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Giant aneurysms are lesions with diameter greater than or equal to 25 mm. They are uncommon lesions presenting with features of mass effect and rarely rupture. Diagnosis confirmed on angiography. This case describes a young female with giant paraclinoid internal carotid artery aneurysm. The patient was managed with superficial temporal artery to middle cerebral artery bypass with aneurysm trapping. Keywords Giant aneurysm, STA-MCA bypass, aneurysm trapping

Cysts occupying the third ventricle are rare lesions and may appear as an unusual cause of hydrocephalic crisis. A 40-year old woman with headache and one episode of fainting attack was diagnosed with a cystic lesion in the third ventricle after brain MRI study. She was operated with the pre-operative diagnosis of a colloid cyst. A yellowish, thick and mucoid cyst was observed intra-operatively. The total removal of the cyst was done along with the cyst wall. On histopathological evaluation, the cyst wall was lined by ciliated cuboidal to pseudostratified columnar epithelium resting on an eosinophilic basement membrane. The ultrastructural study showed the characteristic 9+2 pattern of cilia. Immunohistochemistry showed positive staining for epithelial membrane antigen (EMA), cytokeratin (CK), and negative staining for Glial fibrillary acidic protein (GFAP). Histopathological and ultrastructural findings confirm the diagnosis of a colloid cyst of third ventricles favoring the endodermal origin of the cyst.

Majority of the orchid species are used in the traditional medicines for the treatment of several diseases. They are the sources of polysaccharides, phenanthrenes, bibenzyl derivatives, revesteral, stilbenoids and polyphenol compounds. This study explored the cytotoxic activity of seven wild orchid species and identification of medicinally active compounds. The extracts of orchid species were screened for cytotoxic effect on the human cervical cancer cells (HeLa) and human glioblastoma cells (U251) using an MTT assay. The medicinally active compounds of high cytotoxic extracts were identified by GC-MS resulting in many stilbenoids and phenolic derivatives. The extract of Dendrobium transparens (DTs) and Vanda cristata (VCw) showed high cytotoxic effect towards the HeLa and U251 cell lines (IC50 of DTs: 382.14 μg/ml and 75.84 μg/ml respectively and IC50 of VCw: 317.23 μg/ml and 163.66 μg/ml respectively). This study concludes that they could be used as cancer therapeutics., Plant biology; Bioactive plant product; Biological sciences; Botany; Natural product; Pharmaceutical science; Bioactive compounds; GC-MS; MTT assay; Orchids.

Deep Sylvian meningiomas are rare, accounting for 0.3–0.4% of all meningiomas, and mostly present in young adults and children. We report on a 32-year-old man who presented with headache but had no neurological deficits. Computed tomography of brain revealed a 24 × 19 × 21 mm3 mass lesion in the right Sylvian fissure with calcification. Magnetic resonance imaging showed that the lesion was isointense on T1- and T2-weighted images (WI), with homogenous enhancement on post-gadolinium T1WI. The lesion was surgically removed via right fronto-temporal craniotomy. The tumor was located in deep Sylvian fissure and had no dural attachment. Histopathological examination of the lesion revealed both meningothelial and fibroblastic features, thereby suggesting the diagnosis of transitional meningioma (WHO grade I), with Ki-67 labeling index of 6.9%. Thus, meningioma should be considered as a differential diagnosis of enhancing mass lesions in the Sylvian fissure even in the absence of dural tail sign, especially in young adults and children.

