148 Skull tumour & GB 21.4 skull tumors

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Greenberg,Handbook of neurosurgery 21.4 Skull TumorsYoumans,Neurological surgery Chapter 148 Skull TumorsOsborn,Expert ddx in brain&spine

Skull tumors

OutlineOsteomaHemangiomaDermoid and epidermoid tumorsChondroma (osteochondroma)MeningiomaAneurysmal bone cystMalignant tumorsBone metastases to the skullChondrosarcomaOsteogenic sarcomaFibrosarcomaBenign tumorsNon-neoplastic skull lesionPaget's disease of the skullLangerhans Cell Histiocytosis (Histiocytosis X)Fibrous dysplasiaHyperostosis frontalis internaSinus pericranii

Benign tumorsOsteomaHemangiomaDermoid and epidermoid tumorsChondroma(osteochondroma)MeningiomaAneurysmal bone cystGreenberg,Handbook of neurosurgery 21.4 Skull Tumors

OsteomaThe most common primary bone tumor of the calvariaBenign,slow-growing lesionsOccur commonly in the cranial vault, mastoid and paranasalair sinuses, and the mandibleCommon in females, highest incidence is in 6th decade

Pathology : Consists of osteoid tissue within osteoblastic tissue, surrounded by reactive boneGreenberg,Handbook of neurosurgery 21.4 Skull Tumors

OsteomaSkull x-rayRound, sclerotic, well demarcated, homogeneous dense projection. Usually arise from outer table of skull (inner table less common). May be compact or spongy(spongy osteoma may be radiolucent)Unlike meningiomas, diploe are preserved and vascular channels are not increased.

Treatment Asymptomatic lesions may simply be followed.Surgery may be considered for cosmetic reasons, or if pressure on adjacent tissues produces discomfort.

Greenberg,Handbook of neurosurgery 21.4 Skull Tumors

Osborn,Expert ddx in brain&spine

7% of skull tumorsTwo types: cavernous (most common) and capillary(rare)

X-rayCharacteristically shows a circular lucency with honeycomb or trabecular pattern (50% of cases) or radial trabeculations producing a sunburst pattern (11% of cases)Sclerotic margins are evident in only ... 33%.CT: hypodense lesion with sclerotic spaced trabeculations. NonenhancingBone scan: typically hot.HemangiomaGreenberg,Handbook of neurosurgery 21.4 Skull Tumors

HemangiomaTreatmentAccessible lesions may be cured by en bloc excision or curettage. The gross appearances of a hard, blue-domed mass beneath the pericranium. Radiation may be considered for inaccessible tumors

Greenberg,Handbook of neurosurgery 21.4 Skull Tumors

Osborn,Expert ddx in brain&spine

RareUsually midlineArise within the diploe and expand both inner and outer tablesThese benign lesions may involve underlying dural venous structures or brainDermoid and epidermoid tumorGreenberg,Handbook of neurosurgery 21.4 Skull Tumors

Dermoid and epidermoid tumorX-rayOsteolytic lesions have well-defined, sclerotic margins CT : hypodense (keratin contains fats), non-enhancing MRI : like CSF, they are low intensity on T1 WI and high signal on T2WI, but unlike CSF they are high signal on DWI MRITreatmentSurgicalSearch must be made for a tract leading to the intracranial cavity which must be followed if foundGreenberg,Handbook of neurosurgery 21.4 Skull Tumors

Osborn,Expert ddx in brain&spine

Chondroma(Osteochondroma)Arise form ectopic hyaline cartilaginous rest trapped within suture lineCommon : skull base,anterior to pon ,sphenoid bone, boardering of foramen lacerum

CT Well-demarcated, off midline, lobulated, contrast-enhancing, dense mass contiginous with the underlying bone and marked by popcorn calcificationMRIThin cartilaginous cap overlying the dense osseous coreYoumans,Neurological surgery Chapter 148 Skull Tumors

Chondroma(Osteochondroma)TreatmentComplete resection,including cartilaginous capsuleYoumans,Neurological surgery Chapter 148 Skull Tumors

MeningiomaIntraosseous(intradiploic) meningioma are uncommonPrimary intraosseous meningiomas do not involve the inner or outer tables of the skull or the duraectopic meningiomas or primary extradural meningiomasArise from rests of arachnoid cap cells trapped within sutures at birth and during molding of the headYoumans,Neurological surgery Chapter 148 Skull Tumors

MeningiomaPlain radiograph and CTHyperostosis(some are lytic or both lytic and sclerotic)Expansion of the diplo, with the inner and outer tables of the skull separated and thinned over the biconvex massMRITW1 : hypointense, TW2 : hyperintenseHomogeneous contrast enhancement on both CT and MRI

Treatment En bloc resection with marginYoumans,Neurological surgery Chapter 148 Skull Tumors

