Lateral ventricle tumors in children: a series of 54 cases

Cylinder tumor surgery in pediatric low-grade gliomas

BACKGROUND

Periventricular pediatric low-grade gliomas (pLGG) present a surgical challenge due to their deep-seated location, accessibility, and relationship with the subcortical network connections. Minimally invasive parafascicular approaches with tubular brain retractors (port brain surgery) have emerged, in recent years, as an alternative to conventional microsurgical and endoscopic approaches for removal of periventricular tumors.

OBJECTIVES

To describe the minimally invasive approach with tubular brain retractors for periventricular pLGG, its technique, applications, safety, and efficacy.

METHODS

In this article, we describe the port brain surgery techniques for periventricular pLGG as performed in different centers, with different commercialized tubular retractor systems. Illustrative cases followed by a literature review are analyzed, with a detailed description of different approaches or techniques, comparing their advantages and disadvantages with contemporary microsurgical and endoscopic approaches.

CONCLUSIONS

The port brain surgery with micro-exoscopic vision and endoscopic assistance, for the treatment of deep-seated lesions such as periventricular pLGG, is an alternative for achieving a functionally safe-gross total or subtotal-tumor resection, obtaining adequate tissue for pathological examination. This technique could offer a new dimension for a less-invasive, safe, and effective access to deep-seated tumors, offering the possibility to lower morbidity in experienced hands.

Comparative Analysis of Supratentorial Intraventricular Tumors in Adults and Pediatrics in a Developing Country: Clinicopathological Features, Surgical Management, and Outcomes

BACKGROUND

 Supratentorial intraventricular tumors, encompassing lateral and third ventricular tumors, are uncommon intracranial neoplasms, typically slow-growing and benign, manifesting symptoms only upon reaching a substantial size. This study aims to identify optimal surgical approaches, assess the prevalence and characteristics of these tumors, and evaluate postoperative outcomes among pediatric and adult age groups.

METHODS

 A retrospective comparative study at a tertiary care hospital from January 2014 to June 2020 included 165 patients (68 pediatrics, 97 adults) meeting inclusion criteria for intraventricular tumor management. Data covered demographic factors, clinical history, neurological assessments, neuroimaging, surgical approaches, histopathological diagnoses, immunohistochemical features, adjuvant therapies, follow-up status, postoperative complications, and morbidity/mortality.

RESULTS

 Ventricular tumor incidence showed male preponderance in both adults (M:F = 1.2:1) and pediatrics (M:F = 3:1). Lateral ventricles were the most common location. Pediatric cases exhibited more frequent calcifications on computed tomography scans (35.6% vs. 29.5%). Grade II and III tumors were more prevalent in adults within the lateral ventricle (27.1 and 1.9%) compared with pediatrics (6.5 and 8.4%). The third ventricle predominantly featured benign lesions, with pediatric patients experiencing significantly longer hospital stays (16.12 ± 21.94 days vs. 9.58 ± 6.21 days) (p = 0.006). Adults and pediatric patients showed a significant difference in high-grade lateral ventricle tumors (p-value = 0.002*).

CONCLUSIONS

 Supratentorial ventricular tumors are relatively more prevalent in children than adults, presenting challenges due to size and bleeding risks. Surgical resection is the primary treatment, with a focus on the optimal approach for gross total excision to reduce recurrence risk.

Pediatric primary intraventricular hemorrhage: A case report of isolated fourth ventricle hemorrhage in a 10-year-old boy

Key Clinical Message

Primary intraventricular hemorrhage (PIVH) is a rare condition in pediatric patients, presenting with headache, vomiting, and altered mental status. Surgical interventions, such as external ventricular drain placement, followed by ventriculoperitoneal shunting, show promising outcomes. Further research is needed to enhance understanding and optimize management strategies for pediatric PIVH.

Abstract

This case report describes a 10-year-old boy with isolated primary intraventricular hemorrhage (PIVH) in the fourth ventricle, shedding light on its clinical presentation and management challenges. The patient presented with headache, vomiting, and altered sensorium, and was subsequently diagnosed with obstructive hydrocephalus due to intraventricular bleeding. Emergency external ventricular drain (EVD) insertion was performed, followed by ventriculoperitoneal shunt placement, resulting in a favorable outcome. The etiology of PIVH in children differs from that in adults, with arteriovenous malformations, Moyamoya disease, and aneurysms being commonly implicated causes. Management strategies for pediatric PIVH are challenging due to limited research, but EVD placement and surgical interventions have shown promise.

Transcortical approaches to large intraventricular tumors: a prospective case series of 20 patients

Background

Large intraventricular tumors (IVTs) impose technical and surgical challenges, due to their enormous sizes, mass effect, vast extensions, and vascularity.