Background: Accurate diagnosis of brain tumor is crucial for adequate surgical strategy. Our institution follows a comprehensive preoperative evaluation based on clinical and imaging information. Methods: To assess the precision of preoperative diagnosis, we compared the “top three list” of differential diagnosis (the first, second, and third diagnoses according to the WHO 2007 classification including grading) of 1061 brain tumors, prospectively and consecutively registered in preoperative case conferences from 2010 to the end of 2017, with postoperative pathology reports. Results: The correct diagnosis rate (sensitivity) of the first diagnosis was 75.8% in total. The sensitivity of the first diagnosis was high (84–94%) in hypothalamic-pituitary and extra-axial tumors, 67–75% in intra-axial tumors, and relatively low (29–42%) in intraventricular and pineal region tumors. Among major three intra-axial tumors, the sensitivity was highest in brain metastasis: 83.8% followed by malignant lymphoma: 81.4% and glioblastoma multiforme: 73.1%. Sensitivity was generally low (≦60%) in other gliomas. These sensitivities generally improved when the second and third diagnoses were included; 86.3% in total. Positive predictive value (PPV) was 76.9% in total. All the three preoperative diagnoses were incorrect in 3.4% (36/1061) of cases even when broader brain tumor classification was applied. Conclusion: Our institutional experience on precision of preoperative diagnosis appeared around 75% of sensitivity and PPV for brain tumor. Sensitivity improved by 10% when the second and third diagnoses were included. Neurosurgeons should be aware of these features of precision in preoperative differential diagnosis of a brain tumor for better surgical strategy and to adequately inform the patients.

Dural arteriovenous fistula (DAVF) of the anterior condylar confluence (ACC) is a rare entity accounting for about 3.6% of all DAVFs. We report on a 63-year-old male patient who presented with pulsatile tinnitus. Angiography revealed a DAVF supplied mainly by neuromeningeal branches of bilateral ascending pharyngeal arteries and draining into the ACC. Transvenous transjugular coil embolization was performed resulting in complete obliteration of the fistula and resolution of the symptoms. Due to the complexity of this venous structure at the skull base, detailed angiographic study is crucial for proper therapeutic planning and management of the patient. We here discuss the clinico-radiological features and various treatment modalities of the ACC DAVF.Nepal Journal of Neuroscience, Volume 15, Number 2, 2018, page: 41-44

Background Xanthogranuloma is a chronic inflammatory mass characterized by cholesterol crystal deposition, which is rarely seen in the sellar region. The objective of this study is to identify the clinical features and cause of sellar xanthogranulomas. Methods We retrospectively analyzed manifestation, radiographic, and endocrinologic presentation in 9 patients (7 women and 2 men) whom we had previously treated. Results The patients were between 26 and 73 years of age (median, 56 years). The chief symptoms were visual symptoms in 3, polyuria in 3, headache in 4, and tiredness in 4 patients. Perimetry found visual field deficit in 6 patients. Anterior pituitary provocation tests disclosed impairment of ≥1 hormone in all patients: growth hormone in 8 patients and adrenocorticotropic hormone–cortisol axis in 8 patients. The lesions were suprasellar in 2 patients, intrasellar in 2 patients, and intrasuprasellar region in 5 patients. Three of the lesions were solid and 6 were single cystic to multicystic. Very low intensity area on T2-weighted magnetic resonance imaging was observed in 4 lesions. Postcontrast study performed in 7 lesions showed enhancement in solid parts or cyst walls. Surgical decompression improved visual disturbance in half of the patients but rarely improved hormonal deficits. Follow-up (median, 47 months) found no recurrence of the lesion. In addition to these 9 cases, we found 2 xanthogranulomatous lesions pathologically associated with ciliated epithelia, which also presented with severe hypopituitarism. Conclusions Xanthogranuloma seems to be the last stage of the chronic inflammation affecting Rathke cleft cyst or craniopharyngioma presenting with severe anterior pituitary insufficiency.

Patients with acromegaly have a compromised quality of life (QOL). Modern surgical techniques have improved the surgical cure rate. However, there are no prospective studies reporting postoperative changes in QOL among patients cured solely by surgery. The aim of the present study was to determine the effect of surgery on QOL using the 36-item short form health survey (SF-36) questionnaire. SF-36 scores comprise 3 components: the physical component summary (PCS), the mental component summary (MCS) and role-social component summary (RCS). Included in this prospective cohort were 41 patients with acromegaly who underwent surgery alone and achieved postoperative normalization of insulin-like growth factor-1. All participants completed the SF-36 preoperatively and 1 year postoperatively. Preoperatively, RCS and 4 subscale scores (role physical, social functioning, role emotional, mental health) were below the set standards for the normal population. Postoperatively, the PCS and RCS scores did not change significantly, but the MCS score improved significantly (from 48.1 ± 11.3 to 51.7 ± 8.9, p=0.03). Further we compared the QOL of 26 patients whose nadir GH level was < 0.4 μg/L during postoperative oral glucose tolerance testing (complete remission group) with that of 15 patients whose nadir GH level was ≥ 0.4 μg/L (partial remission group). There were no significant differences between these groups in terms of PCS, MCS, RCS, or any subscale scores. In conclusion, surgical remission mostly improved the participants' mental condition. There was no difference in QOL between patients who achieved the new remission criteria and those who did not.

