EPIDERMOID CYST OF THE

ANTERIOR FORAMEN MAGNUM

Jimmy, Nyoman Golden
INTRODUCTION

Slow-growing congenital lesions of

ectodermal origin
1% of all primary intracranial tumors
Most frequent sites:
CP angle
Suprasellar
4th ventricle
Resection of the tumor well
conceptualized operative approach
CASE REPORT

26 y.o. alert female

with headache &
difficulty in swallowing
Stable vital sign
Normal neurological
examination
CASE REPORT

Brain MRI revealed a

large lobulated tumor
at the anterior foramen
magnum and attached
into the brainstem
CASE REPORT

Procedures:
Shunting
Cyst removal extreme lateral approach
This approach is best performed with excellent
exposure of anterior foramen magnum
During operation well confined cyst, white
yellowish fluid after puncturing the wall, some
hard component was adhered to the brain stem
at the 6th nerve root
Pathological report epidermoid cyst
CASE REPORT

Brain MRI after

resection of the tumor
showed restoration of
the brainstem and 4th
ventricle
DISCUSSION

1829, Cruveilhier tumeurs perlees

1838, Mueller cholesteatoma
(cholesterol cyrstals)
1854, von Remak epidermoid (lesions
arising from embryonic epithelial cell rests)
DISCUSSION

Epidermoid cyst = cholesteatoma (pearly

tumor)
Predilection site:
CP angle
4th ventricle
Suprasellar region
Spinal cord
1% of intracranial tumors
7% of CPA tumors
DISCUSSION

May arise from:

Displaced dorsal midline ectodermal cell rests
trapped during neural tube closure between
gestational weeks 3-5
Multipotential embryonic cell rests
Epithelial cell rests carried to the CPA with the
developing otic vesicle
Epidermal cells displaced into CNS, e.g by LP
DISCUSSION

Intracranial epidermoid cysts

Congenital
Characterized by stratified squamous epithelium,
and contain keratin, cellular debris, and
cholesterol
May be liquid or a flaky consistency
Differ from cholesterol granuloma ( the latter
usually occurs following chronic inflammation)
Symptoms vary depending on location
DISCUSSION

Evaluation:
CT-Scan low density, slightly greater than CSF,
with no enhancement; bone erosion in 33%
MRI T1W1: intensity is slightly > CSF; T2W1:
tumor and CSF have similar high intensity
DISCUSSION

Total removal is ideal & must be the goal of

the operation
Adhesion to vital neurovascular structures &
tumor extension far beyond midline leave
remnants behind
Many studies support that total resection
should be abandoned if the lesion is near the
brainstem or cranial nerves
Good prognosis
DISCUSSION

Extreme lateral posterior fossa approach

Allows access to antero-lateral region of
brainstem with proximal control of vertebral
artery
Differs from other approach in that the skin
incision is designed to get the bulk of the skin and
muscle flap out of the way
CONCLUSION

Epidermoid cyst of the anterior foramen

magnum is rare
Prognosis good result
Proper surgical approach
Good instrumentation and illumination
Experienced surgeon
THANK YOU