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   Table of Contents      
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 48-51

Extrusion of Intracranial Tumor Mass—A Rare Phenomenon


1 Maulana Azad Medical College and G. B. Pant Institute of Post Graduate Medical Education and Research (GIPMER), New Delhi, India
2 Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India

Date of Web Publication27-Mar-2018

Correspondence Address:
Charandeep S Gandhoke
Room No. 307, New Resident Doctor’s Hostel (NRDH), G. B. Pant Hospital, 1, Jawaharlal Nehru Marg, Near Daryaganj, New Delhi 110002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_53_17

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  Abstract 


Introduction: The extrusion of intramedullary spinal cord tumor is a well known fact. Charles Elsberg described a two-staged approach for the removal of these tumors. In the first stage, a posterior midline myelotomy was performed overlying the tumor followed by a nondural closure. During the second surgery, 7 days later, the extruded tumor, through the myelotomy, was removed. However, an extrusion of the intracranial tumor mass has never been reported. We report a rare case wherein there was extrusion of the intracranial tumor after the first surgery. Case Report: A 19-year-old male presented with chief complaints of headache, vomiting on and off, and blurring of vision in both the eyes since 2 months. The patient also complained of swelling over the right side of the skull. Radiological imaging was suggestive of a heterogeneous contrast-enhancing right parietal bone osteolytic lesion with subgaleal and intracranial extension. Right parietal craniectomy and a subtotal removal of the mass was done. Due to excessive blood loss and hemodynamic instability, it was decided to do a two-stage surgery. After 7 days, during the second operation, the brain had extruded the residual mass, which was lying just beneath the skin flap. A complete excision of the tumor with duraplasty using tensor fascia latae was performed. Conclusion: In some cases, two-stage surgery for the resection of large intracranial tumors is beneficial. However, two-stage surgery should only be undertaken as a damage control measure and not as a routine standard of care.

Keywords: Brain edema, craniectomy, extrusion, intracranial, osteosarcoma, pulsations, tumor


How to cite this article:
Gandhoke CS, Syal SK, Singhal GD, Singh H, Singh D. Extrusion of Intracranial Tumor Mass—A Rare Phenomenon. MAMC J Med Sci 2018;4:48-51

How to cite this URL:
Gandhoke CS, Syal SK, Singhal GD, Singh H, Singh D. Extrusion of Intracranial Tumor Mass—A Rare Phenomenon. MAMC J Med Sci [serial online] 2018 [cited 2019 Oct 22];4:48-51. Available from: http://www.mamcjms.in/text.asp?2018/4/1/48/228652




  Introduction Top


The extrusion of intramedullary spinal cord tumor is a well-known fact. Charles Elsberg described a two-staged approach for the removal of these tumors.[1] In the first stage, a posterior midline myelotomy was performed overlying the tumor followed by a nondural closure.[1] During the second surgery, 7 days later, the extruded tumor, through the myelotomy, was removed.[1] However, an extrusion of the intracranial tumor mass has never been reported. We report a rare case wherein there was extrusion of the intracranial tumor after the first surgery.


  Case Report Top


A 19-year-old male presented with chief complaints of headache, vomiting on and off, and the blurring of vision in both the eyes since 2 months. The patient also complained of swelling over the right side of the skull, which had gradually increased in size over a period of 1 month to its present size of a tennis ball. Radiological imaging was suggestive of a heterogeneous contrast-enhancing right parietal bone osteolytic lesion with subgaleal and intracranial extension with mass effect and a midline shift of 1.16 cm towards the left side [[Figure 1] and [Figure 2]]. Right parietal craniectomy and a subtotal removal of the mass was done [Figure 2]. Due to excessive blood loss and hemodynamic instability, it was decided to do a two-stage surgery. After 7 days, during the second operation, the brain had extruded the residual mass, which was lying just beneath the skin flap [Figure 2]. A complete excision of the tumor with duraplasty using tensor fascia latae was performed [Figure 2]. A histopathological examination suggested an “osteosarcoma of the right parietal bone.”
Figure 1: Magnetic resonance imaging of the brain was suggestive of heterogeneous contrast enhancing extra-axial lesion in the right parietal region with subgaleal and intracranial extension with mass effect and a midline shift of 1.16 cm towards the left side

