Bilateral choroid plexus hyperplasia: a case report and management strategies

Imaging of supratentorial intraventricular masses in children:a pictorial review- part 1

PURPOSE

This article is the first in a two-part series designed to provide a comprehensive overview of the range of supratentorial intraventricular masses observed in children. Our primary objective is to discuss the diverse types of intraventricular masses that originate not only from cells within the choroid plexus but also from other sources.

METHODS

In this article, we review relevant epidemiological data, the current genetics/molecular classification as outlined in the fifth edition of the World Health Organization's Classification of tumours of the Central Nervous System and noteworthy imaging findings. We conduct an exhaustive analysis of primary choroid plexus tumours as well as other conditions such as choroid plexus hyperplasia, choroid plexus cyst, choroid plexus xanthogranuloma, atypical teratoid rhabdoid tumour, meningioma, arteriovenous malformation and metastasis.

RESULTS

We comprehensively evaluated each supratentorial intraventricular mass, providing an in-depth analysis of their unique clinical and histological characteristics. The fifth edition of the World Health Organization Classification of Tumours of the Central Nervous System introduces major modifications. These important changes could potentially have a profound impact on the management strategies and subsequent outcomes of these tumours.

CONCLUSION

Intraventricular masses in children can arise from various sources. Surgical intervention is key for certain supratentorial intraventricular masses in paediatric patients, with preoperative neuroimaging essential to decide the best treatment approach, surgical or otherwise, as some cases may not require surgery.

The association of CSF biomarkers and cognitive decline with choroid plexus volume in early Parkinson's disease

OBJECTIVE

This study aims to determine the link between choroid plexus (CP) volume and cognitive decline in patients with early-stage Parkinson's disease (PD) and to test whether pathological proteins in the cerebrospinal fluid (CSF) are involved in the modulation of any detrimental effects from CP volume.

METHODS

Data on 95 early-stage PD patients with 5 years of follow-up were collected from the Parkinson's Progression Marker Initiative cohort. The patients were separated into three groups based on tertiles of baseline CP volume. We then used a linear mixed model for longitudinal analysis and conducted path analysis to investigate mediating effects.

RESULTS

At baseline, the patients in both the upper and middle tertile group were older and had lower concentrations of CSF Aβ1-42 than those in the lowest tertile group. Longitudinal analysis showed that the upper tertile group suffered from a more rapid cognitive decline in the Symbol Digit Modalities test, Hopkins Verbal Learning Test (HVLT)-retention, and HVLT delayed recalled score. Furthermore, path analysis showed that the pathological effects of CP volume on the 5-year decline in memory might be partly mediated by the CSF Aβ1-42/αsyn ratio.

CONCLUSION

CP enlargement could be an independent risk factor for decreased cognition in patients with early-stage PD, and this risk may be mediated by CSF pathological proteins.

A case report of hydrocephalus due to diffuse villous hyperplasia of the choroid plexus: surgical treatment by combination a flexible videoscope with a rigid endoscope

PURPOSE

Diffuse villous hyperplasia of the choroid plexus (DVHCP) and choroid plexus papilloma (CPP) are rare benign tumors usually diagnosed as a result of progressive hydrocephalus, especially in childhood. We present the case of a Japanese boy diagnosed with progressive hydrocephalus due to DVHCP.

METHODS

Case: A 2-year and 3-month-old Japanese boy was found to have delayed motor development (equivalent to 1 year and 2 months old), an enlarged head circumference of 51 cm within + 1.5 standard deviation (S.D.), and incomplete closure of the anterior fontanel. The magnetic resonance imaging (MRI) showed lobular enlargement of the bilateral choroid plexuses extending from the trigone to the body and inferior horn of the lateral ventricle. The endoscopic choroid plexus coagulation surgery was performed to reduce the CSF formation rate.

RESULTS

DVHCP was diagnosed both pathologically and clinically. Postoperatively, the patient progressed without complications, such as cerebrospinal fluid leakage. Although ventricular enlargement persisted, the anterior fontanel recessed, and the expansion of the head circumference stopped.

CONCLUSION

Few cases of bilateral DVHCP and CPP have been reported in the literature. We encountered a case in which effective choroid plexus coagulation was performed for hydrocephalus due to DVHCP using less invasive endoscopic technique. It also represented an association between DVHCP and the gain of chromosome 9p.