Osborn,Expert ddx in brain&spine

Aneurysmal bone cystRareSecondary to trauma to be caused by a circulatory disturbance resulting in venous hypertension and venous pooling within the boneA typical finding : local swelling and tenderness of a few month durationGross : vascular channel that give them spongy-like appearanceHistologic : communicating pools of venous blood without endothelium in a thin matrix of fibro-osseous strands along with frequent multinucleate giant cells.Youmans,Neurological surgery Chapter 148 Skull Tumors

Aneurysmal bone cystImagingLyticLoculated lesion with fluid-fluid levels caused by layering of blood products within internal cavitiesThe lesion typically begins in the diplo, and expansion or blowout of the inner and outer cortices

TreatmentGross total resection

Youmans,Neurological surgery Chapter 148 Skull Tumors

Malignant tumorsBone metastases to the skull1. prostate2. breast3. lung4. kidney5. thyroid6. lymphoma7. multiple myeloma/plasmacytomaChondrosarcomaOsteogenic sarcomaFibrosarcomaGreenberg,Handbook of neurosurgery 21.4 Skull Tumors

Bone metastasis to skullMost common : breast, lung, and prostateUncommon : renal and thyroid carcinoma Cranila vault more than skull base

RadiographicLytic lesion except prostate cause sclerotic lesionMRI : T1W : hypointense with variable T2W characteristic and variable contrast enhancementRadionuclide bone scanning : sensitive method for detecting skull metastasis

Youmans,Neurological surgery Chapter 148 Skull Tumors

Bone metastasis to skullCSFHelpful in suspected metastasis to the skull baseIf CSF is normal, metastasis is more likely than infection to be the cause of multiple cranial neuropathies A CSF study may also reveal the presence of meningeal carcinomatosis

Youmans,Neurological surgery Chapter 148 Skull Tumors

Bone metastasis to skullTreatmentPatients with skull metastases are frequently at an advanced stage of their primary disease and often asymptomatic : Surgery may not be required for diagnostic or even therapeutic purposesSymptomatic or palpable skull mass may be the first sign of the underlying cancer : surgical resection may be helpful or FNA in multiple or too indolent to need resection

Youmans,Neurological surgery Chapter 148 Skull Tumors

Osborn,Expert ddx in brain&spine

Osborn,Expert ddx in brain&spine

ChondrosarcomaRare,malignant neoplasm of cartilageFound away from midline with cranial neuropathies(particularly abducen neuropathy)Skull : painless expanding massSubtypeMyxoid(conventional low grade) most commonDedifferentiatedMesenchymalPathologyhypercellular with hyperchromatic and pleomorphic nuclei

Youmans,Neurological surgery Chapter 148 Skull Tumors

ChondrosarcomaCTCalcifications and ossifications within the tumor massMRILobulated lesions that appear isointense to hypointense on T1-weighted images and hyperintense on T2-weighted imagesShow heterogeneous contrast enhancement

TreatmentSurgical resection with adjuvant therapy

Youmans,Neurological surgery Chapter 148 Skull Tumors

Osborn,Expert ddx in brain&spine

Osteogenic sarcomaMost common malignanat tumor in bone but it is relatively rare in skullCranial vault than skull baseSecondary to radiationPatients with tumors attaining large size or involving the skull base may complain of local tenderness, headaches, proptosis, ophthalmoplegia, facial weakness, decreasedhearing ability, or tinnitusThe alkaline phosphatase level may be a useful diagnostic testYoumans,Neurological surgery Chapter 148 Skull Tumors

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Osteogenic sarcomaPathologySarcomatous spindle cell stroma with an associated osseous componentCTBony destruction, cortical expansion, and a sunburst periosteal reactionDemonstrate areas of irregular calcification, as well as low-attenuation areas representing necrosisMRIheterogeneous signal on both T1- and T2-weightedTreatmentGross total resectionYoumans,Neurological surgery Chapter 148 Skull Tumors

FibrosarcomaRareMay arise from degeneration of a preexisting lesion such as a fibroma from Pagets disease or it may occur after radiation treatmentTypically indolent, asymptomatic massesType : low grade (most differentiated), moderately differentiated, and poorly differentiated

Pathology interlaced bundles of spindle cells and collagen fibers in a herringbone pattern

Youmans,Neurological surgery Chapter 148 Skull Tumors

FibrosarcomaRadiographicLytic lesion with cortical destruction or expansion, or both, and soft tissue extensionRadiolucent

TreatmentEn bloc resectionYoumans,Neurological surgery Chapter 148 Skull Tumors

Non-neoplastic skull lesionPaget's disease of the skullLangerhans Cell Histiocytosis(Histiocytosis X)Fibrous dysplasiaHyperostosis frontalis internaSinus pericranii

Youmans,Neurological surgery Chapter 148 Skull Tumors

Pagets disease of the skull(Osteitis Deformans)Disorder characterized by the uncoupling of bone formation and resorption, with resultant bone thickening and weakeningClinicalHeadache, cranial neuropathy, EDH fron trauma