Combined Endoscopic and Exoscopic Resection of Intracranial Epidermoid Cysts

Objective In the past ten years, a fully endoscopic technique has also been widely used. Exoscope has also been developed for microneurosurgery which offers quality image and convenient manipulation. This article aims at introducing an endoscopic-exoscopic technique for the resection of epidermoid cysts. Methods We retrospectively analyzed the patients with intracranial epidermoid cysts who received whole course combined endoscopic and exoscopic resection between 2017 and 2020 at our institution, to explore the benefit of combined endoscopic and exoscopic resection of intracranial epidermoid cysts and evaluated the clinical utility of endoscopic-exoscopic technique. Results A total of 17 patients were enrolled in the study. Of all patients, 6 patients (6/17, 35.3%) underwent total resection, 10 patients (10/17, 58.8%) underwent subtotal resection (residual capsule and/or) and 1 patients (1/17, 5.9%) underwent partial resection. Postoperative surgical complications were seen in 3 patients (3/17, 17.6%), including intracranial infection in 2 patients (2/17, 11.8%), and a delayed postoperative hematoma observed in the seventh day after operation for 1 patient (1/17, 5.9%), who was treated in a conservative manner and recovered smoothly from the hemorrhage. The median follow-up time was 33.3 months (range 14.5-54.5 months). During the follow-up period, there was no recurrence of the tumors that received total resection. 2 patients developed residual tumor regrowth but did not show any symptom therefore no further surgery was required. Conclusions Endoscopic-exoscopic technique is safe and efficient in the resection of intracranial epidermoid cysts with panoramic views and superior maneuverability. With further development and accumulation of practical experiences, the endoscopic-exoscopic technique can also be applied in the resection of other intracranial tumors.

Primary Squamous Cell Carcinomas Arising in Intracranial Epidermoid Cysts: A Series of Nine Cases and Systematic Review

ObjectivePrimary squamous cell carcinomas (PSCCs) arising in intracranial epidermoid cysts (IECs) are very rare, and their management and prognostic factors remain unclear. This study aimed to enunciate the clinical features and suggest a treatment protocol based on cases from the literature and the cases from our institution.MethodsThe clinicoradiological data were obtained from nine patients with PSCCs arising in IECs, who underwent surgical treatment at Beijing Tiantan Hospital between July 2012 and June 2018. We also searched the PubMed database using the keywords “epidermoid cyst(s)” or “epidermoid tumor(s)” combined with “malignant” or “malignancy” or “intracranial” or “brain” or “squamous cell carcinoma” between 1960 and 2020. Risk factors for overall survival (OS) were evaluated in the pooled cohort.ResultsThe mean age of our cohort was 51.2 ± 8.3 years (range: 39–61 years), which included eight males and one female. Gross total resection (GTR) was achieved in three patients, while non-GTR was achieved in six patients. Radiotherapy was administered to five patients. After a median follow-up of 16.7 ± 21.6 months (range: 3–72 months), eight patients died with a mean OS time of 9.75 ± 6.6 months (range: 3–23 months). In the literature between 1965 and 2020, 45 cases of PSCCs arising in IECs were identified in 23 males and 22 females with a mean age of 55.2 ± 12.4 years. GTR, non-GTR, and biopsy were achieved in six (13.3%), 36 (80%), and three (6.7%) cases, respectively. After a mean follow-up of 12.7 ± 13.4 months (range: 0.33–60 months), 54.1% (20/37) patients died, and recurrence occurred in 53.6% (15/28) patients. A multivariate analysis demonstrated that postoperative radiotherapy (p = 0.002) was the only factor that favored OS. The Kaplan–Meier analysis showed that, compared with no radiotherapy (median survival time: 4 months), radiotherapy (median survival time: 24 months) had significantly prolonged OS (p = 0.0011), and GTR could not improve OS (p = 0.5826), compared with non-GTR. The 1-year OS of patients with or without radiotherapy was 72.5% or 18.2%, respectively.ConclusionMalignant transformation of IEC into PSCC was prevalent in elderly patients, with slight male predominance. GTR of previous benign IECs is recommended. For remnant benign IECs, close follow-up should be performed. Postoperative radiotherapy for PSCCs could bring survival benefit. GTR of these malignant intracranial tumors is difficult when they involve important brain structures. Future studies with larger cohorts are necessary to verify our findings.

