Intracranial cystic meningiomas: A series of six patients

Altunrende, Muhittin Emre; Göker, Burcu; Dolgun, Müge; Akçakaya, Mehmet Osman; Kasımcan, Mustafa Ömür; Şencan, Fahir; Hamamcıoğlu, Mustafa Kemal; Kırış, Talat

doi:10.1016/j.neucie.2019.01.001

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Transfrontal ipsilaterally trajectory was used for the biopsy. Short-term transient respiratory arrest was observed in the patient during the biopsy via transfrontal ipsilateral approach. (b) Control CT scan was performed on this patient following the procedure. The CT scan showing trajectory of needle in red circle and hemorrhage in the area where biopsy samples were taken." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ali Akay, Sertaç Işlekel" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Ali" "apellidos" => "Akay" ] 1 => array:2 [ "nombre" => "Sertaç" "apellidos" => "Işlekel" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529849619300231?idApp=UINPBA00004B" "url" => "/25298496/0000003000000004/v1_201906221012/S2529849619300231/v1_201906221012/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Clinical Research" "titulo" => "Intracranial cystic meningiomas: A series of six patients" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "159" "paginaFinal" => "166" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Muhittin Emre Altunrende, Burcu Göker, Müge Dolgun, Mehmet Osman Akçakaya, Mustafa Ömür Kasımcan, Fahir Şencan, Mustafa Kemal Hamamcıoğlu, Talat Kırış" "autores" => array:8 [ 0 => array:3 [ "nombre" => "Muhittin Emre" "apellidos" => "Altunrende" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 1 => array:3 [ "nombre" => "Burcu" "apellidos" => "Göker" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Müge" "apellidos" => "Dolgun" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:4 [ "nombre" => "Mehmet Osman" "apellidos" => "Akçakaya" "email" => array:1 [ 0 => "moakcakaya@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 4 => array:3 [ "nombre" => "Mustafa Ömür" "apellidos" => "Kasımcan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Fahir" "apellidos" => "Şencan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "Mustafa Kemal" "apellidos" => "Hamamcıoğlu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 7 => array:3 [ "nombre" => "Talat" "apellidos" => "Kırış" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Neurosurgery, GOP Taksim Training and Research Hospital, Istanbul, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Neurosurgery, Istinye University Medical Faculty, Liv Hospital, Istanbul, Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Meningiomas quísticos intracraneales: una serie de seis pacientes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1611 "Ancho" => 1667 "Tamanyo" => 183076 ] ] "descripcion" => array:1 [ "en" => "(A) Preoperative cranial MRI of the patient with a left frontal lesion indicates the cystic component of the lesion on the axial view of the T1 contrast enhanced sequence. (B) Preoperative axial view of T1 contrast-enhancing sequence shows the mural nodule of the lesion. (C and D) Postoperative cranial MRI on an axial view of the T1 contrast enhancing sequence shows the resected tumor cavity." ] ] ] "textoCompleto" => "IntroductionMeningiomas are tumors of the cranial and spinal meninges, arising from the arachnoid cap cells on the external layer of the arachnoid membrane. Meningiomas are the most common primary non-glial intracranial tumors. They represent 10–20% of all adult intracranial tumors.<a class="elsevierStyleCrossRefs" href="#bib0205">1,2</a> Meningiomas are most commonly encountered in female and elderly patients.<a class="elsevierStyleCrossRefs" href="#bib0210">2–4</a> They are generally solid, well-vascularized, benign tumors. However cystic formation of the mass lesion may be seen in some instances. Cystic meningiomas are quite rare, and they represent only 1.6–10% of all meningiomas. In contrast to solid meningiomas, cystic meningiomas are seen more often in males than in females.<a class="elsevierStyleCrossRef" href="#bib0225">5</a>Because meningiomas are usually solid tumors (as revealed by homogenous contrast enhancement), diagnosis of cystic meningiomas through radiological investigations can be challenging. The differential diagnosis of a solid lesion with a cystic component may include various pathologies, such as hemangioblastoma, neuroblastoma, glioblastoma, cystic astrocytoma, or metastatic tumors with necrotic or cystic components. Considering the incidence of cystic meningiomas, they are not usually primarily considered in the differential diagnosis of these lesions. The diagnosis of cystic meningiomas is usually established through histopathological investigations. In this study, we share our experience with six cases in order to discuss the clinical, radiological, surgical, and pathological features of cystic meningiomas.Material and methodsHospital records of the patients—all of whom underwent surgery for the excision of intracranial meningiomas—were retrospectively reviewed. Six patients underwent operation for cystic meningiomas between the years 2007 and 2016. The clinical, radiological, surgical, and pathological features of these six patients were analyzed. For each patient, history of the complaints, additional health problems, and drug usage information were recorded. Each patient had a complete neurological examination and radiological evaluation performed. Each patient underwent preoperative magnetic resonance imaging (MRI) studies with and without contrast, and preoperative computed tomography (CT) scans of the brain were performed in order to evaluate calcifications within the tumor and changes in the adjacent bony structures. Nauta and Rengachary Classifications were used to describe the cyst location.<a class="elsevierStyleCrossRefs" href="#bib0230">6,7</a> Postoperative CT scans were performed within six hours following surgery in each patient. In addition, postoperative MRI was performed within 24h following surgery in three patients. Each patient underwent postoperative MRI scans at the third and 12th months after the operation; the MRI scans were then repeated annually. The patients were followed up in the outpatient clinic.In 1979, Nauta et al. divided cystic meningiomas into four subtypes according to the location of the cyst in relation to the brain and the tumor.<a class="elsevierStyleCrossRef" href="#bib0230">6</a> We have categorized our patients according to this classification.<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">Type 1 – Cyst formation is in the center of the tumor.</li><li class="elsevierStyleListItem" id="lsti0010">Type 2 – Cyst formation is at the periphery but still within the margins of the tumor.</li><li class="elsevierStyleListItem" id="lsti0015">Type 3 – Peritumoral cyst formation is seen in the adjacent brain rather than the tumor itself.</li><li class="elsevierStyleListItem" id="lsti0020">Type 4 – Cyst formation is at the interface between the tumor and the brain.</li></ul>In addition to this classification, Rengachary classified meningiomas into two groups: intratumoral and peritumoral cystic meningiomas.<a class="elsevierStyleCrossRef" href="#bib0235">7</a> Besides the classification of Nauta, we have also categorized our patients according to this classification.ResultsThe clinical features of the patients in the current series are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. All patients presented with long standing headache dating back at least two years. There was no gender predominance in our series (three males and three females for a total of 6 patients). The mean age of the patients was 57.3 years (range: 27–76). Radiological evaluation revealed two parasagittal and two convexity mass lesions with a cystic formation located at the frontal region. In one patient, the mass lesion was located at the tuberculum sellae and at the foramen magnum in one patient. The tumors had cystic components and homogenously contrast-enhancing mural nodules, as shown in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1–4</a>. Two patients had type 1 cystic meningiomas, three patients had type 2, and one patient had type 4 according to the Nauta classification (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1–4</a>). According to Rengachary classification, there were four patients with peritumoral cystic meningiomas and two patients with intratumoral cystic meningiomas. Two of the six patients (33%) had cystic meningiomas in a parasagittal location. All patients had a mural nodule and a concomitant cystic component. MRI imagings revealed a dural tail in two patients. The only patients who exhibited a contrast-enhanced cyst wall were the two patients with intratumoral cystic meningiomas. In the diffusion-weighted images (DWI) series, all of the lesions showed restriction of the mural nodule.