Objective

The authors aim at presenting their results, clinical outcomes, and the surgical strategies in the management of large IVTs through transcortical approaches.

Methods

A prospective trial was conducted at the Main Hospital of Alexandria University, Egypt, between August 2018 and October 2020 on 20 patients harboring IVTs larger than 5 cm or bilaterally represented. The variables evaluated included the extent of resection, postoperative neurological deficits, blood loss, surgical approaches, intraoperative challenges, complications, adjuvant therapies, Glasgow Outcome Scale, hydrocephalus, and cerebrospinal fluid (CSF) diversion.

Results

The study included 20 cases (9 males and 11 females). Mean age at diagnosis was 16.1 years (range 1–45). Mean follow-up was 12 months (range 9–26). Primary tumor locations were ventricular body, atrium, temporal horn, and frontal horn in 11, 5, 3, and 1 cases, respectively. Main pathologies were central neurocytomas (7 patients/35%), ependymomas (3 patients/15%), and subependymal giant cell astrocytoma (SEGA) (3 patients/15%). Excision was gross total (n = 19) and near-total (n = 1). Significant intraoperative bleeding (n = 6). Postoperative minor intraventricular hemorrhage (n = 6), subdural collections (n = 8), hydrocephalus (n = 9), memory affection (n = 4), and motor deficits (n = 4). Postoperative Glasgow Outcome Scale of 5/5 (n = 20), no mortalities were recorded. preoperative seizures (n = 7), new onset postoperative seizures (n = 2).

Conclusion

Surgical approaches to large tumors of the lateral ventricles should be tailored to the variability of tumor locations, dimensions, extensions, and the individual morbid anatomy, in addition to the surgeon’s experience and preferences. Trans-cortical approaches can provide safe surgical corridors to tackle these challenging subtypes of IVTs with good clinical outcomes, tumor resectability rates, and seizure control.

Presenting Psychiatric and Neurological Symptoms and Signs of Brain Tumors before Diagnosis: A Systematic Review

Brain tumors can present with various psychiatric symptoms, with or without neurological symptoms, an aspect that complicates the clinical picture. However, no systematic description of symptoms that should prompt a neurological investigation has been provided. This review aims to summarize available case reports describing patients with brain tumors showing psychiatric symptoms before brain tumor diagnosis, in order to provide a comprehensive description of these symptoms as well as their potential relationship with delay in the diagnosis. A systematic literature review on case reports of brain tumors and psychiatric symptoms from 1970 to 2020 was conducted on PubMed, Ovid, Psych Info, and MEDLINE. Exclusion criteria comprised tumors not included in the World Health Organization (WHO) Classification 4th edition and cases in which psychiatric symptoms were absent or followed the diagnosis. A total of 165 case reports were analyzed. In a subset of patients with brain tumors, psychiatric symptoms can be the only manifestation or precede focal neurological signs by months or even years. The appearance of focal or generalized neurological symptoms after, rather than along with, psychiatric symptoms was associated with a significant delay in the diagnosis in adults. A timely assessment of psychiatric symptoms might help to improve early diagnosis of brain tumors.

From first symptoms to diagnosis: Initial clinical presentation of primary brain tumors

Background:

Despite modern imaging methods, a long symptom-to-diagnosis interval can be observed in patients with primary brain tumors.

Objective:

The study evaluated the initial and subsequent clinical presentation of patients with brain tumors in the context of time to diagnosis, localization, histology, and tumor grading.

Methods:

In this retrospective analysis of 85 consecutive patients with primary brain tumors, we assessed the presenting symptoms and signs. The analyses were based on entries from medical records at the Department of Neurology of Zurich University Hospital between 2005 and 2010.

Results:

A total of 54 men and 31 women with a mean age at diagnosis of 48 years were included. 60% of the patients present with a malignant tumor (World Health Organization grading III–IV), 24.7% with a benign tumor (I–II), and 15.3% were not classified. The interval between symptom onset and diagnosis varied from 1 day to 96 months (median: 39 days). High-grade tumors (III–IV) were diagnosed significantly earlier than low-grade tumors (II) after the first symptoms occurred (median: 26 vs. 138 days; z = −3.847, p < 0.001).

Conclusions:

Symptoms with a short symptom-to-diagnosis interval such as nausea/vomiting, seizures, as well as of personality change are assumed to contribute to a faster diagnosis in high-grade tumors. Visual disturbances and headaches, although occurring relatively seldom, did not contribute to a decrease in time to diagnosis and should therefore be considered for further diagnostic workup.

