Sellar and Parasellar Metastatic Tumors

The sellar and parasellar (SPS) region is a complex area rich in vital neurovascular structures and as such may be the location of first manifestation of a systemic malignancy. Metastases to this region are rare; breast cancer is the most common source among those that metastasize to the SPS region. Ophthalmoplegia, headache, retroorbital or facial pain, diabetes insipidus, and visual field defects are the most commonly reported symptoms. Lack of specific clinical and radiological features renders SPS metastases difficult to differentiate from the other frequently encountered lesions in this area, especially when there is no known history of a primary disease. Currently accepted management is multimodality therapy that includes biopsy and/or palliative surgical resection, radiation, and chemotherapy. Although no significant survival benefits have been shown by the surgical series, surgical resection may improve quality of life. Here we review the relevant literature and present six illustrative cases from our own institution

Tanycytic Ependymoma: A Challenging Histological Diagnosis

Tanycytic ependymoma is a rare form of ependymoma that usually arises in the intramedullary spine. It has a unique histology emphasized by the inconspicuous ependymal pattern of cells and close resemblance to schwannoma and astrocytoma. The authors report a 50-year-old man with a cervical tanycytic ependymoma that was initially thought to be a schwannoma. The frozen histology section showed spindle cells with oval and elongated nuclei with occasional hemosiderin deposits present suggesting a preliminary diagnosis of schwannoma. Immunohistochemical staining of the permanent section revealed strong immunoreactivity for glial fibrillary acidic protein with intermittent S-100 positivity, confirming that the tumor was a tanycytic ependymoma. This underlines the challenges involved in making an accurate diagnosis and demonstrates that careful and detailed histological inspection with immunohistochemical stains and ultrastructural microscopy may be necessary to distinguish tanycytic ependymoma from other neoplasms

Intraventricular Hemorrhage after Epidural Blood Patching: An Unusual Complication

The authors present two cases of intraventricular hemorrhage (IVH) believed to be a result of epidural blood patching. The first was a 71-year-old woman who had new onset of nontraumatic IVH on computed tomography (CT) scan after undergoing an epidural blood patch (EBP). This amount of intraventricular blood was deemed an incidental finding since it was of very small volume to account for her overall symptoms. The second patient, a 29-year-old woman, was found to have nontraumatic IVH three days after undergoing an EBP. This was seen on CT scan of the head for workup of pressure-like headaches, nausea, vomiting, and absence seizures. Conservative management was followed in both instances. Serial CT scan of the head in our first patient displayed complete resolution of her IVH. The second patient did not have follow-up CT scans because her overall clinical picture had improved significantly. This highlights a potential sequel of EBP that may be observed on CT scan of the head. In the event that IVH is detected, signs and symptoms of hydrocephalus should be closely monitored with the consideration for a future workup if warranted by the clinical picture

Extraspinal Type I Dural Arteriovenous Fistula with a Lumbosacral Lipomyelomeningocele: A Case Report and Review of the Literature

Seven cases of adult spinal vascular malformations presenting in conjunction with spinal dysraphism have been reported in the literature. Two of these involved male patients with a combined dural arteriovenous fistula (DAVF) and lipomyelomeningocele. The authors present the third case of a patient with an extraspinal DAVF and associated lipomyelomeningocele in a lumbosacral location. A 58-year-old woman with rapid decline in bilateral motor function 10 years after a prior L4-5 laminectomy and cord detethering for diagnosed tethered cord underwent magnetic resonance imaging showing evidence of persistent cord tethering and a lipomyelomeningocele. Diagnostic spinal angiogram showed a DAVF with arterial feeders from bilateral sacral and the right internal iliac arteries. The patient underwent Onyx embolization of both feeding right and left lateral sacral arteries. At 6-month follow-up, MRI revealed decreased flow voids and new collateralized supply to the DAVF. The patient underwent successful lipomyelomeningocele exploration, resection, AV fistula ligation, and cord detethering. This report discusses management of this patient as well as the importance of endovascular embolization followed by microsurgery for the treatment of cases with combined vascular and dysraphic anomalies