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>Operative techniqueThe head position was established according to the tumor location in each patient. In three instances, the surgical planning was performed with the help of neuronavigation. A merged CT- and MRI-neuronavigation system (StealthStation® S7® System, Medtronic, Louisville, USA) was used in these three cases, with frontal, foramen magnum, and parasagittal meningiomas. Patients were managed according to standard microsurgical technique. In two of these cases, a PENTERO 900 surgical microscope (Carl Zeiss) equipped with the YELLOW-560 filter was used. In these instances, 2ml (2–4mg/kg) of sodium-fluorescein (Na-Fl) (10%) were injected intravenously through a central venous catheter after anesthesia induction. The dura is always stained with Na-Fl under the YELLOW-560 filter following craniotomy. The surgical plan created in the neuronavigation console was used, and the surgical strategy was planned in a three-dimensional environment. After exposure of the tumor, the filter was switched, and Na-Fl enhancement was documented. Tumor dissection and resection were then performed using a standard microneurosurgical technique under white microscope light, and the surgical field was periodically checked with the YELLOW-560 filter.In five of the patients, tumors were seen with a cystic formation and were dissected from the surrounding tissue. The mass lesions were excised totally with the cyst capsule. In one patient with a tuberculum sellae meningioma, the sylvian fissure was opened, and after removing the cerebrospinal fluid (CSF) from the carotid cistern, optic nerves were identified and carefully dissected from the tumor. The tumor was totally removed following the cyst puncture and internal tumor debulking. After total excision of the lesions, the dura was coagulated in one patient, in five patients dural excision is made because of the dural invasion. Galeal grafts that were harvested were used as dural substitute for dural closure. No bony invasion was seen in any patient. Craniotomy flap was repositioned in all of the patients.In two patients who received Na-Fl, the dura was enhanced with Na-Fl under the YELLOW-560 filter. These two tumors in the current series showed diffuse, strong Na-Fl enhancement. Tumor tissue was enhanced until the end of tumor removal. Both tumors were left frontal (one convexity and one parasagittal) tumors that had peritumoral cysts. Na-Fl was very useful for clearly demonstrating the cleavage between brain tissue and the tumor (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The cyst walls showed marked Na-Fl staining during surgery (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). It was particularly useful during tumor dissection and peeling away of the cyst wall from the adjacent cortical surface in order to achieve a total resection.<elsevierMultimedia ident="fig0025"></elsevierMultimedia>The clinical, radiological, and pathological features of the patients in the current series are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. All of the tumors were totally excised (Simpson Grade I and/or Grade II). Histopathologically, all of the tumors were found to be World Health Organization (WHO) Grade I meningiomas. Three patients had a pathology result of meningothelial meningioma, whereas in two patients the pathology was reported as angiomatous meningioma, and one patient had metaplastic meningioma according to the WHO 2007 classification. Pathological specimens revealed no mitosis or necrosis. The cyst capsules were separately sended to pathology in those two instances with Na-Fl enhancement. They were positive for meningioma cells. Detailed pathological staining results are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. None of the patients had any complications after the surgery. Patients left the hospital with no neurological deficits. Patients with seizures were seizure-free after three months, and no neurological deficits or recurrences were noted. The patients were followed-up for a mean period of 51 months (range: 16–102 months) without recurrence.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>DiscussionMeningiomas are extra-axial tumors that are usually solid and they rarely present with cystic component along with the solid part. They tend to have a good prognosis; however, meningiomas with cystic components may have a relatively aggressive natural clinical course.<a class="elsevierStyleCrossRef" href="#bib0225">5</a> In solid meningiomas, hyperostosis is a common finding. If additional bone destruction is demonstrated on the CT scan, it may be related to malignant behavior or to the invasive nature of the tumor, which is indicative of poor prognosis.<a class="elsevierStyleCrossRef" href="#bib0240">8</a> However, that was not the case in our series. On the contrary, the meningiomas in this series had a very benign clinical course. This may be related to two factors: <a class="elsevierStyleCrossRef" href="#bib0205">1</a> total removal of the meningiomas, including the cyst wall, and <a class="elsevierStyleCrossRef" href="#bib0245">9</a> relatively benign histopathological features (lower ki-67 index, lower number of mitosis). Today, MRI and CT imaging technologies may contribute to the differential diagnosis of these cystic meningiomas. In MRI, dural enhancement is a typical sign of meningiomas, which is called the “dural tail sign.” The presence of a dural tail sign leads the surgeon to reconsider the prediagnosis. Because meningiomas are generally isointense in the T1 sequence and isointense or hyperintense in the T2 sequence, a contrast-enhanced series helps locate the contrast-enhanced mural nodule, cystic formation, and dural tail sign (if present).Unlike those of gliomas or metastatic glial tumors, the cyst walls of meningiomas do not always enhance with contrast. This could distinguish the cyst walls formed by gliotic tissue from those of tumor cells.<a class="elsevierStyleCrossRef" href="#bib0250">10</a> Total surgical excision generally results in total remission; however, to prevent the recurrence, the cyst capsule must be removed totally along with the tumor.<a class="elsevierStyleCrossRefs" href="#bib0225">5,8–11</a> Recent studies show that contrast enhancement can be caused by the tumor cells embedded within the cyst wall.<a class="elsevierStyleCrossRef" href="#bib0260">12</a> However, although the cyst wall has no contrast enhancement, tumor cells can be found within. If the tumor is not totally resected, there may be an increased risk of recurrence. Peeling away of the cyst wall from the adjacent cortical surface should be performed meticulously.Sodium fluorescein (Na-Fl) is a sodium salt and an organic fluorescent dye with peak excitation at 490nm and emission between 500 and 550nm.<a class="elsevierStyleCrossRef" href="#bib0265">13</a> Several studies have shown the promising use of high-dose Na-Fl for determining the extent of resection under normal microscope light in various tumors, including meningiomas.<a class="elsevierStyleCrossRefs" href="#bib0270">14–22</a> A newly developed microscope (PENTERO 900, Carl Zeiss, Meditec, Oberkochen, Germany) equipped with a special filter (YELLOW-560nm) designed to detect low-dose Na-Fl for the demarcation of tumor tissue was previously introduced, and more promising reports have been published regarding extensive tumor resection with the use of this system.<a class="elsevierStyleCrossRefs" href="#bib0315">23–33</a> However, these studies have mainly focused on the resection of intra-axial brain tumors. To our knowledge, only Da Silva et al. published their surgical results of Na-Fl-guided resection of extra-axial brain tumors under standard white microscope light.