Choroid plexus cauterization to treat inadequate abdominal cerebrospinal fluid absorption: case report

INTRODUCTION

Inadequate absorption of cerebrospinal fluid (CSF) in the setting of high CSF production is a relatively rare cause of shunt malfunction.

CASE REPORT

We present the unique case of a 3-year-old boy who developed sterile ascites and abdominal distension in a delayed fashion after shunt placement. The shunt was externalized, and the patient was noted to have high CSF output. Bilateral choroid plexus cauterization resulted in a significant decrease in CSF production and enabled the shunt to be re-inserted into the abdomen.

Hydrocephalus-Associated Hyponatremia: A Review

Hydrocephalus is the pathological accumulation of cerebrospinal fluid within the ventricles of the brain. Hydrocephalus may be broadly divided into three categories: congenital, acquired, or other. Hyponatremia, serum sodium level <135 meq/ml, may be caused by dilution (e.g. syndrome of inappropriate antidiuretic hormone (SIADH)), depletion (e.g. cerebral salt wasting (CSW)), or delusion (e.g. psychogenic water intake) etiologies. This review discusses “hydrocephalus-associated hyponatremia” as a clinical entity, distinct from SIADH and CSW.

Some experts believe that in hydrocephalus patients, increased pressure on the hypothalamus leads to the release of antidiuretic hormone (ADH), which in turn causes hyponatremia. The true etiology of hyponatremia is critical to diagnose, as it will determine the treatment. So while both SIADH and CSW may result in hyponatremia, the former is treated with fluid restriction, while the latter requires fluid repletion; treating SIADH as CSW, and vice versa, will exacerbate the hyponatremia.

The etiology and severity of hyponatremia will determine the management. For hydrocephalus-associated hyponatremia, treating the underlying problem (i.e. hydrocephalus) is the mainstay of therapy. Theoretically, treatment of hydrocephalus-related hyponatremia with CSF-diversion procedures should relieve the pressure on the hypothalamus, mitigating ADH production, which in turn will decrease sodium excretion and ameliorate the hyponatremia.

Sterile cerebrospinal fluid ascites, hydrothorax and hydrocele as a complication of ventriculoperitoneal shunting in an elderly patient

An 89-year-old man with a history of multiple abdominal surgeries and ventriculoperitoneal (VP) shunt placement for normal pressure hydrocephalus presented for intractable abdominal bloating and scrotal swelling, for which imaging revealed massive ascites, bilateral hydrocele and small bilateral pleural effusions. Cardiac, hepatic and renal workup were insignificant. Culture and cytology of ascitic fluid were negative for infection or malignancy. Aetiology of the ascites as secondary to Cerebrospinal fluid (CSF) from the VP shunt was confirmed via ligation of the shunt. Sterile CSF ascites, hydrothorax and hydrocele are rare complications of VP shunt for hydrocephalus and are mostly presented in paediatric patients. We report the first known case of concurrent CSF ascites, hydrothorax and hydrocele in an elderly patient. We examine the difficulty of shunt replacement as a diagnostic and treatment modality in this age group and propose the use of reversible shunt ligation as a diagnostic modality.

Hydrocephalus in infants: the unique biomechanics and why they matter

OBJECT

Hydrocephalus diagnosed prenatally or in infancy differs substantially from hydrocephalus that develops later in life. The purpose of this review is to explore hydrocephalus that begins before skull closure and full development of the brain. Understanding the unique biomechanics of hydrocephalus beginning very early in life is essential to explain two poorly understood and controversial issues. The first is why is endoscopic third ventriculostomy (ETV) less likely to be successful in premature babies and in infants? The second relates to shunt failure in a subset of older patients treated in infancy leading to life-threatening intracranial pressure without increase in ventricular volume.

METHODS

The review will utilize engineering concepts related to ventricular volume regulation to explain the unique nature of hydrocephalus developing in the fetus and infant. Based on these concepts, their application to the treatment of complex issues of hydrocephalus management, and a review of the literature, it is possible to assess treatment strategies specific to the infant or former infant with hydrocephalus-related issues throughout life.