Background Flow diversion with the Pipeline embolization device (PED) is a widely accepted treatment modality for aneurysm occlusion. Previous reports have shown no recanalization of aneurysms on long-term follow-up once total occlusion has been achieved. Case description We report on a 63-year-old male who had a large internal carotid artery cavernous segment aneurysm. Treatment with PED resulted in complete occlusion of the aneurysm. However, follow-up angiography at four years revealed recurrence of the aneurysm due to disconnection of the two PEDs placed in telescoping fashion. Conclusion Herein, we present the clinico-radiological features and discuss the possible mechanisms resulting in the recanalization of aneurysms treated with flow diversion.

The endoscopic method is used to treat suprasellar arachnoid cysts (SACs) but it is sometimes difficult to make sufficiently sized fenestrations. Creating a larger fenestration on the cyst wall is preferable to prevent closure of the stoma. In this paper, we report a novel endoscopic approach for SAC treatment in which we use bilateral burr holes to achieve a more extensive cyst fenestration. A 7-year-old girl was referred to our hospital because of incidentally detected hydrocephalus by computed tomography scans. Physical examination did not show any signs of intracranial hypertension, but a digital impression of her skull on X-ray implied chronic intracranial hypertension. Magnetic resonance imaging (MRI) revealed enlargement of both lateral ventricles and a cystic mass occupying the third ventricle. We performed cyst wall fenestration using a bilateral approach in which we created two burr holes to introduce a flexible endoscope and a rigid endoscope. The cyst wall was held by forceps with the flexible endoscope, and resection of the cyst wall was achieved by using a pair of scissors with the rigid endoscope. There were no postoperative complications, and MRI performed 1 year after treatment showed disappearance of the superior part of the cyst wall.

Choroid plexus tumors (CPTs) are rare intraventricular neoplasms accounting for about 0.3–0.6% of all intracranial tumors. This retrospective study on CPTs presents clinico-pathological features and management strategies based on a 20-year single-institutional experience. This series included 10 consecutive patients with pathologically proven CPTs; 5 choroid plexus papillomas (CPPs), 3 atypical CPPs (ACPPs), and 2 choroid plexus carcinomas (CPCs). Their clinical, radiological, and histopathological features as well as management including follow-up studies were reviewed. The patients included five males and five females, aging from 0 years to 61 years with median of 28 years. The affected site was lateral ventricle in two adults and fourth ventricle in eight patients; four children and four adults. The most common symptoms were gait disturbance and memory disturbance. All the patients underwent craniotomy with total, subtotal, and partial removals achieved in 50%, 40%, and 10% of the patients, respectively. The occurrence of the high grade subtypes was 50% in both the adult and pediatric groups. The Ki-67/MIB-1 index increased across the three histological subtypes, from CPP to ACPP and then to CPC. Adjuvant therapy was administered in three patients. The two patients (one adult and one child) with CPC died of whole central nervous system dissemination. At a median of 62-month follow-up, the other eight patients were alive, with only one patient having recurrence and reoperation. The results demonstrate that gross total resection is usually curative for CPP and ACPP, and adjuvant chemoradiotherapy would be required for CPC and incompletely resected ACPP.