<a class="elsevierStyleCrossRefs" href="#bib0300">20–22</a> By using quantitative digital analysis of tumor enhancement with Na-Fl, they objectively demonstrated a strong presence of enhancement in all of the tumors.<a class="elsevierStyleCrossRef" href="#bib0300">20</a> They noted that all of the tumors showed marked contrast enhancement (gadolinium) on preoperative MRI, and this corresponded well with the Na-Fl enhancement because a disrupted blood brain barrier plays a role in the effect mechanism of both drugs.<a class="elsevierStyleCrossRef" href="#bib0310">22</a> All meningiomas and dural tails showed strong Na-Fl enhancement intraoperatively.<a class="elsevierStyleCrossRef" href="#bib0305">21</a> The current series contains two cystic meningiomas, which were surgically removed with the use of Na-Fl under a YELLOW 560nm filter. As stated before, Na-Fl was found to be very useful in demonstrating the brain-tumor interface, and it was especially effective in resecting the cyst wall in peritumoral cystic meningiomas. Its effects on solid meningioma surgery require further investigation, but Na-Fl guidance was found to be a useful technical adjunct in cystic meningioma surgery.There have been some studies in the literature concerning the pathophysiology of cyst formation since the 1970s. In these studies, it has been shown that the degeneration, hemorrhage, and ischemia in the central region of the tumor lead to cystic formation; peripherally-located cyst formation is generated by the gathering of the xanthochromic fluid in the subarachnoidal space and reactive gliosis. In addition, white matter edema and perfusion deficits may cause demyelination, leading to the formation of cystic cavities.<a class="elsevierStyleCrossRefs" href="#bib0230">6,34</a> Thus, cystic meningiomas have a higher risk of intratumoral hemorrhage than solid meningiomas.<a class="elsevierStyleCrossRefs" href="#bib0215">3,35</a>In our study, out of six patients, four of them had intratumoral cyst component (%66.6). This was not consistent with the recent literature showing that peritumoral cystic meningiomas are more common than intratumoral cystic meningiomas.<a class="elsevierStyleCrossRef" href="#bib0380">36</a> Previous studies have shown that cystic meningiomas tend to be found in the cerebral convexity and parasagittal regions.<a class="elsevierStyleCrossRefs" href="#bib0375">35,37</a> In our study two of the six patients had cystic meningiomas in a parasagittal location and two patients’ lesions were located in the cerebral convexity. Even though there are limited number of cases in our study, our results were consistent with the previous literature. The number of cases should be augmented in order to get reliable data regarding this matter.Nauta et al. described the cyst location associated with meningiomas in four categories.<a class="elsevierStyleCrossRef" href="#bib0220">4</a> We have seen cysts of type 1 in two patients; type 2 in three patients and type 4 in one patient. There is not a certain predominance according to Nauta classification however, previous case reports also show predominance of type 1 and 2 cysts.<a class="elsevierStyleCrossRef" href="#bib0375">35</a>In our study, we found that all of the mural nodules showed restriction on DWI series on MRI which was consistent with the previous literature.<a class="elsevierStyleCrossRef" href="#bib0390">38</a> MRI of two patients with intratumoral cystic meningiomas revealed contrast-enhanced cyst wall. Because we know that the cyst wall enhancement can be found in intratumoral cystic meningiomas rather than the peritumoral cystic meningiomas, we can claim that these findings are consistent with the recent literature.<a class="elsevierStyleCrossRef" href="#bib0395">39</a>ConclusionCystic meningiomas are rare entities within the meningioma group. Because their differential diagnosis includes cystic astrocytomas, hemangioblastomas, neuroblastomas, glial tumors, and metastatic tumors, it is important to note the specific changes in MRI induced by cystic meningiomas, such as the dural tail sign. In the literature, it is somehow controversial that when the tumor is totally resected with the cyst capsule the prognosis is better; however, it is recommended to resect the capsule whenever possible.<a class="elsevierStyleCrossRef" href="#bib0400">40</a> Na-Fl could be used as a useful adjunct to resect the cyst wall or capsule. Because it is challenging to identify the diagnosis preoperatively because of the nonspecific clinical and radiological features, it is important to include meningiomas in the differential diagnosis of intracranial cystic lesions.Conflict of interestsThe authors declare no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1210226" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1126686" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1210227" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1126687" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Operative technique" ] ] ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-10-19" "fechaAceptado" => "2019-01-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1126686" "palabras" => array:4 [ 0 => "Cystic meningiomas" 1 => "Surgical excision" 2 => "Sodium fluorescein" 3 => "YELLOW 560" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1126687" "palabras" => array:4 [ 0 => "Meningiomas quísticos" 1 => "Escisión quirúrgica" 2 => "Fluoresceína de sodio" 3 => "AMARILLO 560" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveAlthough meningiomas are the most common primary non-glial intracranial tumors, cystic meningiomas are quite rare. This study presents six cases in order to discuss the radiological and pathological features of cystic meningiomas. Patients and methodsSix patients with cystic meningiomas were included in the study. All patients underwent a cranial computed tomography scan and magnetic resonance imaging (MRI) evaluation, pre- and postoperatively. ResultsAll patients presented with long standing headache dating back at least two years. There was no gender predominance in our series. Radiological evaluation revealed two parasagittal and two convexity meningiomas located at the frontal region. Two lesions were located at the tuberculum sellae and the foramen magnum. All of the tumors were totally excised (Simpson Grade I or II). Pathology results included meningothelial meningioma in three patients, angiomatous meningioma in two patients, and metaplastic meningioma in one patient. In two patients, the cystic meningiomas were resected with the use of sodium fluorescein (Na-Fl) under a YELLOW 560nm microscope filter. Na-Fl was found to be very useful in demonstrating the brain–tumor interface, and it was especially effective in resecting the cyst wall of the peritumoural cystic meningiomas. None of the patients had any complications, and no recurrences were noted in any of the patients within the mean follow-up period of 51 months (range: 16–102 months). ConclusionIt is important to note MRI changes specific to cystic meningioma and include meningiomas in the differential diagnosis of intracranial cystic lesions. The use of sodium fluorescein (Na-Fl) under a YELLOW 560nm microscope filter is a useful tool to differentiate the brain-tumor interface, as well as to identify the cyst wall in order to fully resect the tumor with the cystic component to avoid recurrence and achieve better clinical results." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoAunque los meningiomas son los tumores intracraneales primarios no gliales más frecuentes, los meningiomas quísticos son bastante raros. Este estudio presenta 6 casos para discutir las características radiológicas y patológicas de los meningiomas quísticos. Pacientes y métodosSe incluyeron 6 pacientes con meningiomas quísticos en el estudio. Todos los pacientes se sometieron a una tomografía computarizada craneal y a una evaluación por resonancia magnética, antes y después de la operación. ResultadosTodos los pacientes presentaron dolor de cabeza de larga duración de al menos 2 años. No hubo predominio de género. La evaluación radiológica reveló 2 meningiomas parasagitales y 2 de la convexidad ubicados en la región frontal. En los otros 2 pacientes las lesiones se ubicaron en el tubérculo selar y en el foramen magno respectivamente. Todos los tumores fueron totalmente extirpados (grado de Simpson I o II). En 2 pacientes, los meningiomas quísticos se resecaron con el uso de fluoresceína de sodio bajo un filtro de microscopio AMARILLO de 560nm. Se encontró que la fluoresceína de sodio era muy útil para demostrar la interfaz entre el cerebro y el tumor, y fue especialmente eficaz para resecar la pared de los quistes peritumorales. Los resultados de histopatología incluyeron meningioma meningotelial en 3 pacientes, meningioma angiomatoso en 2 y meningioma metaplásico en uno. Ninguno de los pacientes presentó ninguna complicación, y no se observaron recurrencias en ningún paciente dentro del período de seguimiento medio de 51 meses (rango: 16-102 meses). ConclusiónEs importante tener en cuenta los cambios en la resonancia magnética específicos de los meningiomas quísticos e incluir estos tumores en el diagnóstico diferencial de las lesiones quísticas intracraneales. El uso de fluoresceína de sodio bajo un filtro de microscopio AMARILLO de 560nm es una herramienta útil para diferenciar la interfaz cerebro-tumor, así como para identificar la pared del quiste y resecar completamente el tumor con el componente quístico para evitar la recidiva y conseguir mejores resultados clínicos." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 697 "Ancho" => 2000 "Tamanyo" => 135701 ] ] "descripcion" => array:1 [ "en" => "(A and B) Coronal and axial T1-weighted contrast-enhanced images shows a type 4 cystic meningioma at tuberculum sellae. (C) Coronal T1-weighted contrast-enhanced image shows a type 2 cystic convexity meningioma (according to Nauta Classification<a class="elsevierStyleCrossRef" href="#bib0230">6</a>)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1475 "Ancho" => 1200 "Tamanyo" => 124684 ] ] "descripcion" => array:1 [ "en" => "(A) A mass lesion located in the left frontal region can be seen in the T1 FLAIR sequence, causing a midline shift of 16mm on the cranial MRI. In addition to the cystic components, a 8mm hyperintense mural nodule is seen on the contrast-enhanced T1 sequences. (B) Postoperative cranial CT shows total excision of the tumor." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1611 "Ancho" => 1667 "Tamanyo" => 183076 ] ] "descripcion" => array:1 [ "en" => "(A) Preoperative cranial MRI of the patient with a left frontal lesion indicates the cystic component of the lesion on the axial view of the T1 contrast enhanced sequence. (B) Preoperative axial view of T1 contrast-enhancing sequence shows the mural nodule of the lesion. (C and D) Postoperative cranial MRI on an axial view of the T1 contrast enhancing sequence shows the resected tumor cavity." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1737 "Ancho" => 1667 "Tamanyo" => 236234 ] ] "descripcion" => array:1 [ "en" => "(A) Cranial MRI – axial view of T1 sequence with contrast enhancement shows a mural nodule near the border of the dura along with the cystic component. (B) Coronal view of the T2 sequence shows the cystic and solid components of the lesion. (C and D) Postoperative contrast enhancing axial and coronal T1 sequences show total excision of the cystic-solid meningioma." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 667 "Ancho" => 2000 "Tamanyo" => 224495 ] ] "descripcion" => array:1 [ "en" => "(A) Intraoperative microscopic view of a parasagittal frontal meningioma under normal microscope light. (B) The same meningioma showed diffuse Na-Fl staining under YELLOW 560nm filter; note that both the cyst wall and the solid tumor show Na-Fl enhancement. (C) Following the resection of the solid component and cyst drainage, the cyst walls were excised. Note the Na-Fl enhancing cyst wall within the tip of the aspirator under YELLOW 560nm filter." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age (yrs) – sex \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Presenting symptoms \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Localization \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MRI findings \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pathology \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27, F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Headache, visual loss \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meningothelial meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70, M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Headache, vomiting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LF(convexity) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Angiomatous meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76, M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Headache, seizure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LF(parasagittal) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Angiomatous meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45, M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Headache, seizure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LF(parasagittal) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Metaplastic meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69, F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Headache, seizure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LF(convexity) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meningothelial meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57, F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Headache, vomiting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meningothelial meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2066179.png" ] ] ] ] "descripcion" => array:1 [ "en" => "summarizes clinical, radiological and pathological symptoms. TS: tuberculum sella, FM: foramen magnum, LF: left frontal, DT: dural tail seen on MRI." ] ] 6 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age (yrs) – sex \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pathology \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ki-67 (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">EMA \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CD34 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vimentin \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">S-100 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pan-CK \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mitosis \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Necrosis \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27, F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meningothelial meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70, M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Angiomatous meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76, M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Angiomatous Meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45, M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Metaplastic meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69, F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meningothelial meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57, F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meningothelial meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2066178.png" ] ] ] ] "descripcion" => array:1 [ "en" => "summarizes pathological features of the meningiomas in the current series." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:40 [ 0 => array:3 [ "identificador" => "bib0205" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infratentorial benign cystic meningioma mimicking a hemangioblastoma radiologically and a pilocytic astrocytoma intraoperatively: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T.K. 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            "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; Contrast-enhanced T1-weight MRI showing a necrotic lesion on paramedian pons&#46; Transfrontal ipsilaterally trajectory was used for the biopsy&#46; Short-term transient respiratory arrest was observed in the patient during the biopsy via transfrontal ipsilateral approach&#46; &#40;b&#41; Control CT scan was performed on this patient following the procedure&#46; The CT scan showing trajectory of needle in red circle and hemorrhage in the area where biopsy samples were taken&#46;</p>"