RESULTS

Based on engineering, all hydrocephalus, except in choroid plexus tumors or hyperplasia, relates to restriction of the flow of cerebrospinal fluid (CSF). Hydrocephalus develops when there is a pressure difference from the ventricles and a space exterior to the brain. When the intracranial volume is fixed due to a mature skull, that difference is between the ventricle and the cortical subarachnoid space. Due to the distensibility of the skull, hydrocephalus in infants may develop due to failure of the terminal absorption of CSF. The discussion of specific surgical treatments based on biomechanical concepts discussed here has not been specifically validated by prospective trials. The rare nature of the issues discussed and the need to follow the patients for decades make this quite difficult. A prospective registry would be helpful in the validation of surgical recommendations.

CONCLUSION

The time of first intervention for treatment of hydrocephalus is an important part of the history. Treatment strategies should be based on the assessment of the roll of trans-mantle pressure differences in deciding treatment strategies. Following skull closure distension of the ventricles at the time of shunt failure requires a pressure differential between the ventricles and the cortical subarachnoid space.

Complex Management of Hydrocephalus Secondary To Choroid Plexus Hyperplasia

BACKGROUND

Hyperplasia of the choroid plexus represents a rare cause of communicating hydrocephalus in children. Recent work has associated such disease with genetic abnormalities (such as perturbations in chromosome 9). Given such extensive cerebrospinal fluid (CSF) overproduction, patients with choroid plexus hyperplasia often fail CSF diversion and therefore require adjuvant interventions.

CASE DESCRIPTION

We present the case of a male infant with a ventriculoperitoneal shunt and radiographic choroid hyperplasia who presented to our institution with a massive abdominal hydrocele caused by an inability to absorb the significant amount of CSF drainage into the abdomen.

CONCLUSION

The child was treated with an endoscopic third ventriculostomy and choroid plexus coagulation; however, he still required CSF diversion via a ventriculoatrial shunt. A genetic workup showed tetraploidy of chromosome 9. We discuss criteria for selection of treatment strategies, including endoscopic third ventriculostomy with choroid plexus coagulation and/or CSF diversion, that may prevent the need for re-operation in select patients with hydrocephalus due to choroid plexus hyperplasia.

Perinatal (fetal and neonatal) choroid plexus tumors: a review

INTRODUCTION

The object of this review is to describe the choroid plexus tumors (CPTs) occurring in the fetus and neonate with regard to clinical presentation, location, pathology, treatment, and outcome.

MATERIALS AND METHODS

Case histories and clinical outcomes were reviewed from 93 cases of fetal and neonatal tumors obtained from the literature and our own institutional experience from 1980 to 2016.

RESULTS

Choroid plexus papilloma (CPP) is the most common tumor followed by choroid plexus carcinoma (CPC) and atypical choroid plexus papilloma (ACPP). Hydrocephalus and macrocephaly are the presenting features for all three tumors. The lateral ventricles are the main site of tumor origin followed by the third and fourth ventricles, respectively. CPTs of the fetus are detected most often near the end of the third trimester of pregnancy by fetal ultrasound. The extent of surgical resection plays an important role in the treatment and outcome. In spite of excellent survival, which is especially true in the case of CPP, surgical resection may carry significant risks in an immature baby. Given the neonatal low blood volume and increased vascularity of the tumors, there is potential risk for hemorrhage. Although advances in neurosurgical techniques have led to a greater degree of complete surgical resections, survival for the perinatal CPC group remains low even with multimodality therapies.

CONCLUSION

Perinatal CPTs have variable overall survivals depending on degree of surgical resection and tumor biology. An increased understanding of the molecular features of these tumors may lead to improved therapies and ultimately survival.

Choroidal artery embolization in the management of cerebrospinal fluid overproduction: case report and review of the literature

