, and management of this unusual pathology.

Cervicomedullary glioblastoma: A report of two cases with review of literature

Background

Cervicomedullary glioblastoma is an extremely rare clinical entity and the principles of its management are not well understood.

Case Description

We report two cases of cervicomedullary glioblastoma in young patients aged 12 and 30 years with contrasting clinical presentation and outcomes. The 12-year-old child had rapid onset bulbar symptoms, with frank infiltration of the medulla due to which the patient succumbed within 4 weeks of surgery. The 30-year-old adult had a relatively slow disease onset and progression and made a good neurological recovery without disease progression at 16 months after surgery. To the best of our knowledge, we also report only the second adult patient in the literature with a dorsally exophytic cervicomedullary glioblastoma. Difficulties in diagnosis and management are discussed with a review of the pertinent literature.

Conclusion

The overall outcome depends on the rapid progression and severity of preoperative symptoms and the degree of tumor infiltration noted in imaging and during surgery.

Huge Ventral Cervicomedullary Neurenteric Cyst: A Rare Entity with Good Surgical Outcome and Appraisal

Neurenteric cysts are rare congenital lesions of benign nature that can be encountered at any level of the neuraxis, starting from the cranium down to coccyx. Rewarding outcome can be achieved with early diagnosis and complete removal of these benign lesions. Here, we report a case of a huge neurenteric cyst in an 11-year-old boy at the ventral craniocervical junction, a rarely reported entity with literature review. In this article, we focus on the clinical presentation, pathogenesis, radiological findings, surgery, and surgical outcome of this benign lesion, as we succeeded to have gratifying result following surgery in our instance.

Microsurgical Resection of an Intramedullary Ependymoma at the Cervicomedullary Junction: A Two-Dimensional Operative Video

Ependymomas are the most common adult intramedullary spinal tumors.¹ Although uncommon in the brainstem, ependymomas make up a large proportion of tumors of this location.^2-8 We present an operative video case report of an intrinsic ependymoma at the cervicomedullary junction. The purpose of this report is to present the clinical picture, operative setup, and surgical technique involved in resection of an intramedullary tumor of this region. For best outcome for intramedullary ependymomas, the goal should be gross total resection.^1,9,10 These tumors have a relatively distinct plane between tumor and normal parenchyma, making a gross total resection more probable than cases of infiltrative intramedullary astrocytomas.¹¹ Despite this, significant morbidity can be associated with treatment.¹ Proper microsurgical technique with use of operative adjuncts can maximize resection while minimizing neurologic injury to optimize outcomes in patients. We present the case of a 42-year-old man presenting with neck and shoulder pain, upper extremity paresthesias, and gait instability. Magnetic resonance imaging of the neuroaxis revealed a heterogeneously enhancing expansile lesion in the lower medulla and multiple lesions in the thecal sac, representing drop metastases. Due to symptoms and mass effect from the lesion, the patient underwent a suboccipital craniotomy for tumor resection. We highlight operative techniques in our case, including use of neurophysiologic monitoring, intraoperative ultrasound, ultrasonic aspirator, and dissection with microcottonoid pledgets and bimanual technique. Pathology revealed a World Health Organization grade II ependymoma. Postoperative magnetic resonance imaging revealed a small amount of residual. He underwent full craniospinal proton beam therapy with boost to the residual and metastases with good outcome. Patient provided consent for this report.

Far Lateral Approach for In Situ Occlusion of Craniospinal Cervicomedullary Arteriovenous Malformation Presenting with Subarachnoid Hemorrhage

A 49-year-old woman presented with sudden-onset headache and meningismus. Computed tomography scan revealed a posterior fossa subarachnoid hemorrhage extending from the foramen magnum to the ambient cistern. Angiography showed a pial extramedullary arteriovenous malformation (AVM) at the lateral ventral surface of the cervicomedullary junction with primary supply from the left posterior inferior cerebellar artery (PICA) and dominant drainage into the anterior median perimedullary vein. Embolization of the AVM was considered a high-risk procedure, as feeding arteries originated from the proximal lateral medullary segment of the left PICA. A far lateral approach with suboccipital craniotomy and C1-C2 laminectomy was performed (Video 1). The PICA was disconnected from the AVM, and multiple small feeders were interrupted with bipolar cautery and aneurysm clips to achieve an in situ occlusion of the pial AVM. Intraoperative indocyanine green video angiography was used to define the AVM and critical en passant vessels before disconnection and to demonstrate no residual early venous filling after the in situ occlusion. Postoperative angiography demonstrated no residual arteriovenous shunting or nidiform vessels, with preservation of patency of the left PICA. The patient had an uneventful postoperative course and was discharged with no significant neurologic deficits.