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    "titulo" => "Intracranial cystic meningiomas&#58; A series of six patients"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Preoperative cranial MRI of the patient with a left frontal lesion indicates the cystic component of the lesion on the axial view of the T1 contrast enhanced sequence&#46; &#40;B&#41; Preoperative axial view of T1 contrast-enhancing sequence shows the mural nodule of the lesion&#46; &#40;C and D&#41; Postoperative cranial MRI on an axial view of the T1 contrast enhancing sequence shows the resected tumor cavity&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Meningiomas are tumors of the cranial and spinal meninges&#44; arising from the arachnoid cap cells on the external layer of the arachnoid membrane&#46; Meningiomas are the most common primary non-glial intracranial tumors&#46; They represent 10&#8211;20&#37; of all adult intracranial tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#44;2</span></a> Meningiomas are most commonly encountered in female and elderly patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">2&#8211;4</span></a> They are generally solid&#44; well-vascularized&#44; benign tumors&#46; However cystic formation of the mass lesion may be seen in some instances&#46; Cystic meningiomas are quite rare&#44; and they represent only 1&#46;6&#8211;10&#37; of all meningiomas&#46; In contrast to solid meningiomas&#44; cystic meningiomas are seen more often in males than in females&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Because meningiomas are usually solid tumors &#40;as revealed by homogenous contrast enhancement&#41;&#44; diagnosis of cystic meningiomas through radiological investigations can be challenging&#46; The differential diagnosis of a solid lesion with a cystic component may include various pathologies&#44; such as hemangioblastoma&#44; neuroblastoma&#44; glioblastoma&#44; cystic astrocytoma&#44; or metastatic tumors with necrotic or cystic components&#46; Considering the incidence of cystic meningiomas&#44; they are not usually primarily considered in the differential diagnosis of these lesions&#46; The diagnosis of cystic meningiomas is usually established through histopathological investigations&#46; In this study&#44; we share our experience with six cases in order to discuss the clinical&#44; radiological&#44; surgical&#44; and pathological features of cystic meningiomas&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">Hospital records of the patients&#8212;all of whom underwent surgery for the excision of intracranial meningiomas&#8212;were retrospectively reviewed&#46; Six patients underwent operation for cystic meningiomas between the years 2007 and 2016&#46; The clinical&#44; radiological&#44; surgical&#44; and pathological features of these six patients were analyzed&#46; For each patient&#44; history of the complaints&#44; additional health problems&#44; and drug usage information were recorded&#46; Each patient had a complete neurological examination and radiological evaluation performed&#46; Each patient underwent preoperative magnetic resonance imaging &#40;MRI&#41; studies with and without contrast&#44; and preoperative computed tomography &#40;CT&#41; scans of the brain were performed in order to evaluate calcifications within the tumor and changes in the adjacent bony structures&#46; Nauta and Rengachary Classifications were used to describe the cyst location&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">6&#44;7</span></a> Postoperative CT scans were performed within six hours following surgery in each patient&#46; In addition&#44; postoperative MRI was performed within 24<span class="elsevierStyleHsp" style=""></span>h following surgery in three patients&#46; Each patient underwent postoperative MRI scans at the third and 12th months after the operation&#59; the MRI scans were then repeated annually&#46; The patients were followed up in the outpatient clinic&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In 1979&#44; Nauta et al&#46; divided cystic meningiomas into four subtypes according to the location of the cyst in relation to the brain and the tumor&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">6</span></a> We have categorized our patients according to this classification&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Type 1</span> &#8211; Cyst formation is in the center of the tumor&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Type 2</span> &#8211; Cyst formation is at the periphery but still within the margins of the tumor&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Type 3</span> &#8211; Peritumoral cyst formation is seen in the adjacent brain rather than the tumor itself&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Type 4</span> &#8211; Cyst formation is at the interface between the tumor and the brain&#46;</p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">In addition to this classification&#44; Rengachary classified meningiomas into two groups&#58; intratumoral and peritumoral cystic meningiomas&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a> Besides the classification of Nauta&#44; we have also categorized our patients according to this classification&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">The clinical features of the patients in the current series are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; All patients presented with long standing headache dating back at least two years&#46; There was no gender predominance in our series &#40;three males and three females for a total of 6 patients&#41;&#46; The mean age of the patients was 57&#46;3 years &#40;range&#58; 27&#8211;76&#41;&#46; Radiological evaluation revealed two parasagittal and two convexity mass lesions with a cystic formation located at the frontal region&#46; In one patient&#44; the mass lesion was located at the tuberculum sellae and at the foramen magnum in one patient&#46; The tumors had cystic components and homogenously contrast-enhancing mural nodules&#44; as shown in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1&#8211;4</a>&#46; Two patients had <span class="elsevierStyleItalic">type 1</span> cystic meningiomas&#44; three patients had <span class="elsevierStyleItalic">type 2</span>&#44; and one patient had <span class="elsevierStyleItalic">type 4</span> according to the Nauta classification &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1&#8211;4</a>&#41;&#46; According to Rengachary classification&#44; there were four patients with peritumoral cystic meningiomas and two patients with intratumoral cystic meningiomas&#46; Two of the six patients &#40;33&#37;&#41; had cystic meningiomas in a parasagittal location&#46; All patients had a mural nodule and a concomitant cystic component&#46; MRI imagings revealed a dural tail in two patients&#46; The only patients who exhibited a contrast-enhanced cyst wall were the two patients with intratumoral cystic meningiomas&#46; In the diffusion-weighted images &#40;DWI&#41; series&#44; all of the lesions showed restriction of the mural nodule&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Operative technique</span><p id="par0055" class="elsevierStylePara elsevierViewall">The head position was established according to the tumor location in each patient&#46; In three instances&#44; the surgical planning was performed with the help of neuronavigation&#46; A merged CT- and MRI-neuronavigation system &#40;StealthStation<span class="elsevierStyleSup">&#174;</span> S7<span class="elsevierStyleSup">&#174;</span> System&#44; Medtronic&#44; Louisville&#44; USA&#41; was used in these three cases&#44; with frontal&#44; foramen magnum&#44; and parasagittal meningiomas&#46; Patients were managed according to standard microsurgical technique&#46; In two of these cases&#44; a PENTERO 900 surgical microscope &#40;Carl Zeiss&#41; equipped with the YELLOW-560 filter was used&#46; In these instances&#44; 2<span class="elsevierStyleHsp" style=""></span>ml &#40;2&#8211;4<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; of