Background
Plasmacytomas of the skull base are not commonly encountered in clinical practice, with few reported cases in the literature. They form part of the spectrum of plasma cell neoplasms and are classified as a solitary bone plasmacytoma if arising from the sphenoid bone. Its radiographic appearance can lead to misdiagnosis as one of the tumours that are more frequently seen in the skull base, especially meningiomas. Due to the risk of evolution into multiple myeloma, accurate diagnosis is essential.
Case presentation
A 56-year-old male presented to the emergency department with rapid proptosis and worsening vision in his right eye for one week’s duration. Imaging studies revealed an extra-axial right sphenoid bone tumour with invasion into the temporalis muscle and orbit, leading to significant proptosis. Tumour debulking was done, but there was no improvement in vision postoperatively. Final histology was consistent with a plasmacytoma. The patient was referred to the oncologist for radiation therapy, but subsequently developed further lesions consistent with multiple myeloma.
Conclusions
Plasmacytomas need to be considered in the differential diagnosis of skull base tumours. Due to their excellent response to radiation, these patients should have early oncology intervention to prevent irreversible neurological deficits.
The treatment paradigm for intracranial aneurysms has evolved with technological advancements, resulting in improved patient outcomes. In particular, the management of posterior circulation aneurysms has shifted to favor endovascular therapy (EVT). However, this modality is not always accessible in low-resource settings.
In our country (Trinidad and Tobago), neuroendovascular services are not readily available. We report a case of a patient with a ruptured left posterior inferior cerebellar artery (PICA) aneurysm (Fisher grade 4) who underwent a far-lateral craniotomy and clip ligation. It was done by a fellowship-trained vascular neurosurgeon in a public hospital and resulted in an excellent patient outcome. This highlights the need to maintain this surgical skill set in resource-poor countries, in spite of the increasing popularity of endovascular therapy.
Background:
Pineal tumors are very rarely encountered, with an incidence of <1% of intracranial lesions in adults. Life-threatening hydrocephalus due to obstruction of the third ventricle can result from the location of these tumours. Endoscopic third ventriculostomy (ETV) and tumor biopsy is a safe and feasible strategy, particularly if the tumor appears benign. This mitigates the high risks of uncontrollable venous bleeding from open and stereotactic biopsies. While typically performed using either ipsilateral single or dual bur holes, the location of the tumor may require modifications to the standard endoscopic techniques.
Case Description:
A 55-year-old male presented with signs of intracranial hypertension and was found to have obstructive hydrocephalus due to a pineal tumour. The tumour displayed a right-sided dominance when the pre-operative imaging was assessed, which would risk forniceal injury if biopsied via a right-sided burr hole. Craniometric measurements revealed a superior trajectory to the tumour via the left foramen of Monro. A biforaminal approach was performed, with a traditional ETV using a right coronal bur hole and biopsy via a left frontal bur hole. This minimized forniceal stretching and allowed a safe biopsy.
Conclusion:
The bi-foraminal approach has not been widely described in the literature but can potentially avoid morbidity with biopsy in patients with right-sided pineal tumours. We believe this technique should be considered, particularly in low-resource settings where neuroendoscopy is not commonly done, and where the use of ipsilateral single or dual-bur holes may lead to forniceal injury.
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