Meningiomas in the third ventricle are rare, with only very few cases reported in the literature. We report a case of primary third ventricular anaplastic meningioma in a 49-year-old man who presented with progressive weakness of the left limbs and headache. Magnetic resonance imaging revealed a tumor which seemed to arise from the right thalamus and extending into third ventricle. The tumor was heterogeneously enhanced with gadolinium. It was totally removed by right transventricular-subchoroidal approach. The lesion was intraoperatively found to be whitish hard and embedded in right thalamus, but had attachment to choroid plexus near foramen Monroi with narrow interface. The histological diagnosis was atypical meningioma, WHO Grade II. Lesion recurred 20 months later and was resected via the same approach, which turned out to be papillary meningioma, WHO Grade III. The patient had second recurrence 23 months after second surgery which was operated and the final diagnosis was anaplastic meningioma (WHO Grade III). Literature review showed meningioma of the third ventricle is quite exceptional and more than half of the cases were aggressive subtypes (Grade II or III).

C-type natriuretic peptide (CNP) is abundant in brain and is reported to exert autocrine function in vascular cells, but its effect on blood–brain barrier (BBB) permeability has not been clarified yet. Here, we examined this effect. Transendothelial electrical resistance (TEER) of in vitro BBB model, composed of bovine brain microvascular endothelial cells and astrocytes, was significantly dose dependently decreased by CNP (1, 10, and 100 nmol/L). C-type natriuretic peptide treatment reduced both the messenger RNA (mRNA) and protein expressions of tight junction (TJ) protein zonula occludens-1 (ZO-1). The effects on TEER, mRNA, and protein expressions of ZO-1 were mimicked by cyclic GMP (cGMP) analog 8-bromo-cGMP (1 μmol/L) and reversed by protein kinase G (PKG) inhibitor Rp-8-CPT-cGMPS (100 μmol/L), thus implying the role of PKG and cGMP signaling in BBB function. Transcription factor JunD knockdown by small interfering RNA resulted in no change of permeability by CNP. In vivo study of mouse brain by fluorimetric analysis with intravenous administration of sodium fluorescein (40 mg/kg) also showed a significant increase in BBB permeability by CNP (10 nmol/kg, intravenously). These findings suggest that CNP modulates the BBB permeability by altering ZO-1 expression.

Fibrin glue-soaked gelatin sponge (FGGS) has been used for tissue sealing in neurosurgical practice, but too rapid clotting of fibrin glue occasionally prevents good fixation of FGGS. Dilution of thrombin may provide adequate manipulation time between mixing fibrinogen and thrombin on gelatin sponge and application into the tissue defects. The present study characterized the effect of thrombin dilution on the adhesion strength of FGGS and retrospectively assessed the clinical usage of the dilution for filling dead space or sealing arachnoid defect in 255 cases who underwent transsphenoidal surgery for the last 66 months. FGGS was prepared using three different concentrations of thrombin: 250 (standard), 50 (1:5 dilution), and 25 (1:10 dilution) units/ml, and incubated for three different periods (5, 20, and 60 seconds). FGGSs were applied over two adjacently positioned porcine skins placed on two metallic plates. The adhesion strength was evaluated by measuring maximum tensile strength during pulling out the sliding plate at a constant rate of displacement. The maximum adhesion strength was greater for FGGS with 1:10 diluted thrombin solution than for FGGS prepared with higher concentrations (p < 0.05). Adhesion strength did not decay for 20 seconds after the mixture. Only four of 255 cases (1.6%) required second reconstruction of sella floor due to the cerebrospinal fluid leakage. FGGS prepared with diluted thrombin solution can provide adequate adhesion strength for clinical use.

ObjectiveThe glomerular filtration rate (GFR) is increased in patients with active acromegaly. The aim of this study is to elucidate whether renal function deteriorates in patients with acromegaly and whether this deterioration is reversible after surgical remission.Design/methodsA case–control study of 48 acromegalic patients who were surgically cured (cases) and 48 patients with nonfunctioning pituitary adenomas (NFomas, controls) was conducted. We performed clinical and biochemical examinations before surgery and 3months post-surgery. The GFR of each patient was estimated (estimated GFR, eGFR) using their serum creatinine, age, sex, and body surface area, and postoperative changes in the eGFR were assessed.ResultsThe preoperative eGFR was significantly higher in patients with acromegaly than in those with NFoma (99.8 vs 75.1mL/min respectively,PPP=0.12). Among the acromegalic patients, the postoperative decreases in the eGFR were more prominent in patients with a preoperatively high or normal vs low eGFR.ConclusionsOur data demonstrated a significant post-surgical eGFR decrease in patients with acromegaly, but not in patients with NFomas. This change in the eGFR was reversible in acromegalic patients with a high/normal preoperative eGFR, but not in those with a low preoperative eGFR. This suggests that the reversible pathophysiological change in some patients is functional but not organic.