sodium-fluorescein &#40;Na-Fl&#41; &#40;10&#37;&#41; were injected intravenously through a central venous catheter after anesthesia induction&#46; The dura is always stained with Na-Fl under the YELLOW-560 filter following craniotomy&#46; The surgical plan created in the neuronavigation console was used&#44; and the surgical strategy was planned in a three-dimensional environment&#46; After exposure of the tumor&#44; the filter was switched&#44; and Na-Fl enhancement was documented&#46; Tumor dissection and resection were then performed using a standard microneurosurgical technique under white microscope light&#44; and the surgical field was periodically checked with the YELLOW-560 filter&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In five of the patients&#44; tumors were seen with a cystic formation and were dissected from the surrounding tissue&#46; The mass lesions were excised totally with the cyst capsule&#46; In one patient with a tuberculum sellae meningioma&#44; the sylvian fissure was opened&#44; and after removing the cerebrospinal fluid &#40;CSF&#41; from the carotid cistern&#44; optic nerves were identified and carefully dissected from the tumor&#46; The tumor was totally removed following the cyst puncture and internal tumor debulking&#46; After total excision of the lesions&#44; the dura was coagulated in one patient&#44; in five patients dural excision is made because of the dural invasion&#46; Galeal grafts that were harvested were used as dural substitute for dural closure&#46; No bony invasion was seen in any patient&#46; Craniotomy flap was repositioned in all of the patients&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In two patients who received Na-Fl&#44; the dura was enhanced with Na-Fl under the YELLOW-560 filter&#46; These two tumors in the current series showed diffuse&#44; strong Na-Fl enhancement&#46; Tumor tissue was enhanced until the end of tumor removal&#46; Both tumors were left frontal &#40;one convexity and one parasagittal&#41; tumors that had peritumoral cysts&#46; Na-Fl was very useful for clearly demonstrating the cleavage between brain tissue and the tumor &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The cyst walls showed marked Na-Fl staining during surgery &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; It was particularly useful during tumor dissection and peeling away of the cyst wall from the adjacent cortical surface in order to achieve a total resection&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The clinical&#44; radiological&#44; and pathological features of the patients in the current series are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; All of the tumors were totally excised &#40;Simpson Grade I and&#47;or Grade II&#41;&#46; Histopathologically&#44; all of the tumors were found to be World Health Organization &#40;WHO&#41; Grade I meningiomas&#46; Three patients had a pathology result of meningothelial meningioma&#44; whereas in two patients the pathology was reported as angiomatous meningioma&#44; and one patient had metaplastic meningioma according to the WHO 2007 classification&#46; Pathological specimens revealed no mitosis or necrosis&#46; The cyst capsules were separately sended to pathology in those two instances with Na-Fl enhancement&#46; They were positive for meningioma cells&#46; Detailed pathological staining results are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; None of the patients had any complications after the surgery&#46; Patients left the hospital with no neurological deficits&#46; Patients with seizures were seizure-free after three months&#44; and no neurological deficits or recurrences were noted&#46; The patients were followed-up for a mean period of 51 months &#40;range&#58; 16&#8211;102 months&#41; without recurrence&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Meningiomas are extra-axial tumors that are usually solid and they rarely present with cystic component along with the solid part&#46; They tend to have a good prognosis&#59; however&#44; meningiomas with cystic components may have a relatively aggressive natural clinical course&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">5</span></a> In solid meningiomas&#44; hyperostosis is a common finding&#46; If additional bone destruction is demonstrated on the CT scan&#44; it may be related to malignant behavior or to the invasive nature of the tumor&#44; which is indicative of poor prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> However&#44; that was not the case in our series&#46; On the contrary&#44; the meningiomas in this series had a very benign clinical course&#46; This may be related to two factors&#58; <a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a> total removal of the meningiomas&#44; including the cyst wall&#44; and <a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a> relatively benign histopathological features &#40;lower ki-67 index&#44; lower number of mitosis&#41;&#46; Today&#44; MRI and CT imaging technologies may contribute to the differential diagnosis of these cystic meningiomas&#46; In MRI&#44; dural enhancement is a typical sign of meningiomas&#44; which is called the &#8220;dural tail sign&#46;&#8221; The presence of a dural tail sign leads the surgeon to reconsider the prediagnosis&#46; Because meningiomas are generally isointense in the T1 sequence and isointense or hyperintense in the T2 sequence&#44; a contrast-enhanced series helps locate the contrast-enhanced mural nodule&#44; cystic formation&#44; and dural tail sign &#40;if present&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Unlike those of gliomas or metastatic glial tumors&#44; the cyst walls of meningiomas do not always enhance with contrast&#46; This could distinguish the cyst walls formed by gliotic tissue from those of tumor cells&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">10</span></a> Total surgical excision generally results in total remission&#59; however&#44; to prevent the recurrence&#44; the cyst capsule must be removed totally along with the tumor&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">5&#44;8&#8211;11</span></a> Recent studies show that contrast enhancement can be caused by the tumor cells embedded within the cyst wall&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> However&#44; although the cyst wall has no contrast enhancement&#44; tumor cells can be found within&#46; If the tumor is not totally resected&#44; there may be an increased risk of recurrence&#46; Peeling away of the cyst wall from the adjacent cortical surface should be performed meticulously&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Sodium fluorescein &#40;Na-Fl&#41; is a sodium salt and an organic fluorescent dye with peak excitation at 490<span class="elsevierStyleHsp" style=""></span>nm and emission between 500 and 550<span class="elsevierStyleHsp" style=""></span>nm&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">13</span></a> Several studies have shown the promising use of high-dose Na-Fl for determining the extent of resection under normal microscope light in various tumors&#44; including meningiomas&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#8211;22</span></a> A newly developed microscope &#40;PENTERO 900&#44; Carl Zeiss&#44; Meditec&#44; Oberkochen&#44; Germany&#41; equipped with a special filter &#40;YELLOW-560<span class="elsevierStyleHsp" style=""></span>nm&#41; designed to detect low-dose Na-Fl for the demarcation of tumor tissue was previously introduced&#44; and more promising reports have been published regarding extensive tumor resection with the use of this system&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">23&#8211;33</span></a> However&#44; these studies have mainly focused on the resection of intra-axial brain tumors&#46; To our knowledge&#44; only Da Silva et al&#46; published their surgical results of Na-Fl-guided resection of extra-axial brain tumors under standard white microscope light&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">20&#8211;22</span></a> By using quantitative digital analysis of tumor enhancement with Na-Fl&#44; they objectively demonstrated a strong presence of enhancement in all of the tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">20</span></a> They