Posts Tagged ‘Cranial’

Case Study Series: Giant Aneurysm

This patient was an 11 year-old who presented with sudden onset of left-sided weakness. Her imaging showed a lesion on the right side of her brain with associated right sided infarcts. Her evaluation included an MRI and then an angiogram. The angiogram revealed a giant fusiform aneurysm of the middle cerebral artery (MCA). 

A giant aneurysm is one that is over 2.5 cm in size. Giant fusiform aneurysms are a rare cerebrovascular pathology, especially in the pediatric population. They represent only approximately 5% of aneurysms.

Treatment of these giant aneurysms is very complicated. The standard treatment options of surgical clip ligation or endovascular coil occlusion are not possible. Though the entire artery is abnormal, it is still functioning to deliver blood to the brain. So, any treatment option must eliminate the aneurysm while still allowing blood to reach the brain distal to the aneurysm.

The main approach has been to trap the aneurysm by closing its inflow and its outflow, then to perform a bypass procedure by sewing another artery to the middle cerebral artery distal to the aneurysm to restore blood flow.

We discussed the options with her family and they agreed to proceed with the trapping and bypass procedure. We elected to use the superficial temporal artery as a donor vessel to sew to the middle cerebral artery, which is called STA-MCA bypass.

She underwent a successful trapping and STA-MCA bypass, and has recovered a significant amount of the function on the left side that was lost because of her stroke. She is now back to her regular life. 

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Case Study Series: Clival Chordoma

This child was 9 years old when I first met her. She presented with progressive weakness on the left side, a weak voice, swallowing difficulties and impaired balance. Her imaging showed a lesion (tumor) in the posterior fossa compressing the brain stem.

Our initial impression was that this tumor was most consistent with a clival chordoma. We discussed the treatment options, and my plan was for a multi-staged approach for the resection of the lesion. I chose this treatment because I did not think it was possible to safely resect the entire lesion via a single surgery.


We began by doing an endoscopic endonasal approach to debulk the tumor and achieved about a 60 percent resection through this approach. Her pathology confirmed this tumor was indeed a chordoma. These tumors are benign, but they are extremely aggressive locally.

The best treatment for this type of tumor is what is called an en bloc resection, which means the tumor is removed with a cuff of surrounding normal tissue without ever actually seeing the tumor. However, this treatment is not possible when it is located in the clivus/skull base for two reasons. First, it is not technically possible, because it is impossible to get that wide of an exposure. It is also not possible neurologically, because you cannot remove all the neural elements and blood vessels that the tumor touches.

That is why for clival chordomas the goal is to remove all of the tumor, then treat the tumor bed with high doses of highly focused radiation — in this case proton beam therapy. Therefore, she needed more surgery in order to remove the remainder of the tumor.

She subsequently underwent a right-sided far lateral skull base craniotomy to approach the tumor from the lateral trajectory. We removed almost all of the residual tumor from this approach.

We did have to go after a few residual spots where the tumor was still visible on imaging. These included disease in the spinal canal on the left side, as well as disease in the petrous bone. She had a left-sided spinal approach from the base of the skull to the third cervical vertebrae to remove the left-sided spinal disease. For the tumor in her petrous bone, which was smaller than a centimeter in size, she underwent further endoscopic endonasal surgery.

We were able to achieve a gross total resection while avoiding any neurological deficits. She is now completely normal neurologically. Her pre-op weakness resolved soon after the endoscopic endonasal procedure. She did have transient worsening of her swallowing difficulty after the far lateral skull base craniotomy, but that resolved quickly as well.

She is now awaiting her proton beam therapy. I don’t know if her tumor will recur, but we are all very excited about how well she has done so far. I will post follow-up images on a delayed basis after her radiation treatment.

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Case Studies Series: Cerebellar AVM

This child was 10 years old when he initially presented to the hospital.  He was with his grandmother when he began complaining of a headache, after which he lost consciousness. His grandmother called the paramedics but the sheriff got to the house first.  The sheriff found the child not only unresponsive but also not breathing. According to the sheriff, he was purple. He initiated CPR and was able to get his pulse back. The sheriff saved him!

He was brought into the emergency room and was intubated.  He had a CT scan of the brain that showed an intracranial hemorrhage.  During the time in the ER, he arrested again and was brought back.

The ER called me after the CT scan on the way up to the Pediatric ICU.

I met him and his family in the ICU.

His CT head showed blood in the cerebellum with compression of the brain stem. There was also some hydrocephalus. His CT angiogram showed an associated arteriovenous malformation that had caused the hemorrhage.

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Case Studies Series: Multiple Hemangiomas

This child was 3 months old when she presented to the emergency room with evidence of increased pressure inside of her head.  She had rapid head growth and the soft spot at the top of her head (anterior fontanelle) was tense.  Interestingly, she had multiple skin lesions that were consistent with cutaneous hemangiomas.

Based on her clinical condition, she underwent a CT scan of the brain, followed by an MRI of the brain. We could not do a contrast MRI since she was allergic to the contrast material for the MRI but we did a contrast CT and MRI without contrast. For a lot of tumors, it’s easier to see the tumors with the contrast dye but we had to proceed without it.  

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