Tumors of the lateral and third ventricle: surgical management and outcome analysis in 42 cases

Objectives:

To discuss the clinical presentation, pathological diagnosis, and surgical outcome for a series of 42 consecutive patients treated for lateral and third ventricular tumors.

Methods:

This is a retrospective series study conducted between 2001 and 2015 and included 42 patients (mean age: 25 years; range: 2 months-65 years) with lateral and third ventricle tumors surgically treated at King Khaled University Hospital, Riyadh, Kingdom of Saudi Arabia. Demographic, clinical, radiological, surgical, histopathological, and follow up data were analyzed.

Results:

The most common symptoms at presentation included headache (69%), nausea/vomiting (38%), visual deficits (24%), and seizures (17%). Lesions were located in the lateral ventricle in 15 patients, third ventricle in 20 patients, and involved both the lateral and third ventricles in 7 patients. The most common tumor types in the overall cohort were colloid cysts (n=6) and pineal tumors (n=6). The postoperative complication rate was 36%. The most common postoperative complications were seizure and hydrocephalus (n=5 each, 12%). Surgical mortality was 5%.

Conclusion:

The selection of the surgical approach for intraventricular tumor resection is fundamentally dependent on the surgeon’s experience and preference. We recommend that this decision be based on the anatomic considerations that provide the best and safest access to the mass, rather than on the risk of seizure following transcortical approach.

Reliability of Imaging-Based Diagnosis of Lateral Ventricular Masses in Children

OBJECTIVE

We studied the accuracy of the radiologic diagnosis of lateral ventricular masses in children (<20 years of age).

METHODS

In this retrospective study, data were collected from children with lateral ventricular masses managed in our unit between 2001 and 2016. There were 43 patients (26 boys and 17 girls; mean age, 12.1 years; range, 8 months to 20 years). Magnetic resonance imaging was available for 36 patients, whereas in 7 patients only a contrast-enhanced computed tomography scan was available. The images were read independently by 3 radiologists, who were blinded to the pathology. Two differential diagnoses were offered for each patient. The agreement between the 3 radiologists was calculated using the Fleiss κ statistic.

RESULTS

The common pathologic diagnoses were subependymal giant cell astrocytoma (SEGA) (20.9%), low-grade astrocytoma (16.3%), high-grade astrocytoma (9.3%), choroid plexus papilloma (9.3%), and meningioma (9.3%). The sensitivity, specificity, and accuracy of the radiologic diagnoses were 62%, 96.7%, and 94.2%, respectively. Low-grade tumors such as low-grade gliomas, SEGAs, choroid plexus papillomas, and meningiomas were diagnosed with a high level of accuracy. High-grade gliomas, choroid plexus carcinomas, and other malignant neoplasms were difficult to diagnose on imaging. Cavernous angiomas were also difficult to diagnose. There was only fair agreement between the 3 radiologists (Fleiss κ = 0.24).

CONCLUSIONS

The pathologic spectrum of lateral ventricular tumors in children is wide, and identifying the pathology on imaging is difficult for malignant tumors. Benign tumors such as SEGAs, low-grade astrocytomas, and choroid plexus papillomas are relatively easier to diagnose. There is significant interobserver variability in the radiologic diagnosis of these tumors.

Delays in diagnosis for children with newly diagnosed central nervous system tumors

Background

United States studies documenting time interval from symptom onset to definitive diagnosis for childhood central nervous system (CNS) tumors are more than a quarter-century old. The purpose of this study is to establish an accurate and contemporary Ohio baseline of the diagnostic interval for children with newly diagnosed CNS tumors.

Methods

Medical records were retrospectively reviewed for 301 children with newly diagnosed CNS tumors from January 2004 to August 2015 at Nationwide Children's Hospital. We obtained comprehensive data on 171 patients (56.8%). Records were reviewed for age, gender, tumor type, presenting symptoms, number of health care visits prior to diagnosis, time interval (in months) from onset of symptoms to definitive diagnosis, and any associated genetic syndromes.

Results

Of the 171 patients with newly diagnosed CNS tumors, 25 children (14.6%) had a known cancer predisposition syndrome (all with neurofibromatosis type 1). Among the remaining 146 children, the median and mean time intervals from symptom onset to definitive diagnosis were 42 days and 138 days (range < 1 to 2190 days), respectively.

Conclusions

We have documented and quantified the contemporary delays in diagnosis of childhood brain tumors in central Ohio to serve as a benchmark for our future planned interventions to reduce the time interval from symptom onset to diagnosis through adaptation of the United Kingdom HeadSmart program throughout the state of Ohio and ultimately throughout the United States.