Langerhans cell histiocytosis (LCH) is a proliferation of Langerhans cells intermixed with inflammatory cells, in particular eosinophils, that may manifest as a unisystem (unifocal or multifocal) or multisystem disease. We describe the clinical and histologic spectrum of LCH of the orbit and skull in our two cases. Both cases had unifocal erosive skull lesions with a history of trauma. Typical histologic features included numerous histiocytes with varying degrees of giant cell formation and scattered eosinophilic granulocytes. The presence of Langerhans cells was confirmed by CD1a and S100 immunohistochemistry. LCH has an excellent prognosis when treated with surgical resection, steroids and radiotherapy or chemotherapy. One of our patients is disease free at 7 year follow-up and one patient had regression of lesion on follow-up.

To know the longitudinal shift of blood IGF-1 of cured acromegaly, we conducted retrospective survey of changes in blood IGF-1 over two years, which has not been previously investigated. Blood IGF-1 levels were measured for longer than 2 years after TSS in 37 patients whose nadir GH during postoperative oral glucose tolerance test (OGTt) was under 1 ng/mL. Blood IGF-1 very gradually declined after three months; 230.6 (mean) ng/mL at 3-12 months, 202.3 ng/mL at 12-24 months, and 198.6 ng/mL at 24-36 months. Their SD values, calculated based on standard IGF-1 values of age- and sex-matched Japanese population, also slowly decreased after three months; 1.69 (mean) at 3-12 months, 1.23 at 12-24 months, and 1.12 at 24-36 months. Very slow decrease of the IGF-1 levels continued beyond the first several months and even the first year after TSS. The declination of values is greater than that associated with aging. This declination may be at least partially a reflection of the slow decrease and late normalization of GH secretion.

Episodic headache is common in childhood moyamoya disease (MMD). The onset, mechanism, cause of headache and the effect of revascularization surgery on headache are not yet clear. We studied 10 cases of children (7 boys and 3 girls) younger than 18 years who underwent revascularization for MMD between 2009 and 2013. We evaluated frequency of headache and cerebral blood flow changes by single photon emission computed tomography brain imaging with [I123]-labeled iofetamine (IMP-SPECT) before and after surgery. Patients' ages ranged from 0 to 15 years at onset and 2 to 17 years at the time of surgery, mean age being 6.7 and 8.0 years respectively. 9 of 10 patients presented with ischemic symptoms and 8 had headache. 5 patients underwent indirect bypass and 5 underwent combined direct and indirect bypass. Cerebral blood flow improvement was obtained in 14 of the 15 cerebral hemispheres revascularized. The mean follow-up duration was 32.9 months. All the patients had good outcomes with improvement of ischemic neurological deficits. Headache improved in 7 (87.5%) of 8 patients. Headache in pediatric moyamoya disease is associated with change in cerebral hemodynamics. Revascularization including combined direct bypass and indirect techniques may be required to reduce headache in patients with MMD.

Nepal Journal of Neuroscience 12:38-39, 2015

Apart from the radiologic features regarding size and invasiveness, we had noticed some differences in morphology among types of pituitary adenomas. We conducted this study to verify the differences in radiologic morphology between growth hormone producing pituitary adenomas (GHoma) and nonfunctioning pituitary adenomas (NFoma). Pre-surgical magnetic resonance images (MRIs) were assessed in 50 cases of GHoma and 50 cases of NFoma. Geometric parameters on MRI were set in accordance with sellar anatomy. Intensity of T1-weighted image was not different between the two groups, but hypo-intensity of T2-weighted image was more frequently seen in GHoma. Predominant inferior extension of tumor was seen mostly in GHoma (88 vs. 38%). Extension of the tumor to the superior compartment of cavernous sinus was more frequent in NFoma. Pituitary gland was generally located superior to GHoma and postero-superior to NFoma. Growth characteristics of pituitary adenoma were confirmed to differ between GHoma and NFoma.