noted that all of the tumors showed marked contrast enhancement &#40;gadolinium&#41; on preoperative MRI&#44; and this corresponded well with the Na-Fl enhancement because a disrupted blood brain barrier plays a role in the effect mechanism of both drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">22</span></a> All meningiomas and dural tails showed strong Na-Fl enhancement intraoperatively&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">21</span></a> The current series contains two cystic meningiomas&#44; which were surgically removed with the use of Na-Fl under a YELLOW 560<span class="elsevierStyleHsp" style=""></span>nm filter&#46; As stated before&#44; Na-Fl was found to be very useful in demonstrating the brain-tumor interface&#44; and it was especially effective in resecting the cyst wall in peritumoral cystic meningiomas&#46; Its effects on solid meningioma surgery require further investigation&#44; but Na-Fl guidance was found to be a useful technical adjunct in cystic meningioma surgery&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">There have been some studies in the literature concerning the pathophysiology of cyst formation since the 1970s&#46; In these studies&#44; it has been shown that the degeneration&#44; hemorrhage&#44; and ischemia in the central region of the tumor lead to cystic formation&#59; peripherally-located cyst formation is generated by the gathering of the xanthochromic fluid in the subarachnoidal space and reactive gliosis&#46; In addition&#44; white matter edema and perfusion deficits may cause demyelination&#44; leading to the formation of cystic cavities&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">6&#44;34</span></a> Thus&#44; cystic meningiomas have a higher risk of intratumoral hemorrhage than solid meningiomas&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;35</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In our study&#44; out of six patients&#44; four of them had intratumoral cyst component &#40;&#37;66&#46;6&#41;&#46; This was not consistent with the recent literature showing that peritumoral cystic meningiomas are more common than intratumoral cystic meningiomas&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">36</span></a> Previous studies have shown that cystic meningiomas tend to be found in the cerebral convexity and parasagittal regions&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">35&#44;37</span></a> In our study two of the six patients had cystic meningiomas in a parasagittal location and two patients&#8217; lesions were located in the cerebral convexity&#46; Even though there are limited number of cases in our study&#44; our results were consistent with the previous literature&#46; The number of cases should be augmented in order to get reliable data regarding this matter&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Nauta et al&#46; described the cyst location associated with meningiomas in four categories&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">4</span></a> We have seen cysts of type 1 in two patients&#59; type 2 in three patients and type 4 in one patient&#46; There is not a certain predominance according to Nauta classification however&#44; previous case reports also show predominance of type 1 and 2 cysts&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">35</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">In our study&#44; we found that all of the mural nodules showed restriction on DWI series on MRI which was consistent with the previous literature&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">38</span></a> MRI of two patients with intratumoral cystic meningiomas revealed contrast-enhanced cyst wall&#46; Because we know that the cyst wall enhancement can be found in intratumoral cystic meningiomas rather than the peritumoral cystic meningiomas&#44; we can claim that these findings are consistent with the recent literature&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">39</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusion</span><p id="par0110" class="elsevierStylePara elsevierViewall">Cystic meningiomas are rare entities within the meningioma group&#46; Because their differential diagnosis includes cystic astrocytomas&#44; hemangioblastomas&#44; neuroblastomas&#44; glial tumors&#44; and metastatic tumors&#44; it is important to note the specific changes in MRI induced by cystic meningiomas&#44; such as the dural tail sign&#46; In the literature&#44; it is somehow controversial that when the tumor is totally resected with the cyst capsule the prognosis is better&#59; however&#44; it is recommended to resect the capsule whenever possible&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a> Na-Fl could be used as a useful adjunct to resect the cyst wall or capsule&#46; Because it is challenging to identify the diagnosis preoperatively because of the nonspecific clinical and radiological features&#44; it is important to include meningiomas in the differential diagnosis of intracranial cystic lesions&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests&#46;</p></span></span>"
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    "fechaAceptado" => "2019-01-14"
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            0 => "Cystic meningiomas"
            1 => "Surgical excision"
            2 => "Sodium fluorescein"
            3 => "YELLOW 560"
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            0 => "Meningiomas qu&#237;sticos"
            1 => "Escisi&#243;n quir&#250;rgica"
            2 => "Fluoresce&#237;na de sodio"
            3 => "AMARILLO 560"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Although meningiomas are the most common primary non-glial intracranial tumors&#44; cystic meningiomas are quite rare&#46; This study presents six cases in order to discuss the radiological and pathological features of cystic meningiomas&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Six patients with cystic meningiomas were included in the study&#46; All patients underwent a cranial computed tomography scan and magnetic resonance imaging &#40;MRI&#41; evaluation&#44; pre- and postoperatively&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All patients presented with long standing headache dating back at least two years&#46; There was no gender predominance in our series&#46; Radiological evaluation revealed two parasagittal and two convexity meningiomas located at the frontal region&#46; Two lesions were located at the tuberculum sellae and the foramen magnum&#46; All of the tumors were totally excised &#40;Simpson Grade I or II&#41;&#46; Pathology results included meningothelial meningioma in three patients&#44; angiomatous meningioma in two patients&#44; and metaplastic meningioma in one patient&#46; In two patients&#44; the cystic meningiomas were resected with the use of sodium fluorescein &#40;Na-Fl&#41; under a YELLOW 560<span class="elsevierStyleHsp" style=""></span>nm microscope filter&#46; Na-Fl was found to be very useful in demonstrating the brain&#8211;tumor interface&#44; and it was especially effective in resecting the cyst wall of the peritumoural cystic meningiomas&#46; None of the patients had any complications&#44; and no recurrences were noted in any of the patients within the mean follow-up period of 51 months &#40;range&#58; 16&#8211;102 months&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">It is important to note MRI changes specific to cystic meningioma and include meningiomas in the differential diagnosis of intracranial cystic lesions&#46; The use of sodium fluorescein &#40;Na-Fl&#41; under a YELLOW 560<span class="elsevierStyleHsp" style=""></span>nm microscope filter is a useful tool to differentiate the brain-tumor interface&#44; as well as to identify the cyst wall in order to fully resect the tumor with the cystic component to avoid recurrence and achieve better clinical results&#46;</p></span>"
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            "titulo" => "Patients and methods"