Diffuse villous hyperplasia of the choroid plexus (DVHCP) is a rare cause of communicating hydrocephalus. DVHCP may be diagnosed radiographically and through histological evaluation. It may be associated with genetic abnormalities, particularly involving chromosome 9. Due to CSF overproduction, patients with DVHCP often fail management with shunting alone and may require adjuvant interventions. The authors present the case of a child with partial trisomy 9p and delayed diagnosis of hydrocephalus with radiographic evidence of DVHCP who was successfully managed with ventriculoperitoneal shunt (VPS) placement, adjuvant bilateral endoscopic choroid plexus coagulation (CPC), and the novel application of anterior choroidal artery embolization. In addition, a systematic MEDLINE search was conducted using the keywords "diffuse villous hyperplasia," "choroid plexus hypertrophy," and "idiopathic cerebrospinal fluid overproduction." Clinicopathological characteristics and outcomes of the present case were reviewed and compared to those in the literature.A 14-month-old girl with partial trisomy 9p presented with macrocephaly and radiographic evidence of communicating hydrocephalus and DVHCP. Ventriculoperitoneal shunting resulted in distal failure due to inadequate CSF absorption, and ventriculoatrial shunt (VAS) placement was not possible due to multiple cardiac anomalies. Daily CSF production was reduced via endoscopic third ventriculostomy and bilateral CPC, followed by distal choroidal artery embolization, enabling VPS re-internalization. The embolization was complicated by radiographic evidence of an iatrogenic cerebral infarct, but this was clinically occult. Thirty-two additional cases of communicating hydrocephalus due to DVHCP are reported in the literature: 27 pediatric, 3 adult, and 2 postmortem. Genetic abnormalities were noted in 14, with 7 (50%) involving chromosome 9. Twelve patients underwent plexectomy (9 bilateral, 2 unilateral, 1 partial), and 10 underwent CPC (4 bilateral, 3 unilateral, and 3 unspecified), with or without shunting. Eight patients were successfully managed with shunting alone (6 VASs, 2 VPSs), and none underwent arterial embolization.DVHCP is a rare cause of communicating hydrocephalus that may be associated with genetic abnormalities. A thorough review of the literature highlights diagnostic criteria and interventional options involved in managing this cause of CSF overproduction. The present case demonstrates that angiographic confirmation of prominent choroidal arteries may contribute to the diagnosis DVHCP. In addition, embolization of the distal choroidal arteries may be considered as a potential adjuvant treatment in patients for whom conventional treatments have failed or are not feasible.

Benign Postnatal Outcome after Prenatal Diagnosis of Fetal Ventriculomegaly with Choroid Plexus Hyperplasia: A Case Report

Prenatal counselling following the diagnosis of fetal ventriculomegaly is challenging. Fetal MRI (magnetic resonance imaging) can be helpful in characterizing ventriculomegaly severity and associated anomalies, hence contributing to prognosis establishment. Choroid plexus hyperplasia (CPH) is a rare entity characterized by enlargement of the choroid plexuses, usually progressing to severe hydrocephalus with an associated poor outcome. We present a case of CPH diagnosed by fetal MRI at 23 weeks of gestation following referral for ventriculomegaly. The pregnancy was carried to term and the child was monitored clinically and radiologically. Despite the persistence of enlarged choroid plexuses, the ventricular size has progressively decreased, and at the 4-year follow-up the child presented normal psychomotor development. This case highlights the added value of MRI in prenatal diagnosis of fetal ventriculomegaly and its management. The unusual benign outcome in this case can be considered for parental counselling when faced with a fetus with similar findings.

9p24 triplication in syndromic hydrocephalus with diffuse villous hyperplasia of the choroid plexus

Hydrocephalus, a disorder of impaired cerebrospinal fluid (CSF) homeostasis, often results from an imbalance between CSF production and reabsorption. Rarely, hydrocephalus is the consequence of CSF hypersecretion in the context of diffuse villous hyperplasia of the choroid plexus (DVHCP). The limited genetic information in previously reported cases suggests a high prevalence of gains of Chromosome 9p in this disease, although the critical genes involved in DVHCP pathogenesis have not been identified. Here, we report a patient with syndromic hydrocephalus with DVHCP associated with a novel 9p24.3-11.2 triplication and 15q13.2-q13.3 microdeletion. We review the clinical, radiological, and pathological features of DVHCP, as well as its surgical management. A better understanding of the genetic basis of DVHCP could spur the development of rational, targeted nonsurgical hydrocephalus treatments.

Choroid Plexus Hyperplasia with Intractable Ascites and a Resulting Communicating Hydrocele following Shunt Operation for Hydrocephalus

Choroid plexus hyperplasia/papilloma and resulting hyperproduction of cerebrospinal fluid is a rare cause of hydrocephalus. In these patients, intractable ascites can occur after a ventriculoperitoneal (VP) shunting operation. However, shunt-related hydrocele is a rare complication of VP shunting. Previous reports have indicated catheter-tip migration to the scrotum as a cause of hydrocele. Here, we present the first documented case of choroid plexus hyperplasia that led to intractable ascites after shunting and a resulting hydrocele without catheter-tip migration into the scrotum.