Pilocytic astrocytoma: A rare presentation as intraventricular tumor

Background:

Pilocytic astrocytoma (PA) is the most prevalent central nervous system (CNS) tumor in pediatric population and accounts for an approximate of 5–6% of all gliomas. This neoplasm can occur at all levels of the neuraxis, with majority (67%) arising in the cerebellum and optic pathway. PAs are World Health Organization Grade I tumors and are the most benign of all astrocytomas characterized by an excellent prognosis. Other differentials include subependymal giant cell astrocytoma (SEGA), ependymoma, meningioma, and low-grade gliomas such as pilocytic or diffuse astrocytoma; calcification is more commonly regarded as a feature of benign or slow-growing tumors.

Case Description:

We present a case of a 17-year-old female presenting with an unusual cause of hydrocephalus, a rare case of a calcified pilocytic astrocytoma as an intraventricular tumor.

Conclusion:

PA rarely presents as an intraventricular tumor and should be included in the differential diagnosis of a large mass with massive intratumoral calcification.

Choroid Plexus Tumors: Experience of 10 Cases with Special References to Adult Cases

Choroid plexus tumors (CPTs) are rare intraventricular neoplasms accounting for about 0.3–0.6% of all intracranial tumors. This retrospective study on CPTs presents clinico-pathological features and management strategies based on a 20-year single-institutional experience. This series included 10 consecutive patients with pathologically proven CPTs; 5 choroid plexus papillomas (CPPs), 3 atypical CPPs (ACPPs), and 2 choroid plexus carcinomas (CPCs). Their clinical, radiological, and histopathological features as well as management including follow-up studies were reviewed. The patients included five males and five females, aging from 0 years to 61 years with median of 28 years. The affected site was lateral ventricle in two adults and fourth ventricle in eight patients; four children and four adults. The most common symptoms were gait disturbance and memory disturbance. All the patients underwent craniotomy with total, subtotal, and partial removals achieved in 50%, 40%, and 10% of the patients, respectively. The occurrence of the high grade subtypes was 50% in both the adult and pediatric groups. The Ki-67/MIB-1 index increased across the three histological subtypes, from CPP to ACPP and then to CPC. Adjuvant therapy was administered in three patients. The two patients (one adult and one child) with CPC died of whole central nervous system dissemination. At a median of 62-month follow-up, the other eight patients were alive, with only one patient having recurrence and reoperation. The results demonstrate that gross total resection is usually curative for CPP and ACPP, and adjuvant chemoradiotherapy would be required for CPC and incompletely resected ACPP.

The gut or the brain?--Gastrointestinal misdiagnoses of infantile brain tumors

PURPOSE

Central nervous system tumors account for the largest number of cancer deaths in childhood. Brain tumors in infants less than 3 years of age are rare; symptoms and signs are often non-specific. Patent anterior fontanelles/unfused cranial sutures in infants can accommodate rising intracranial pressure without acutely compromising the neurological status. We hypothesize that vomiting as the initial symptom, in infants with brain tumors, can possibly lead to extensive gastrointestinal evaluation, delaying the diagnosis of intracranial pathology.

METHODS

We conducted a retrospective chart review of infants less than 3 years of age diagnosed with brain tumors over the period of 4.7 years from February 2008 to October 2012 at Inova Children's Hospital, Virginia.

RESULTS

We identified three of 21 patients (14.3 %) who presented with vomiting and underwent initial or extensive abdominal imaging investigations. All patients were relatively young (median age, 5.4 months). Working diagnoses were pyloric stenosis, viral gastritis, or gastroesophageal reflux. All patients eventually had computed tomography of the head to rule out increased intracranial pressure and were found to have large brain tumors with obstructive hydrocephalus. Tumor locations were cerebral hemispheres (2/3) and posterior fossa (1/3). All patients had biologically aggressive high-grade tumors (glioblastoma multiforme, atypical teratoid rhabdoid tumor, and anaplastic/large cell medulloblastoma) and died within weeks of diagnosis.

CONCLUSIONS

Our study highlights a clinical challenge of persistent vomiting in infants, which in the absence of convincing gastrointestinal pathology after evaluation should raise the physician's suspicion of an underlying intracranial pathology even if neurological features are absent.

Neuroendoscopic surgery in empty ventricular system under continuous gas infusion experimental study of pressure changes and complications

INTRODUCTION

The most important limitations to endoscopic procedures in the ventricular system of the brain are due to the constraint of working inside a fluid. The evacuation of cerebrospinal fluid (CSF) from the ventricles is performed often in microsurgical interventions using a surgical microscope. This study aimed at studying the evacuation of CSF during neuroendoscopic surgery in animals while infusing gas to avoid ventricular collapse.

