PMC8645466_01
Magnetic resonance imaging reveals a large mass located ventral to the brainstem extending from the suprasellar region to the pontomedullary junction (a, contrast-enhanced T1-weighted image, sagittal plane; b-d, T2-weighted image, axial plane).
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F1
A 46-year-old male patient who suffered from progressive diplopia, dysphagia, and hoarseness was referred for the management of a 35 x 32 x 51 mm lobulated cystic lesion located ventral to the brainstem, extending from the suprasellar region to the pontomedullary junction, involving the oculomotor, trochlear, trigeminal, abducens, facial, and acoustic nerves [Figure 1a]. The mass appeared isointense on T1- and T2-weighted images without contrast enhancement, containing small areas showing hyperintensity on T1-weighted images and hypointensity on T2-weighted images [Figure 1b-d].
Suprasellar part of the mass is removed through the transtubercular route, and the lesion in the posterior cranial fossa is resected through the transclival route (a). The cyst is composed of soft grayish capsule, and yellow mucinous and caseous components are observed (b). During the procedure, we identified the stalk, pituitary gland (c), basilar artery, facial nerve, vestibulocochlear nerve (d), and oculomotor nerve (e). Surgical resection was enabled under direct vision (f). The skull base defects are reconstructed using gelfoam, in-lay and over-lay fascial grafts with abdominal fat pieces in a multilayer fashion (g-i).
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F2
The ventral duramater was exposed to facilitate both transtubercular and transclival approaches [Figure 2a]. The suprasellar part of the mass was removed through the transtubercular route. The cyst comprised a soft, grayish capsule filled with yellow mucinous and caseous components [Figure 2b]. During the procedure, we identified the optic chiasma, bilateral oculomotor, trigeminal, abducens, and facial nerves, and the posterior cerebral arteries, superior cerebellar arteries, and basilar artery [Figure 2c-e]. Maximum surgical resection was safely performed under direct vision [Figure 2f]. The skull base defects were reconstructed using gelfoam, with in-lay and over-lay fascial grafts with abdominal fat pieces in a multilayered fashion [Figure 2g-i].
Histological examination demonstrates colloidal material and fragments of ciliated columnar epithelium, which indicates the diagnosis of neurenteric cyst (a, hematoxylin-eosin stain, x40). Follow-up magnetic resonance imaging demonstrates gross total resection (b-d), with no sign of recurrence at 3 years after surgery.
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F3
Histological examination revealed colloidal material and fragments of ciliated columnar epithelium, consistent with the diagnosis of NC [Figure 3a], and follow-up MRI demonstrated gross total resection with no sign of recurrence at the most recent follow-up, 3 years postoperatively [Figure 3b-d].