Primary intraosseous meningiomas (PIMs) are rare tumors that present with a variable radiological appearance and a clinical behavior that is considerably different from that of intracranial meningiomas. Treatment of PIMs consists of complete resection, which may be difficult to achieve due to the lack of clear tumor margins on conventional imaging studies. PET/CT using 68Ga-DOTA–conjugated peptides has been used for the diagnosis and treatment planning of different types of meningiomas due to these tracers’ affinity to somatostatin receptors, which are found in most meningiomas. However, this imaging modality’s use as an intraoperative adjunct has not been reported for PIMs. In this technical note, the authors describe a [68Ga-DOTA0-Tyr3]octreotide (68Ga-DOTATOC)-PET/CT–guided resection of a PIM. In this case, the area of increased uptake in the 68Ga-DOTATOC-PET/CT study extended well beyond the tumor margins identified on MRI. The patient’s pathology report confirmed the presence of tumor cells within peripheral bone, which macroscopically appeared normal. The authors propose 68Ga-DOTATOC-PET/CT as a valuable adjunct in the surgical management of PIMs and offer a reasonable justification for its use based on current evidence. Its use for intraoperative image guidance may aid neurosurgeons in achieving a complete resection, thus minimizing the risk of recurrence of this complex pathological entity.

The purpose of this study was to analyze and discuss the clinical characteristics, long-term outcome, and prognostic factors of cerebellar strokes treated in a single health care facility in Mexico. MethodsWe retrospectively reviewed the medical records of adult patients admitted to our hospital with diagnosis of cerebellar ischemic and hemorrhagic stroke between 2018 and 2020. Baseline data included sociodemographic and radiological variables, treatment (surgical versus conservative), and Glasgow Coma Scale on arrival (GCSOA). The final neurological outcome was evaluated with the Glasgow Outcome Scale (GOS) six months after hospital discharge. ResultsTen patients (seven male and three female) with a mean age of 57.9 ± 9.3 years were included, six with cerebellar ischemic infarction and four with cerebellar hemorrhage. Out of the 10 patients, four underwent surgery (suboccipital decompressive craniectomy {SDC} ± ventriculostomy). The outcome was favorable in four cases (40%) and unfavorable in six (60%). Patients who underwent surgical treatment fared worse with all four cases associating poor outcome. The comparison between good and poor outcome groups showed significant differences in the presence of obstructive hydrocephalus (one versus six, p = 0.05) and poorer GCSOA (6.16 ± 1.72 versus 12.5 ± 3.6, p = 0.05), associating poorer outcome. ConclusionThere is still controversy regarding the appropriate management of cerebellar strokes. The presence of obstructive hydrocephalus and poorer GCSOA are associated to worse outcomes.

BACKGROUND Unruptured incidental intracranial aneurysm can coexist with pituitary adenoma, however, the occurrence is extremely rare. Timely diagnosis of asymptomatic intracranial aneurysms with pituitary adenoma may lead to planning a tailored surgical strategy to deal with both pathologies simultaneously. A case of a patient who underwent transcranial resection of a pituitary adenoma with clipping of two mirror aneurysms is reported. OBSERVATIONS A 55-year-old female presented with deterioration of visual acuity that progressed over 1 year, as well as presence of right eyelid ptosis. Magnetic resonance imaging of the head showed the presence of an intrasellar pituitary macroadenoma. Bilateral paraclinoid aneurysms were documented to be in contact with the pituitary tumor. The patient underwent surgery with simultaneous aneurysm clipping and tumor resection through a standard pterional approach with intradural clinoidectomy. The aneurysms were successfully clipped after the tumoral debulking. After clipping, the pseudocapsule was fully resected. LESSONS Various treatment options are available. Although endovascular securing of the aneurysms prior to the tumor resection would be ideal, in cases in which this resource is not readily available at all times, the surgeon must be prepared to solve pathologies with an elevated level of complexity.

Background: Central nervous system involvement due to aspergillosis is an extremely serious entity, particularly in patients with severe neutropenia, hematological diseases, or post-transplant cases. Immunocompetent patients can be infected by intense exposure, particularly iatrogenic after invasive procedures. Case Description: We present the case of a 26-year-old male with a 1 year appendectomy background, which required epidural anesthesia. After that surgery, insidious headache presented, requiring mild analgesics for adequate control. In the following weeks, headaches increased and tomographic imaging revealed hydrocephalus. A ventriculoperitoneal shunt was placed, and empirical treatment for neurocysticercosis was established, but diagnosis was never confirmed. Sequentially, shunt dysfunction occurred twice, for which shunt replacement was performed. Cerebrospinal fluid and shunt’s catheter were cultured. Some days later, a filamentous fungus was isolated and finally identified as Aspergillus sp. Intravenous amphotericin B and fluconazole at therapeutic dosage were administered; however, a torpid clinical evolution was observed. After a 2-week antifungal scheme, the fungus was identified as Aspergillus terreus. The patient developed sudden rostrocaudal deterioration. Computed tomography imaging was done, revealing a 70 cc hematoma in the right operculoinsular region, midline shift, and a 9 mm saccular aneurysm at the bifurcation of the middle cerebral artery. Conclusion: Cerebral aspergillosis is a serious disease with high mortality in patients, particularly those without identifiable risk factors. The iatrogenic forms are serious, due to the delay of clinical diagnosis. It is important to have a high index of suspicion in patients with a history of invasive procedures such as epidural anesthesia or surgery, and who develop a persistent chronic headache or chronic meningitis.

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