MATERIALS AND METHODS

Hydrocephalus was provoked in five adult New Zealand rabbits by intracisternal injection of kaolin. Endoscopic intervention was performed later; fluid was given as a continuous infusion at constant speed into the CSF for 3 min. In the next stage, CSF was evacuated from the ventricles, which were infused with gas at a stable rate for the same amount of time. The intracranial pressure (ICP) of the rabbits was recorded during both operations. The animals were sacrificed and the brain subjected to pathology examination at the end of the experiment.

RESULTS

Mean ICP value in the rabbit ventricle was 19.1 while working in CSF and 17.6 when working in air. The difference by a paired test was statistically significant for each individual rabbit except one. The ICP measurement, however, was never lower than the ambient pressure, even while working in continuous gas infusion. No epidural or subdural hematomas were found at autopsy.

CONCLUSIONS

Endoscopic surgery is feasible in a ventricular system that has been insufflated with gas after CSF has been evacuated. During the experiment, however, steadily diminishing ICP values were measured. As a result, new devices, such as small-flow insufflators able to perform sensitive pressure adjustments are needed.

[Subependymomas of lateral ventricle. Analysis of our series and review of literature]

Subependymoma is a benign lesion, slow-growing neoplasm, representing 0.2 to 0.7 % of intracranial tumors. They are often clinically silent, incidentally discovered at autopsy. These symptoms are related to big volume. They are attached to the septum pellucidum, leading to hydrocephalus by Monro foramen obstruction. Overall mean age at diagnosis is 39 years with more males than females. At CT-scan, subependymoma shows a slightly low attenuation compared to gray matter. There is no or mild enhancement following contrast injection. On MR T1-weighted imaging, subependymoma is isointense and hyperintense on MR T2-weighted imaging. Intramural calcifications and cystic components are noted in 20 to 30 % of patients. Peritumoral oedema is absent. Immunohistochemicals studies show intense positivity for S-100 and GFAP. The treatment is surgical with an excellent prognosis.

[Surgical anatomy of the lateral ventricles]

The lateral ventricle is a deep-seated cavity, overlayed by a cortical mantle which contains eloquent areas, especially on the dominant hemisphere, and surrounded by the optic radiations. The surgical approach requires a thorough preoperative reflexion based on magnetic resonance imaging, in order to understand the site of origin and the vascular pedicles of the tumor. Surgical approaches to the frontal horn, temporal horn and atrium are successively described.

[Tumors of the lateral ventricle in child: characteristics and specificities]

Tumors of the lateral ventricle are not as rare in children as in adults and present complex problems which are to be dealt with often in a context of emergency, on account of their large size and the risk of life-threatening bleeding in a small child. Their diagnostic features are different in children, especially in infants and even more so in the fetus. The main surgical problems are the risk of bleeding and of hydraulic complications. From an oncological perspective, the main tumor types are choroid plexus tumors, subependymal giant-cell astrocytoma, and low-grade gliomas. The developmental outcome of these patients is often poor, on account of severe intracranial hypertension and young age at diagnosis.

[Meningiomas of the lateral ventricle. A series of 40 cases with analysis of the literature]

This series reports 40 cases of meningiomas of the lateral ventricle treated in France between 1995 and 2010. The mean age was 52 years. The revelation was incidental in 23% of cases. 36 patients underwent surgery with uneventful postoperative course in 75% of them. Visual field deficits were the most frequent sequelae. In six cases, recurrences occurred during the follow-up period. The relevant series of the literature were discussed in order to precise the therapeutic strategies and the outcome.

Dynamic susceptibility contrast-enhanced MRI evaluation of cerebral intraventricular tumors: preliminary results

INTRODUCTION

The aims of the present study were to determine the perfusion characteristics of several types of intraventricular tumors and to evaluate the usefulness of dynamic contrast-enhanced MRI in making the differential diagnosis.

METHODS

A total of 28 patients with intraventricular tumors (five meningiomas, five papillomas, three ependymomas, four subependymomas, seven central neurocytomas, two subependymal giant cell astrocytomas and two metastases) underwent conventional and dynamic susceptibility contrast-enhanced MRI. Cerebral blood volume (CBV) maps were obtained and the relative CBV (rCBV) calculated for each tumor. Mean rCBV(max) values were compared across the different types of tumors (ANOVA, P=0.05).

RESULTS

Intraventricular tumors presented with three different patterns of vascularization: highly vascularized tumors (mean rCBV(max)>3), including papillomas, meningiomas and renal carcinoma metastases; poorly vascularized tumors (mean rCBV(max)<2), including ependymomas and subependymomas; and intermediately vascularized tumors (mean rCBV(max)>2 but<3), including central neurocytomas and lung metastases. There was a significant difference between the highly vascularized (papillomas, meningiomas) and poorly vascularized (subependymomas) tumors. In cases of suspected meningioma, papilloma or neurocytoma, low rCBV values (<3) point to a diagnosis of neurocytoma rather than either of the other tumor types.

