- Department of Surgery, Gynecology and Reproductive Biology, Michigan State University College of Human Medicine, East Lansing, MI, USA
- Department of Pathology, Hurley Medical Center, Flint, MI, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University College of Human Medicine, East Lansing, MI, USA
- Department of Radiology, Hurley Medical Center, Flint, MI, USA
Aftab S. Karim
Department of Surgery, Gynecology and Reproductive Biology, Michigan State University College of Human Medicine, East Lansing, MI, USA
DOI:10.4103/2152-7806.94930Copyright: © 2012 Yeung JT. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Yeung JT, Krznarich TS, Moreno EA, Mukkamala A, Karim AS. Intracranial parafalcine chondroma in a pregnant patient. Surg Neurol Int 25-Apr-2012;3:44
How to cite this URL: Yeung JT, Krznarich TS, Moreno EA, Mukkamala A, Karim AS. Intracranial parafalcine chondroma in a pregnant patient. Surg Neurol Int 25-Apr-2012;3:44. Available from: http://sni.wpengine.com/surgicalint_articles/intracranial-parafalcine-chondroma-in-a-pregnant-patient/
Background:Intracranial chondromas are rare benign neoplasms. We report a patient incidentally diagnosed with an intracranial chondroma during her second trimester.
Case Description:A 22-year-old Caucasian was diagnosed with an incidental parafalcine lesion found during admission due to a motor vehicle accident. Prior to the admission, the patient did not present with any neurological symptom. Magnetic resonance spectroscopy (MRS) suggested this intracranial lesion to be benign. A decision was made to delay the tumor excision until after delivery. Special anesthesia considerations were made to maintain stable blood pressure and euvolemia during the Cesarean section. The patient underwent a successful gross total removal of the intracranial tumor two months postpartum without any post-operative deficit.
Conclusion:This is the first case report of an intracranial parafalcine chondroma in pregnancy. This report highlights the disease course of this rare type of tumor during pregnancy. This case illustrates relevant aspects of the management of a neurologically asymptomatic patient with an incidentally discovered intracranial tumor of which MRS suggested a benign nature.
Keywords: Falx, intracranial chondroma, pregnancy, spectroscopy
An intracranial chondroma (IC) is a benign cartilaginous tumor first reported by Hirschfeld in 1851.[
We report a case of a parafalcine chondroma in a pregnant patient. The use of magnetic resonance spectroscopy (MRS) in this case provided a unique radiographic tool to optimize the timing of surgical resection.
A 22-year-old Caucasian female in her 24th week of pregnancy was evaluated for a mild headache after being in a motor vehicle accident as a restrained passenger. A non-contrast computed tomography (CT) scan was performed and revealed a hypodense lesion with hyperdense margins in the right frontal lobe [
(a) Sagittal head CT without contrast demonstrating predominantly cystic lesion in the right frontal lobe at time of trauma. (b) Pre-operative sagittal T1-weighted MRI with gadolinium contrast. (c) Axial T2-weighted MRI showing minimal edema. (d) Axial Diffusion-weighted imaging also showing lack of vasogenic edema
The patient's medical history was significant for two episodes of seizure at 4 and 15 years of age. No tumor was detected at that time as demonstrated by CT imaging used during the second episode. A discussion with the patient's obstetrician ensued. Given the fact that the patient's MRS suggested a benign nature of the brain lesions, and considering that she had no prior symptoms, and the T2 weighted images showed no edema, it was determined that there was no need for acute intervention. Stereotactic biopsy was considered as an option, but it was thought that the risk of intracranial hemorrhage outweighed the benefit of the invasive procedure in the otherwise asymptomatic patient. The patient, her obstetrician, and her primary care doctor were instructed to be aware of neurological symptoms, such as headache, dizziness, nausea, weakness, and numbness. Neurosurgical follow-up was offered to the patient, but she wished to continue the rest of her monitoring with her obstetrician and primary care doctor.
The baby was carried to full term and delivered via Cesarean section under spinal anesthesia. Epidural anesthesia was an optimal choice because it allowed the maintenance of stable blood pressure and neurological assessment of the patient during the section.[
Two months after the patient delivered her baby and recovered from the Cesarean section, she underwent a right frontal craniotomy with the use of Neuronavigation to remove the tumor. The patient was placed in a supine position with her head rotated to the left. She was typed and crossed with blood available on call. The patient was given 50 g of mannitol and 10 mg of dexamethasone. The anesthesia service was instructed to maintain the patient's pCo2 at approximately 30 mmHg. The gross tumor was dissected from the falx. Parts of the falx that were adherent to the tumor were resected. The dura overlying the tumor was also resected. Immediately following the surgery, the patient was kept on dexamethasone and was assessed neurologically every hour.
The intra-op fresh frozen sample of the brain lesion demonstrated cartilaginous tissue, which was later determined to be a parafalcine chondroma [
Intracranial chondromas (ICs) are rare, benign lesions of which the pathogenesis is still unknown. It is theorized that chondromas may arise from heterotopic chondrocytes, metaplastic meningeal fibroblasts, perivascular mesenchymal tissue, or aberrant activation of fibroblasts as a result of trauma.[
ICs have been documented in patients from the age of 15 months to 60 years.[
There have only been two reported cases of ICs involving pregnant patients. Wu and Lapi first described in 1970 a patient with fainting spells, increasingly severe speech difficulty, and weakness in her right arm in the third trimester.[
Our patient was asymptomatic with no neurological deficits at presentation. This was a key determinant in this patient's management when the benefits of tumor removal and the risks of surgery during pregnancy were weighed. Prior to the MRS, the radiographic characteristics of the tumor and the indolent clinical presentation suggested a benign process. The most likely differential diagnoses at that point were meningioma, hemangiopericytoma, or old calcified hematoma. Other possibilities included oligodendroglioma, glioblastoma multiforme, hemangioblastoma, chondrosarcoma, vascular malformation, cerebral abscess, and fungal infection. The lack of neurological symptoms favored conservative management to avoid surgical risks during pregnancy due to elevated blood pressure and the increased rate of intracranial hemorrhage.[
Poptani et al., showed that pyogenic abscesses display strong resonances for lactate, alanine, and acetate with absence of NAA, Choline (Cho), and creatine (Cr) peaks.[
In this case the combination of 3 features supported our decision to delay surgical intervention until after delivery: 1) the lack of neurological symptoms, 2) well-circumscribed finding on MRI, and 3) an MRS study that suggested a benign process. Stereotactic biopsy under local anesthesia was considered and discussed with the patient. Given the benign nature of the tumor as suggested by MRS, it was thought that the risk of intracranial hemorrhage in an otherwise neurologically asymptomatic patient outweighed the benefits obtained from an intracranial biopsy.
The patient was followed by her obstetrician for the rest of her pregnancy as a normal pregnancy. She was neurologically asymptomatic and, therefore, no interval imaging was performed during the rest of her pregnancy. The patient underwent a successful gross total removal of the intracranial tumor two months postpartum. MRS was key in providing guidance in the management of the intracranial neoplasm in this pregnant patient. The clinical course of intracranial parafalcine chondroma in this case allowed enough time for a complete course of pregnancy to occur.
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