The deformation of the skull base in patients with unilateral frontal plagiocephaly (UFP) is well known, but the mechanism is not still clear. We analyzed the skull base in the patients with UFP who underwent fronto-orbital advancement (FOA) in the early life during the last decade. We assessed the treatment results and outcome of FOA performed in six patients, four girls and two boys younger than 2 years, in the last decade. Also, the basal cranium’s angles were measured by 3D reconstruction images on computed tomography (CT) scan. The mean patients’ age at FOAs was 11 months. Two cases were classified as grade 2A, two cases as grade 2B, and two cases as grade 3 (the classification of Di Rocco and Velardi). The ethmoidal axis was deviated a mean of 8.2° to the affected side. The mean angle between the petrosal pyramids and the midline (anterior-petrosal-sagittal angle, APSA) was 75.3° on the affected side and 66.2° on the normal side. The mean difference of APSA was 9.2°. On the follow-up CT images 5 years after surgery, the deviations of the ethmoidal axis clearly decreased, 5.7°, but the differences of APSA did not change, 8.8°. The midline distortion of anterior skull base should be considered to be spontaneously corrected during the follow-up periods in patients with all types of UFP who underwent FOA, unlike posterior skull base in the patients with grades 2B and 3 classification.

The migration of lumboperitoneal shunt cathe- ters into the abdominal subcutaneous space is not uncom- mon. To prevent migration we devised a new method for installing the peritoneal tube. After catheter insertion into the lumbar spinal subarachnoid space, the tube on the peritoneal side is pulled into the areolar space between the abdominal fat and the anterior rectus sheath. A 4 cm incision is made in the sheath and the tip of the catheter is obliquely passed through the rectus abdominis muscle using a mosquito clamp. The tube is then inserted into the abdominal cavity through small openings in the posterior sheath and peritoneal membrane, located 3 cm inferior and 3 cm medial to the opening on the anterior rectus sheath. Consequently, the peritoneal tube runs obliquely, upper lateral to lower medial, through the anterior sheath, the rectus abdominis muscle, the posterior sheath, and the peritoneum. To date, we operated on 59 patients using this method. No migration of the abdominal shunt cathe- ter occurred during a follow-up period of 5.51 ± 3.6 months (mean ± standard deviation). Our technique is safe, effec- tive without migration of the peritoneal tube, and can be performed in less well-equipped operating rooms.

Growth hormone deficiency (GHD) in surgically-cured acromegalics has been reported to negatively affect their metabolic condition and quality of life (QOL). The incidence of GHD, its causes, and its effects on their physio-psychological condition remain to be examined in detail. We performed a retrospective study to investigate GH secretory function in surgically-cured acromegalics, prognostic factors of GHD, and its impact on QOL. The study population consisted of 72 acromegalics who were determined to be surgically cured according to the Cortina consensus criteria. We recorded the incidence of impaired GH secretory function based on the peak GH level during postoperative insulin tolerance test (ITT) which lowered their nadir blood sugar to under 50 mg/dL. Their QOL was evaluated by SF-36. In surgically-cured acromegalics, the incidence of severe GHD (peak GH during ITT ≦ 3.0 μg/L) was 12.5 % (9/72). The preoperative tumor size was significantly larger in patients with severe GHD than without severe GHD (21.9 ± 9.0 vs. 15.5 ± 7.1 mm, p = 0.017). The peak GH levels during postoperative ITT were statistically correlated with the physical but not the mental component summary of the SF-36 score. The incidence of GHD was 12.5 % in our surgically-cured acromegalics. As some QOL aspects are positively related with peak GH levels during postoperative ITT, efforts should be made to preserve pituitary function in acromegalic patients undergoing adenomectomy.