CONCLUSION

Susceptibility contrast-enhanced MRI can provide additional information on the vascularization of intraventricular cerebral tumors and may help in making the differential diagnosis.

Intraventricular glioblastoma multiforme: a pediatric case report

Glioblastoma multiforme (GBM) is the most common lethal primary central nervous system tumor in adults. GBM is rarely seen in childhood and adolescence as primary intraventricular tumors. Few cases of solitary intraventricular GBM in adolescence have been reported to date. We report a 16-year-old boy with progressive disorientation, diffuse headache, vomiting, and increased intracranial pressure. Computed tomography and magnetic resonance imaging confirmed that the tumor filled posterior body and occipital horn of the left lateral ventricle and also invaded the surrounding parenchyma. Incomplete removal of the lesion was achieved and a pathologic diagnosis of GBM was carried out. We present a case with an uncommon subtype of glial tumor (GBM) in childhood located in a very rare site. The clinical course, radiologic findings, and possible treatment regimens are reviewed.

Diagnosis of childhood astrocytomas

BACKGROUND

Astrocytomas are the most common brain tumours, accounting for 28 - 50% of all primary CNS tumours. Diagnosis of CNS tumours remains difficult because the varied and nonspecific presentations of CNS tumours in childhood. Objectives/method: The clinical presentations of CNS astrocytomas vary with their sites of location; therefore, a period of uncertainty often precedes diagnosis, and approximately 42% of patients with an intracranial process make several visits to various physicians between the onset and diagnosis. However, on clinical suspicion of a brain tumour, a wide range of neuroimaging techniques may be used to assess the diagnosis of paediatric brain lesions. In this review the authors, for ease of presentation, describe the clinical presentations of supratentorial, infratentorial and spinal cord astrocytomas as well as their radiological and pathological features, and discuss their differential diagnoses.

RESULTS/CONCLUSIONS

Understanding and mastering the numerous imaging features of several subtypes of primary brain tumours affecting children, in addition to radiological features of non-tumoural disorders, remains a significant challenge and demands increased awareness of the paediatric brain diseases.

Forniceal glioma in children. Clinical article

OBJECT

Five to ten percent of pediatric brain tumors are located in the ventricles. Among them, forniceal lesions are rare and their management has not often been described. The aim of this study was to review the clinical, radiological, and histopathological features as well as the feasibility of surgical excision and the outcomes in these patients.

METHODS

From a retrospective analysis of 250 cases of supratentorial pediatric glioma, the records of 8 children presenting with forniceal lesions were selected and reviewed.

RESULTS

The median age of patients in the cohort was 13.5 years. Presenting features included intracranial hypertension (7 cases), hypothalamic dysfunction (2), and memory dysfunction (3). Complete resection was possible in only 1 case, where the lesion was mainly exophytic; the remaining patients had either a partial resection or biopsy. On histological review, the tumors were confirmed as pilocytic astrocytoma (4 lesions), WHO Grade II astrocytoma (3), and ganglioglioma (1). Postoperatively, working and retrograde memory was normal for all patients, but the authors found a mild alteration in verbal episodic memory in 5 patients. Despite fatigability for 5 patients, academic achievement was normal for all but 2, both of whom had preoperative school difficulties. Additional treatment was required for 5 patients for tumor progression, with a median interval of 19 months from surgery. At a median follow-up duration of 4.9 years, all patients had stable disease.

CONCLUSIONS

In this series, forniceal gliomas were found to be low-grade gliomas. They are surgically challenging, and only exophytic lesions may be cured surgically. Due to the high rate of progression of residual disease, adjuvant therapy is recommended for infiltrative tumors, and it yielded excellent results.

Surgical anatomy and surgical approaches to the lateral ventricles

This study focuses on the surgical approaches to intraventricular tumors which have developed within the cavity of the lateral ventricle. The first section is dedicated to embryology and describes the wrapping of the telencephalic vesicles around the thalamus and the morphogenesis of basal nuclei and commissures. In the second section, the anatomy of the lateral ventricles is described, along with their arterial and venous vasculature, their relationship with the eloquent cortical areas and cortical sulci, and their relationship with white matter fascicles, especially the optic radiations. In the third part, the main surgical approaches to the frontal horn, to the ventricular atrium and to the temporal horn are detailed.