Cerebrospinal fluid hypersecretion in pediatric hydrocephalus

Hydrocephalus, despite its heterogeneous causes, is ultimately a disease of disordered CSF homeostasis that results in pathological expansion of the cerebral ventricles. Our current understanding of the pathophysiology of hydrocephalus is inadequate but evolving. Over this past century, the majority of hydrocephalus cases has been explained by functional or anatomical obstructions to bulk CSF flow. More recently, hydrodynamic models of hydrocephalus have emphasized the role of abnormal intracranial pulsations in disease pathogenesis. Here, the authors review the molecular mechanisms of CSF secretion by the choroid plexus epithelium, the most efficient and actively secreting epithelium in the human body, and provide experimental and clinical evidence for the role of increased CSF production in hydrocephalus. Although the choroid plexus epithelium might have only an indirect influence on the pathogenesis of many types of pediatric hydrocephalus, the ability to modify CSF secretion with drugs newer than acetazolamide or furosemide would be an invaluable component of future therapies to alleviate permanent shunt dependence. Investigation into the human genetics of developmental hydrocephalus and choroid plexus hyperplasia, and the molecular physiology of the ion channels and transporters responsible for CSF secretion, might yield novel targets that could be exploited for pharmacotherapeutic intervention.

Choroid plexus coagulation for hydrocephalus not due to CSF overproduction: a review

OBJECTIVE

This study aims to review the role of choroid plexus coagulation (CPC) for hydrocephalus not due to CSF overproduction.

METHODS

The literatures covering CPC/cauterization/extirpation and ablation searched through PubMed were reviewed.

RESULTS

The history of CPC goes back to early 1900s by open surgery. It has evolved to mainly an endoscopic surgery since 1930s. With the development of other treatment methods and the understanding of CSF dynamics, the application of CPC dramatically decreased by 1970s. In late 2000, there was a resurgence of CPC in combination with endoscopic third ventriculostomy (ETV) performed in Africa.

CONCLUSIONS

CPC remains one of the options for the treatment of hydrocephalus in selected cases. CPC might provide a temporary reduction in CSF production to allow the further development of CSF absorption in infant. Adding CPC to ETV for infants with communicating hydrocephalus may increase the shunt independent rate thus avoiding the consequence of late complication related to the shunt device. This is important for patients who are difficult to be followed up, due to geographical and/or socioeconomic constrains. Adding CPC to ETV for obstructive hydrocephalus in infant may also increase the successful rate. Furthermore, CPC may be an option for cases with high chance of shunt complication such as hydranencephaly. In addition, CPC may act as an adjunct therapeutic measure for complex cases such as multiloculated hydrocephalus. In comparison with the traditional treatment of CSF shunting, the role of CPC needs to be further evaluated in particular concerning the neurocognitive development.

Endoscopic coagulation of choroid plexus hyperplasia

Hydrocephalus is a clinical disorder resulting from an imbalance between the production of CSF and its resorption, of which the latter is mostly a disadvantage. In rare cases of choroid plexus papilloma or carcinoma, hydrocephalus is due to an overproduction of CSF. Choroid plexus hyperplasia (CPH) is a distinct clinicopathological entity in which the enlarged choroid plexus produces large amounts of CSF. Historically, patients with CPH were treated by shunt procedures or by microsurgical removal of the choroid plexus, which is associated with a high complication rate. In this paper the authors show that endoscopic plexus coagulation can result in restoring the equilibrium of the intracranial fluid volumes, resulting in shunt independency. In this way, both the shunt-related complications and the bleeding risks of microsurgical plexectomy are avoided. In instances of hydrocephalus, thorough efforts should be made to demonstrate the underlying pathophysiology to choose the optimal treatment, of which shunt procedures should receive the least priority.

Diffuse villous hyperplasia of the choroid plexus and its surgical management

Diffuse villous hyperplasia of the choroid plexus (DVHCP) is a very rare cause of hydrocephalus in children. Only 12 cases of DVHCP have been reported in the literature. In this report the authors describe a new case of a patient with DVHCP who was diagnosed prenatally with hydrocephalus. In a comprehensive literature review and discussion, the authors also discuss radiological and histological characteristics of the reported cases, treatment approaches, and surgical modalities that have been used in the treatment of these patients.