We describe a very rare case of mature posterior fossa teratoma in an adult who presented with clinico-radiological findings consistent with a dermoid cyst. A computed tomography scan showed a hypodense mass in the cistern magna with calcification and a sinus tract in the occipital bone. Magnetic resonance imaging revealed a hypo- to hyperintense mass without contrast enhancement. The intraoperative picture showed a dermal sinus and a cyst containing lipid, keratin and hair. Histopathological examination showed a tumor with components of all the three germ layers; thereby, a diagnosis of mature teratoma was made. The histopathological differentiation between teratoma and dermoid cyst is very valuable for ruling out the presence of immature/malignant or germinomatous components that would require further adjuvant therapies. Thus, we here present a rare case of posterior fossa teratoma mimicking dermoid cyst and emphasize the importance of histopathological differentiation between these entities.

Intracranial endodermal cysts presenting with hemifacial spasm (HFS) are extremely rare. We report a right cerebellopontine angle (CPA) endodermal cyst in a 56-year-old man who presented with a 6-month history of right-sided hemifacial spasm. Computed tomography revealed a homogenous, well-demarcated, hyperdense lesion extending from prepontine cistern to right CPA. Magnetic resonance imaging demonstrated a right CPA extra-axial cystic lesion protruding into Meckel’s cave, with compression of cranial nerves VII and VIII. Light brown, creamy cystic content was totally removed, and the thin cyst wall surrounding cranial nerves VII and VIII and the right vertebral artery was subtotally removed through the right lateral suboccipital approach. On microscopic examination, the cyst wall was composed of mono- to multilayered stratified epithelia, which were lined by ciliated or nonciliated cuboidal cells, with cilia showing the characteristic 9 + 2 pattern. Immunohistochemistry showed positive staining of cells composing the cyst wall with carcinoembryonic antigen, epithelial membrane antigen, cytokeratin 8, and negative staining with cytokeratin 20, and S-100, thereby characterizing endodermal cyst. Postoperatively, the patient was free of facial spasm.

Intracranial epidermoid cysts generally appear as hypodense on computed tomography (CT), hypointense on T(1)-weighted magnetic resonance (MR) imaging, and hyperintense on diffusion-weighted MR imaging. We report two cases of posterior fossa epidermoid cysts with unusual radiological features. A 49-year-old male presented with facial dysesthesia and a 12-year-old male presented with diplopia and internuclear ophthalmoplegia. CT of both cases revealed hyperdense lesions. MR imaging showed the first case as hypointense in the posterior part and hyperintense in the anterior part of the tumor on diffusion-weighted imaging, and the second case as hyperintense on diffusion-weighted and T(1)-weighted MR imaging. Surgical exploration revealed that the tumors consisted of creamy materials, instead of the usual semi-solid or flaky texture in epidermoid cysts. Xanthochromic serous fluid was also contained in the superoposterior half of the cyst of the first case. These unusual contents of the cyst may be responsible for the unusual neuroimaging findings. Histological examination showed both cysts were lined with stratified squamous epithelium and contained keratinaceous materials. Therefore, epidermoid cysts can occasionally present with unusual radiological characteristics giving rise to a diagnostic pitfall.

Intracranial germ cell tumors (GCTs) typically affect children and adolescents. We here report on a 59-year-old male patient presenting with diplopia, polydipsia and polyuria. On clinical examination, slight restriction of the upward gaze was seen on the left side. Computed tomography demonstrated calcifications in the pineal region and enhanced neurohypophysis. Magnetic resonance imaging displayed a heterogeneous pineal mass of 3-cm diameter, which was multicystic with an enhanced cyst wall, and also swelling of the pituitary stalk. The pineal lesion of the tumor, which included calcifications and keratinaceous components, was totally excised using an occipital transtentorial approach. Histopathological examination showed it to be a mixed GCT with germinoma and mature teratoma components. Postoperative chemoradiotherapy provided complete disappearance of the suprasellar lesion. To our knowledge, this is the first case of mixed bifocal GCT in an older adult reported in the literature, although a few cases of tumors with a single histological component have been reported. Hence, our case further underlines the possibility of the occurrence of GCTs in older adults and advocates the consideration of GCTs in the differential diagnosis of such cases for appropriate management.