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            "titulo" => "Results"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Aunque los meningiomas son los tumores intracraneales primarios no gliales m&#225;s frecuentes&#44; los meningiomas qu&#237;sticos son bastante raros&#46; Este estudio presenta 6 casos para discutir las caracter&#237;sticas radiol&#243;gicas y patol&#243;gicas de los meningiomas qu&#237;sticos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 6 pacientes con meningiomas qu&#237;sticos en el estudio&#46; Todos los pacientes se sometieron a una tomograf&#237;a computarizada craneal y a una evaluaci&#243;n por resonancia magn&#233;tica&#44; antes y despu&#233;s de la operaci&#243;n&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Todos los pacientes presentaron dolor de cabeza de larga duraci&#243;n de al menos 2 a&#241;os&#46; No hubo predominio de g&#233;nero&#46; La evaluaci&#243;n radiol&#243;gica revel&#243; 2 meningiomas parasagitales y 2 de la convexidad ubicados en la regi&#243;n frontal&#46; En los otros 2 pacientes las lesiones se ubicaron en el tub&#233;rculo selar y en el foramen magno respectivamente&#46; Todos los tumores fueron totalmente extirpados &#40;grado de Simpson I o II&#41;&#46; En 2 pacientes&#44; los meningiomas qu&#237;sticos se resecaron con el uso de fluoresce&#237;na de sodio bajo un filtro de microscopio AMARILLO de 560<span class="elsevierStyleHsp" style=""></span>nm&#46; Se encontr&#243; que la fluoresce&#237;na de sodio era muy &#250;til para demostrar la interfaz entre el cerebro y el tumor&#44; y fue especialmente eficaz para resecar la pared de los quistes peritumorales&#46; Los resultados de histopatolog&#237;a incluyeron meningioma meningotelial en 3 pacientes&#44; meningioma angiomatoso en 2 y meningioma metapl&#225;sico en uno&#46; Ninguno de los pacientes present&#243; ninguna complicaci&#243;n&#44; y no se observaron recurrencias en ning&#250;n paciente dentro del per&#237;odo de seguimiento medio de 51 meses &#40;rango&#58; 16-102 meses&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Es importante tener en cuenta los cambios en la resonancia magn&#233;tica espec&#237;ficos de los meningiomas qu&#237;sticos e incluir estos tumores en el diagn&#243;stico diferencial de las lesiones qu&#237;sticas intracraneales&#46; El uso de fluoresce&#237;na de sodio bajo un filtro de microscopio AMARILLO de 560<span class="elsevierStyleHsp" style=""></span>nm es una herramienta &#250;til para diferenciar la interfaz cerebro-tumor&#44; as&#237; como para identificar la pared del quiste y resecar completamente el tumor con el componente qu&#237;stico para evitar la recidiva y conseguir mejores resultados cl&#237;nicos&#46;</p></span>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">&#40;A and B&#41; Coronal and axial T1-weighted contrast-enhanced images shows a type 4 cystic meningioma at tuberculum sellae&#46; &#40;C&#41; Coronal T1-weighted contrast-enhanced image shows a type 2 cystic convexity meningioma &#40;according to Nauta Classification<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">6</span></a>&#41;&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; A mass lesion located in the left frontal region can be seen in the T1 FLAIR sequence&#44; causing a midline shift of 16<span class="elsevierStyleHsp" style=""></span>mm on the cranial MRI&#46; In addition to the cystic components&#44; a 8<span class="elsevierStyleHsp" style=""></span>mm hyperintense mural nodule is seen on the contrast-enhanced T1 sequences&#46; &#40;B&#41; Postoperative cranial CT shows total excision of the tumor&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Preoperative cranial MRI of the patient with a left frontal lesion indicates the cystic component of the lesion on the axial view of the T1 contrast enhanced sequence&#46; &#40;B&#41; Preoperative axial view of T1 contrast-enhancing sequence shows the mural nodule of the lesion&#46; &#40;C and D&#41; Postoperative cranial MRI on an axial view of the T1 contrast enhancing sequence shows the resected tumor cavity&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Cranial MRI &#8211; axial view of T1 sequence with contrast enhancement shows a mural nodule near the border of the dura along with the cystic component&#46; &#40;B&#41; Coronal view of the T2 sequence shows the cystic and solid components of the lesion&#46; &#40;C and D&#41; Postoperative contrast enhancing axial and coronal T1 sequences show total excision of the cystic-solid meningioma&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Intraoperative microscopic view of a parasagittal frontal meningioma under normal microscope light&#46; &#40;B&#41; The same meningioma showed diffuse Na-Fl staining under YELLOW 560<span class="elsevierStyleHsp" style=""></span>nm filter&#59; note that both the cyst wall and the solid tumor show Na-Fl enhancement&#46; &#40;C&#41; Following the resection of the solid component and cyst drainage&#44; the cyst walls were excised&#46; Note the Na-Fl enhancing cyst wall within the tip of the aspirator under YELLOW 560<span class="elsevierStyleHsp" style=""></span>nm filter&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age &#40;yrs&#41; &#8211; sex&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Presenting symptoms&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Localization&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MRI findings&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pathology&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">27&#44; F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Headache&#44; visual loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Meningothelial meningioma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#44; M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Headache&#44; vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LF&#40;convexity&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Angiomatous meningioma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#44; M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Headache&#44; seizure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LF&#40;parasagittal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Angiomatous meningioma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#44; M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Headache&#44; seizure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LF&#40;parasagittal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaplastic meningioma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#44; F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Headache&#44; seizure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LF&#40;convexity&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Meningothelial meningioma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#44; F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Headache&#44; vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Meningothelial meningioma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2066179.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">summarizes clinical&#44; radiological and pathological symptoms&#46; TS&#58; tuberculum sella&#44; FM&#58; foramen magnum&#44; LF&#58; left frontal&#44; DT&#58; dural tail seen on MRI&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age &#40;yrs&#41; &#8211; sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pathology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ki-67 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">EMA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CD34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vimentin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">S-100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pan-CK&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mitosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Necrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#44; F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Meningothelial meningioma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#62;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#44; M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Angiomatous meningioma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#44; M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Angiomatous Meningioma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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