Long-term surgical outcomes of intracranial epidermoid tumors: impact of extent of resection on recurrence and functional outcomes in 63 patients

OBJECTIVE The authors’ objective was to reevaluate the role of microsurgery for epidermoid tumors by examining the associations between extent of resection (EOR), tumor control, and clinical outcomes. METHODS This was a retrospective study of patients with microsurgically treated intracranial epidermoid tumors. The recurrence-free and intervention-free rates were calculated using the Kaplan-Meier method. EOR was graded as gross-total resection (GTR) (total resection without residual on MRI), near-total resection (NTR) (a cyst lining was left in place), subtotal resection (STR) (> 90% resection), and partial resection (PR) (any other suboptimal resection) and used to stratify outcomes. RESULTS Sixty-three patients with mean clinical and radiological follow-up periods of 87.3 and 81.8 months, respectively, were included. Sixteen patients underwent second resections, and 5 underwent third resections. The rates of GTR/NTR, STR, and PR were 43%, 35%, and 22%, respectively, for the initial resections; 44%, 13%, and 44% for the second resections; and 40%, 0%, and 60% for the third resections (p < 0.001). The 5- and 10-year cumulative recurrence-free rates after initial resection were 64% and 32%, respectively. When stratified according to EOR, the 10-year recurrence-free rate after GTR/NTR was marginally better than that after STR (61% vs 35%, p = 0.130) and significantly better than that after PR (61% vs 0%, p < 0.001). The recurrence-free rates after initial microsurgery were marginally better than those after second surgery (p = 0.102) and third surgery (p = 0.065). The 5- and 10-year cumulative intervention-free rates after initial resection were 91% and 58%, respectively. When stratified according to EOR, the 10-year intervention-free rate after GTR/NTR was significantly better than that after STR (100% vs 51%, p = 0.022) and PR (100% vs 27%, p < 0.001). The 5-year intervention-free rate after initial surgery was marginally better than that after second surgery (52%, p = 0.088) and significantly better than that after third surgery (0%, p = 0.004). After initial, second, and third resections, permanent neurological complications were observed in 6 (10%), 1 (6%), and 1 (20%) patients, respectively. At the last follow-up visit, 82%, 23%, and 7% of patients were free from radiological recurrence after GTR/NTR, STR, and PR as the initial surgical procedure, respectively. CONCLUSIONS GTR/NTR seems to contribute to better disease control without significantly impairing functional status. Initial resection offers the best chance to achieve better EOR, leading to better disease control.

Endoscopic Keyhole Approach for Intracranial Epidermoid

Objective In contemporary neurosurgical practice, keyhole endoscopic approach has established its role in various neurosurgical pathologies. Intracranial epidermoid is an ideal pathology for endoscopic keyhole approach as epidermoid is well encapsulated, extra-axial, avascular, and easily suckable. The objective of this study is to share our experience of endoscopic keyhole approach for intracranial epidermoids at various locations as a new minimally invasive neurosurgical approach to deal with these lesions. Materials and Methods We conducted a retrospective study on 26 patients who underwent keyhole pure endoscopic excision of intracranial epidermoid between July 2015 and December 2019. Patient's demographics, clinical features, radiological imaging, and postoperative complications were noted. Follow-up outcome of preoperative symptoms and postoperative complications were also analyzed. Results The mean age of the study population was 30.5 years with a mean follow-up of 30 months. The common presenting features were headache, hearing loss, and trigeminal neuralgic pain. Gross total resection was achieved in 73.1% cases, while near total resection and subtotal resection were achieved in 19.2 and 7.7% cases, respectively. In the follow-up, maximal improvement was seen in trigeminal neuralgic pain (83%) and headache (66.7%). Major postoperative complications were facial nerve paresis, lower cranial nerve paresis, and transient facial hypoesthesia, most of which improved over time. None of the patients required resurgery till date. Statistical Analysis Patients' data were analyzed using SPSS software version 23 (Statistical Package for Social Sciences, IBM, Chicago, United States). Conclusion This study demonstrates that with careful patient selection, endoscopic keyhole excision of epidermoid is a good alternative to conventional microsurgical excision with comparable surgical and functional outcomes.

Psychotic Features as Initial Presentation of Intracranial Epidermoid of Suprasellar Origin

Intracranial epidermoids are rare congenital lesions which account for around 1% of all intracranial tumors. They present most commonly in cerebello-pontine angle followed by suprasellar region, along with different intracranial areas. The most common presentation includes headache, cranial nerve deficiets, seizures, raised intracranial pressure. It is extremely uncommon for epidermoid tumors to present with psychiatric symptoms. We present a case of 38 year old female with history of psychosis for 2 years with personality change, disorganised behavior and delusions. An episode of increased sedation and semi-consciousness led to neuroimaging which revealed a large epidermoid tumor of suprasellar region and interpeduncular region. Surgical resection of the epidermoid was done and patient was maintained on drug treatment. Keywords: Epidermoid tumour, Psychosis