Cervicomedullary Ependymoma with Hemorrhage: A Case Report and Review of Literature

Ependymoma is a rare tumor central nervous system that arises from the ependymal lining of the ventricles or the central canal of the spinal cord. They are of neuroectodermal in origin and constitute about 30%–86% of tumors arising in the spinal cord. The occurrence of these tumors in the cervicomedullary region is very rare. Sudden symptomatic neurologic presentations due to hemorrhage in cervicomedullary ependymoma is very rare and so far have never been reported. Mostly presenting as neurologic deficits involving limbs, these tumors pose a technical challenge in their removal. We present a patient who presented with sudden-onset dysesthesia of the upper and lower limbs. On imaging, he was found to have a cystic medullary tumor extending to the cervical region with hemorrhage. We discuss the epidemiology, surgical challenges, and outcome along with review of literature of these rare tumors located in this precarious location.

Cervicomedullary primitive neuroectodermal tumor of the spine: Case report

Background

Intramedullary primitive neuroectodermal tumors (PNETs) are tumors found rarely in the cervical region, with only five such cases described in the literature. The available literature contains only one report regarding cervicomedullary junction PNET.

Case Description

The authors present a case report of a 45-year-old male patient who had undergone urgent hospitalization owing to progressive tetraparesis and subtle impairment of respiratory function. He underwent magnetic resonance imaging, which showed an extensive enhancing cervical intramedullary tumor extending from C5 to the bulbar region. Since he developed severe impairment of respiratory function, he required tracheostomy. He then underwent microsurgery 2 days after his admission, and a partial tumor resection was performed. The pathological diagnosis of PNET of the cervicomedullary junction (CMJ) was made. He had slight worsening of strength after surgery with subsequent deterioration over the next 3 weeks. The tumor displayed aggressive growth; thus, radiotherapy was indicated. Unfortunately, he developed severe febrile neutropenia and died after 2 weeks of radiotherapy. Given the rarity of the condition, we wish to review the epidemiology, pathophysiology, and treatment options of his population.

Conclusion

Intramedullary PNETs of the cervical spine and CMJ are exceedingly rare in adults; treatment of such patients remains a challenge, despite the modern neurosurgical armamentarium that is available.

Medullary position at the craniocervical junction in mature cavalier King Charles spaniels: relationship with neurologic signs and syringomyelia

Background

Medullary elevation (ie, medullary kinking) at the craniocervical junction (CCJ) is reported in dogs with Chiari‐like malformations (CM), but its diagnostic criteria and clinical relevance are unclear.

Objective

To describe the position of the medulla at the CCJ in mature cavalier King Charles spaniels (CKCS), and evaluate its relationship with clinical status and the presence of syringomyelia.

Animals

Thirty‐six CKCS, 5–12 years of age, including 16 asymptomatic dogs.

Methods

Dogs were assigned a neurologic grade; magnetic resonance imaging (MRI) of the CCJ then was performed. The presence of a CM and syringomyelia was recorded and syringomyelia severity was quantified. Medullary position was quantified using the medullary kinking index, the elevation angle and obex position relative to the foramen magnum. The relationship between medullary position measures and presence and severity of neurologic signs and syringomyelia was investigated.

Results

Chiari‐like malformation was found in 33 dogs; 26 of them had syringomyelia. Mean medullary kinking index was 46.4% (SD, 10.3), elevation angle was 132° (SD, 12) and obex position was 3.5 mm (SD, 0.8). A higher medullary kinking index was associated with the presence of neurologic signs (P = .0368). Obex position was associated with the presence (P = .0018) and severity of syringomyelia (P = .0164).

Conclusions and clinical importance

There is a significant association between medullary elevation and clinical signs, whereas more caudal brainstem positions appear related to the presence of syringomyelia.