Presentation of childhood CNS tumours: a systematic review and meta-analysis

BACKGROUND

Suspicion of a CNS tumour is classically raised by symptoms of raised intracranial pressure, focal deficits (including seizures), or papilloedema. Development of guidelines is needed for the identification and referral of children who might have a CNS tumour. We did a systematic literature review and meta-analysis to identify the clinical presentation of childhood CNS tumours to provide evidence to support the development of guidelines to assist with the identification and referral for imaging of children who might have a central nervous system tumour.

METHODS

Medline, Embase, and PubMed were searched for cohort studies and case series in children, published between January, 1991, and August, 2005, detailing the symptoms and signs at diagnosis of a CNS tumour.

FINDINGS

74 papers (n=4171) met the inclusion criteria. 56 symptoms and signs at diagnosis were identified, ranked by frequency, and clustered according to age, anatomical criteria, and genetic criteria. The most frequent symptoms and signs at diagnosis were: headache (33%), nausea and vomiting (32%), abnormalities of gait and coordination (27%), and papilloedema (13%) for intracranial tumours; macrocephaly (41%), nausea and vomiting (30%), irritability (24%), and lethargy (21%) for children aged under 4 years with intracranial tumours; reduced visual acuity (41%), exophthalmia (16%), and optic atrophy (15%) for children with an intracranial tumour and neurofibromatosis; nausea and vomiting (75%), headache (67%), abnormal gait and coordination (60%), and papilloedema (34%) for posterior fossa tumours; unspecified symptoms and signs of raised intracranial pressure (47%), seizures (38%), and papilloedema (21%) for supratentorial tumours; headache (49%), abnormal eye movements (21%), squint (21%), and nausea and vomiting (19%) for central brain tumours; abnormal gait and coordination (78%), cranial nerve palsies (52%), pyramidal signs (33%), headache (23%), and squint (19%) for brainstem tumours; and back pain (67%), abnormalities of gait and coordination (42%), spinal deformity (39%), focal weakness (21%), and sphincter disturbance (20%) for spinal-cord tumours. Other features noted were weight loss, growth failure, and precocious puberty. Symptoms of raised intracranial pressure were absent in more than half of children with brain tumours. Other neurological features were heterogeneous and related to tumour location.

INTERPRETATION

Apart from raised intracranial pressure, motor and visual system abnormalities, weight loss, macrocephaly, growth failure, and precocious puberty also suggest presence of an intracranial tumour. Children with signs and symptoms that could result from a CNS tumour need a thorough visual and motor system examination and an assessment of growth and pubertal status. Occurrence of multiple symptoms and signs should alert clinicians to possible CNS tumours.

Papiloma y carcinoma de plexos coroideos en la edad pediátrica

Papillomas of the choroid plexus are rare tumors of neuroectodermal origin; they represent less than 5% of all central nervous system (CNS) tumors in pediatric patients. Choroid plexus carcinomas are even rarer. We reviewed the incidence of these neoplasms at our reference hospital and found six tumors of the choroid plexus (five papillomas and one carcinoma) in five patients. Patient age ranged from prenatal to 25 months. All five patients underwent computed tomography (CT) examination. Four perinatal patients underwent ultrasound examination, four magnetic resonance imaging (MRI), and one (years ago) angiography. All patients had tumors located in the lateral ventricles, and one patient had a second tumor located in the third ventricle. These tumors are predominantly solid, intraventricular, with well-defined polylobulated margins. They show intense vascularization on Doppler studies and marked contrast enhancement on CT and MRI studies. Hydrocephalus was present in three cases. All patients underwent surgery; total resection was achieved in the five papillomas, whereas the carcinoma was partially resected and the patient is currently undergoing chemotherapy. The three patients with a single papilloma are disease free at follow-up (range 7 months to 11 years). The patient with two papillomas shows good recovery at follow-up, whereas the patient with carcinoma of the choroid plexus has a poor prognosis.

The presenting features of brain tumours: a review of 200 cases

OBJECTIVE

To determine the presenting features of brain tumours in children.

DESIGN

Retrospective case note review.

SETTING

Paediatric and neurosurgical services at the Wessex Neurology Centre and Southampton General Hospital, UK.

PATIENTS

200 patients presenting with a CNS tumour between 1988 and 2001.

RESULTS

The commonest first presenting symptoms were headache (41%), vomiting (12%), unsteadiness (11%), visual difficulties (10%), educational or behavioural problems (10%), and seizures (9%). The commonest symptoms occurring at any time were headache (56%), vomiting (51%), educational or behavioural problems (44%), unsteadiness (40%), and visual difficulties (38%). Neurological signs were present at diagnosis in 88%: 38% had papilloedema, 49% cranial nerve abnormalities, 48% cerebellar signs, 27% long tract signs, 11% somatosensory abnormalities, and 12% a reduced level of consciousness. The median symptom interval was 2.5 months (range 1 day to 120 months). A short symptom interval was significantly associated with high grade tumours and patient age of 3 years or younger.