Intra-diploic epidermoid cyst: An iceberg lesion

Introduction: Intraosseous epithelial inclusion cysts of the skull, presenting as lytic defects, constitute a very small percentage of the primary intracranial tumours. The case is presented by virtue of not only the rarity of the variant but also to highlight the importance of timely intervention by a neurosurgeon after adequate investigation and in a tertiary care setting. Case Report: A 45 year old female patient presented to the local Primary Healthcare Centre(PHC) with a small scalp swelling in the occipital region. . Intraoperative identification of intracranial extension was made by the surgeon as inferior margin of the swelling couldn’t be reached and also by palpation of the huge bone defect following which the procedure was abandoned midway and patient was referred to our centre for further management. Imaging: Contrast Enhanced Computerised Tomograhy(CECT) revealed a well defined, mixed density lesion with hypodense and an isodense component in right occipital region. Lesion was measuring 4.2(Cranio caudal) x 3.3(Antero posterior) x 3.6( transverse) cm. A sharp marginated bone defect was noted involving both the outer and inner tables of the occipital bone. Operative management: Lesion was approached through a right occipital craniotomy wherein the margins of bone defect were nibbled away to gain a wide access to the lesion. Pearly white, flaky contents of the lesion along with capsule were identified and excised completely. Discussuion: Intradiploic epidermoid cysts are very rare, accounting for <3% of all intracranial epidermoid cysts.(5) These cysts grow very slowly and usually present as painless bony swelling under the scalp. Conclusion: Cranial epidermoid is a fairly common entity and intradiploic variant of the same isnot uncommonly seen in neurosurgical practise. These lesions may present as a small scalp lesion which should not be judged based on its apparent size as these lesions are not infrequently known to have a bigger intracranial extension

Nanofiber-Mâché Hollow Ball Mimicking the Three-Dimensional Structure of a Cyst

The occasional malignant transformation of intracranial epidermoid cysts into squamous cell carcinomas remains poorly understood; the development of an in vitro cyst model is urgently needed. For this purpose, we designed a hollow nanofiber sphere, the “nanofiber-mâché ball.” This hollow structure was fabricated by electrospinning nanofiber onto alginate hydrogel beads followed by dissolving the beads. A ball with approximately 230 mm3 inner volume provided a fibrous geometry mimicking the topography of the extracellular matrix. Two ducts located on opposite sides provided a route to exchange nutrients and waste. This resulted in a concentration gradient that induced oriented migration, in which seeded cells adhered randomly to the inner surface, formed a highly oriented structure, and then secreted a dense web of collagen fibrils. Circumferentially aligned fibers on the internal interface between the duct and hollow ball inhibited cells from migrating out of the interior, similar to a fish bottle trap. This structure helped to form an adepithelial layer on the inner surface. The novel nanofiber-mâché technique, using a millimeter-sized hollow fibrous scaffold, is excellently suited to investigating cyst physiology.

Clinicoradiological Features and Treatment Outcome of Supratentorial Intraparenchymal Epidermoid Cyst: A Report of Five Cases and Literature Review

Objectives Intraparenchymal epidermoid cysts (IECs) are rare lesions. They represent less than 1% of the intracranial epidermoid cysts. The supratentorial IEC is a clinically and prognostically distinct subset. Given the rarity, most of the articles are case reports. We present a series of five cases of supratentorial IEC to characterize their clinical presentation and outcome, with emphasis on the surgical features. Materials and Methods We searched our database for all cases of intracranial epidermoid cysts operated between January 2005 and January 2020. Five patients were identified having IEC from the hospital information system and the neurosurgical operation record book. Standard craniotomy and decompression of the lesion were performed in all these patients. Standard postoperative care includes computed tomography scan of head on the day of surgery and magnetic resonance imaging of brain after 6 weeks to look for the residual lesion, if any. Subsequent follow-up visits in outpatient department to look for resolution of the presurgical symptoms. Results The mean age of the patients in our series was 28.8 years (range: 28–40 years.). All the five patients were male. Four patients had IEC involving frontal lobe and one in parietal lobe with a small occipital lobe extension. Seizure was the most common presenting complaint followed by headache. Complete excision was achieved in all the cases. All the three patients with seizure attained seizure freedom postlesionectomy. Focal neurological deficits resolved gradually in postoperative period. There was no recurrence of lesion during follow-up. Conclusion Supratentorial IEC most commonly affects young males, involve frontal lobe and present clinically with seizure. Complete surgical excision offers best outcome in the form of remission of seizure disorder.