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Figure 2: Rare phenomenon of extrusion of the intracranial tumor mass

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  Discussion Top


Primary osteosarcoma of the skull is a rare entity constituting <2% of all osteogenic sarcomas.[2] Osteosarcomas most commonly involve the appendicular skeleton (long bones), particularly the metaphyses of the distal femur and the proximal tibia. In the axial skeleton, the pelvis is the most common site. Craniofacial osteosarcomas are rare; in these cases, the mandible and maxilla are the most commonly involved sites, followed by the calvaria and then the skull base.[2]

Osteosarcomas can be either primary or secondary. Primary osteosarcomas typically occur in young patients, with 75% of the cases occurring before the age of 20 years with a slight male predominance. Secondary osteosarcomas occur in the elderly, usually secondary to the Paget’s disease of the bone, fibrous dysplasia, osteochondroma, osteoblastoma, enchondromatosis, bone infarcts, and after radiotherapy. Osteosarcomas usually present as a localized swelling or mass. At times, the first symptom may be related to a pathological fracture. Workup in these cases should include a magnetic resonance imaging of the involved region (for knowing the extent of the disease and to rule out skip lesions) along with a bone scan and a high-resolution computed tomography scan of the chest to look for distant metastasis. A complete radical en bloc resection with negative margins, if possible, is the treatment of choice for osteosarcomas.[2] This is followed by adjuvant multiagent chemotherapy (doxorubicin, cisplatin, methotrexate, and ifosfamide). Neoadjuvant chemotherapy may be considered on a case-by-case basis depending on the precise location of the mass and the feasibility of obtaining a complete resection.[2] Adjuvant radiation therapy is given to patients with positive or uncertain resection margins after surgery. Currently, the 5-year survival rate after adequate therapy is 60–80%.[2]

Chugh et al. described a case of spontaneous elevation of a depressed fracture segment in a child due to the development of a malignant brain edema.[3] Dhandapani and Sharma in their paper, “Is en-bloc excision, an option for select large vascular meningiomas?” stated that nearly always the tumor was pushed gradually by the underlying brain pulsations and edema so that the tumor gets delivered en bloc.[4] It appeared as if the brain pulsations were gently pushing the tumor out of the dural defect.[4] In our patient also, brain pulsations and edema were the two factors responsible for the extrusion of this rare tumor.


  Conclusion Top


In some cases, two-stage surgery for the resection of large intracranial tumors is beneficial. However, two-stage surgery should only be undertaken as a damage control measure and not as a routine standard of care. This is because, two-stage surgery is associated with an increased risk of anesthesia-related complications, prolonged hospital stay, a higher risk of infection, and cerebrospinal fluid leak.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Samartzis D, Gillis CC, Shih P, O’Toole JE, Fessler RG. Intramedullary spinal cord tumors: Part II—Management options and outcomes. Global Spine J 2016;6:176-85.  Back to cited text no. 1
    
2.
Hadley C, Gressot LV, Patel AJ, Wang LL, Flores RJ, Whitehead WE et al. Osteosarcoma of the cranial vault and skull base in pediatric patients. J Neurosurg Pediatr 2014;13:380-7.  Back to cited text no. 2
    
3.
Chugh A, Dang RS, Mamgain A, Husain M, Ojha BK, Rastogi M et al. Cerebral edema spontaneously elevating a compound depressed fracture. J Neurosurg Pediatr 2008;1:172.  Back to cited text no. 3
    
4.
Dhandapani S, Sharma K. Is “en-bloc” excision, an option for select large vascular meningiomas? Surg Neurol Int 2013;4:102.  Back to cited text no. 4
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