CONCLUSIONS

The well known predominance of headache in children with CNS tumours is confirmed. Visual, behavioural, and educational symptoms were also prominent. With the exception of seizures, every initial symptom was accompanied by other symptoms or signs by the time of diagnosis. Questions about visual symptoms and educational or behavioural difficulties, as well as the more widely recognised symptoms of raised intracranial pressure and motor dysfunction, are important in the diagnosis of brain tumours, as are vision assessment and the appropriate plotting of growth and head size.

Lateral Ventricle Tumors: Surgical Strategies According to Tumor Origin and Development— A Series of 72 Cases

OBJECTIVE:

Optimal surgical management in lateral ventricle tumors remains controversial. We conducted a retrospective study of patients with these lesions treated with a surgical strategy on the basis of tumor origin: primary or secondary ventricular and associated transependymal development.

METHODS:

A total of 72 patients underwent surgery for lateral ventricle tumors. The mean patient age was 39 years (range, 6 mo to 78 yr). Raised intracranial pressure occurred in 53% of patients, followed by mental disturbances or psychiatric symptoms (32%) and motor deficits (21%). The transcortical approach was used in 44 patients, and an interhemispheric approach was used in 28 patients; a transcallosal approach was used in 16 patients, and a parasplenial approach was used in 12 patients. Neuropsychological tests were performed in selected patients.

RESULTS:

Total resection was performed in 82% of patients. Sixty-five percent of tumors were benign and low-grade tumors. There was no surgical mortality, and the morbidity rate was 11%. Postoperative epilepsy (5.9%) was significantly increased in the transcortical group. The mean follow-up period was 55 months; 59% of patients achieved good recovery and moderate disability. In postoperative neuropsychological testing sessions, deficits in verbal memory were observed in six patients (8%). Final morbidity correlated well with preoperative clinical condition and pathological diagnosis.

CONCLUSION:

Lateral ventricle tumors can be treated best by careful selection of the approach according to tumor origin and development. Overall, the transcallosal approach is preferred, but in patients with transependymal growth or large primary or secondary ventricular tumors, the transcortical is a better option.

Large Supratentorial Ectopic Ependymoma With Massive Calcification and Cyst Formation-Case Report-

A 6-year-old boy presented with a large supratentorial ependymoma with massive calcification and central cyst formation manifesting as generalized convulsion and right hemiparesis. Computed tomography and magnetic resonance imaging showed a large, poorly enhanced, left frontal mass with massive calcification and a central cyst. Angiography revealed no extracranial blood supply to the tumor, which was supplied by branches of the left middle cerebral artery. The patient underwent total resection of the tumor, which was located in the parenchyma with no dural attachment. The tumor was clearly demarcated and dissected subpially from the surrounding brain parenchyma. The surgical findings suggested no relationship with the lateral ventricular system. Histological examination of the tumor demonstrated perivascular pseudorosette formation and mitosis with massive calcification, and immunocytochemical reactivity for glial fibrillary acidic protein and epithelial membrane antigen, but not synaptophysin. These findings were compatible with ependymoma, World Health Organization grade 2. Postoperative magnetic resonance imaging clearly showed that the tumor was located in the intradural, intraaxial space with no relationship to the ventricles.

En-plaque ventricular ependymoma

An extremely unusual case demonstrating rare behaviour of an ependymoma is presented. The tumour spread in an en-plaque fashion and involved the ependymal lining of the entire ventricular system. The patient, a 56-year-old male, presented with symptoms of raised intracranial pressure and truncal ataxia. The management issues are analyzed on the basis of a brief literature survey.

Pediatric supratentorial intraventricular tumors

A variety of mass lesions can arise within or in proximity to the ventricular system in children. These lesions are relatively uncommon, and they present a unique diagnostic and surgical challenge. The differential diagnosis is determined by tumor location in the ventricular system, clinical presentation, age of the patient, and the imaging characteristics of the lesion. In this report the authors provide an introduction to and an overview of the most common pediatric supratentorial intraventricular tumors. The typical radiographic features of each tumor and location preference within the ventricular system are reviewed. Management and treatment considerations are discussed. Examination of tissue samples to obtain diagnosis is usually required for accurate treatment planning, and resection without adjuvant therapies is often curative. The critical management decision frequently involves determining which lesions are appropriate for surgical therapy. Care ful preoperative neuroimaging is extremely useful in planning surgery. Knowledge of the typical imaging characteristics of these tumors can help to determine the diagnosis with relative certainty when a tissue sample has not been obtained, because a small subset of these lesions can be managed expectantly.