A 20-year-old male patient presented to our outpatient services with complaints of neck pain for 4 months and intermittent vomiting for 2 months duration. General physical examination was unremarkable. Neurological examination revealed left upper limb weakness (power 4+/5, Medical Research Council grading). Rest of the examination was normal.\nGadolinium-enhanced magnetic resonance imaging (MRI) revealed a well-defined lobulated lesion in the ventral cervicomedullary region from medulla to upper border of C2 vertebra. The lesion was heterogeneous in appearance; the anterior part measured 2.8 × 1.6 cm and was hypointense and hyperintense on T1- and T2-weighted images, respectively; while the 1.7 × 1.1 cm sized posterior part was iso to mildly hyperintense on T1 and heterogeneously hyper intense on T2-weighted sequences [Figure and ]. The anterior part of the lesion was isointense, whereas the posterior part was hyperintense on fluid attenuation and inversion recovery (FLAIR) sequences. There was mild restriction on diffusion-weighted sequences. On post-contrast study, rim enhancement was evident in the posterior part of the lesion []. Preoperative diagnosis was neurenteric cyst. Surgery was performed in prone position. A midline suboccipital craniectomy (with bone removal more on left side), left-sided C1 posterior arch removal, and partial C2 hemilaminectomy were performed. Intraoperatively, there was a well-defined, intradural, extra-medullary encapsulated, relatively avascular, lobulated lesion containing easily suckable, cheesy material located anterior to medulla extending up to C2 vertebral level. Vertebral artery, lower cranial nerves, and posterior inferior cerebellar artery were well visualized and preserved. Tumor decompression was followed by near total excision of the cyst wall in view of adherence of the cyst wall focally to surrounding vital structures. Postoperative course was uneventful and he was discharged on 7th postoperative day and is currently on regular follow-up. At the last follow-up of 3 months, patient was well with no deficits. Postoperative MRI showed a very small residual lesion [].\nHematoxylin and eosin photomicrographs showed epithelial lining thrown into folds along with irregular bundles of collagen. Higher magnification images show a prominent columnar epithelial lining with goblet cells focally thrown into papillary formations (×100), pseudostratification, and absence of cilia (×400). Overall features were consistent with an endodermal (neurenteric) cyst of Hind-gut type [Figure and ].
We present a case of a 36-year-old male who was admitted to the hospital due to a 1-month history of daily headaches within the occipital region. The headaches were reported to be worse at night and occasionally accompanied by nausea and dizziness. Neurological examinations revealed a right-sided exaggerated tendon reflex compared to the contralateral side. The patient was diagnosed with a positive pyramidal syndrome, Hoffmann’s reflex, and Babinski’s and Rossolimo’s sign on the right side. A CT scan revealed a 20 × 15 × 23 mm isodense focal lesion in the posterior fossa at the level of the foramen magnum []. The lesion extended to the level of the dens of axis while compressing the spinal cord posteriorly. Proton density [], T1 [ and ], and T2 [ and ] weighted MRI scans revealed a 22 × 11 × 33 mm well-defined cystic mass with two heterogeneous compartments within the foramen magnum at the level of C1-2. The medulla and spinal cord were shown to be displaced and compressed along with remodeling of the vertebral arteries with the right artery mainly affected. The superior half of the lesion was hyperintense on T2WI [] and moderately hypointense on T1WI MRI []. The inferior half of the lesion was hypointense on T2WI and hyperintense on T1WI MRI. No enhancement was shown after contrast administration. After careful consideration, the far lateral approach was chosen, and the patient underwent preparation for the procedure. A J-shaped skin incision followed by a suboccipital craniotomy, C1 laminectomy, and a C2 hemilaminectomy was performed. The dura was opened, exposing the extramedullary cyst. Complete resection (CR) was achieved and a cranioplasty with a typical closure concluded the operation. A histological examination revealed the cyst to be most consistent with a type B NC. The postoperative course was uneventful, and the patient was discharged on the 7th day without any neurological deficits. In a later follow-up, a CT scan revealed no sign of cyst recurrence.