World Neurosurg
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Medulloblastoma is the most common malignant brain tumor in children. Infants are in the high-risk category. Complete surgical resection is the single most important determinant of prognosis and survival in nonmetastatic disease. Infants with large primaries after incomplete resection/biopsy and poor general condition have bad prognosis. They are considered poor candidates for intensive chemotherapy involving high dose methotrexate/autologous stem cell transplantation as they are often unable to tolerate these aggressive regimens. ⋯ We suggest that the role of neoadjuvant chemotherapy should be explored in patients with infantile medulloblastoma in whom upfront complete resection is not possible, considering the gratifying results obtained in our case.
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Surgery for cranial and spinal tumors has evolved tremendously over the years. Not only have neuro-oncologists been able to better understand tumor biology and thereby improve multimodality therapy, but advances in surgical techniques have also directly equipped neurosurgeons with the armamentarium necessary to achieve more radical resections safely. Intraoperative imaging tools are one such adjunct. Though intraoperative magnetic resonance (MR) has emerged as the "gold standard" among these, logistical challenges make it difficult to implement across all centers. On the other hand, the use of ultrasound (US) intraoperatively predates the use of MR. Over the past 4 decades, technologic improvements have refined and expanded the scope and application of intraoperative US technology. Strategies to maximize its efficacy and overcome the various limitations have evolved. A large volume of clinical experience has accumulated with respect to its role as an adjunct specifically in tumor surgery. ⋯ IOUS is a powerful and versatile multipurpose intraoperative adjunct in tumor surgery, especially for resection control. The learning curve is relatively easy to climb and future improvements in technology are likely to widen the scope of its use.
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The place of stereotactic biopsies in the management of diffuse intrinsic pontine gliomas (DIPGs) in children has changed over the years. Nonetheless, stereotactic biopsy remains a surgical procedure with its risks. One complication that has not been reported previously in case of a biopsy of a DIPG is metastatic seeding along the tract of the biopsy. We report the first 2 cases in the literature. ⋯ The era of targeted therapy with molecular and genomic discoveries has paved the way to a research protocol that requires a biopsy from the patient. The reported complications have never been described before. The purpose of this paper is not to suggest that no biopsy should be performed when a DIPG is suspected. For now, biopsy remains investigational, because no benefit in survival could be drawn so far for any patient. This subject deserves honest discussion with the children and their parents.
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Case Reports
Intracranial infantile myofibromatosis mimicking malignant brain tumor: A case report and literature review.
Myofibroma is a fibrous tumor of infancy that sometimes affects a single patient in a multiple fashion (infantile myofibromatosis). Its intracranial involvement is extremely rare, and its clinical picture has been poorly characterized. Here we report an interesting case of myofibromatosis with an intracranial lesion that behaved like an aggressive tumor and yet demonstrated very benign pathology. ⋯ The discrepancy between rapid tumor growth associated with increased uptake on metabolic imaging and benign pathologic findings with a low proliferative index is noteworthy and should be recognized in the management of an intracranial lesion in a patient with infantile myofibromatosis. Given de novo formation of a lesion in this adult patient, long-term follow-up is essential in this disease.
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Venous angioma is an extremely rare vascular malformation of the epidural space. To the best of our knowledge, only 5 cases have been documented to date and none has been reported in the setting of a previous malignancy. ⋯ Venous angioma should be included in the differential diagnosis of spinal epidural masses even in case of previous malignancy. Subtle imaging features should alert clinicians to this rare yet potentially life-threatening condition. Surgery remains the cornerstone of the treatment and can result in remarkable recovery.