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D'Onofrio GF, Rapisarda A, Signorelli F, Ganau M, Chibbaro S, Montano N, Polli FM, Visocchi M. Toward the End of the Funnel: The Ventriculus Terminalis-The State of Art of an Ancient Entity with a Recent History. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:395-397. [PMID: 38153499 DOI: 10.1007/978-3-031-36084-8_60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
PURPOSE The ventriculus terminalis (VT), also called the fifth ventricle, is a small cavity containing cerebrospinal fluid (CSF) that is in the conus medullaris in continuity with the central canal of the spinal cord. In adults, persistent VT is a very rare entity, and the diagnosis is incidental in most cases. Rarely, VT may become symptomatic for still-uncertain reasons but most often for its cystic dilatation. The management of these selected cases is still controversial and sometimes associated with unsatisfactory outcomes. METHODS We performed a critical review of the existing literature on the management of symptomatic VT in adults. The etiology, pathophysiology, and treatment of VT are presented and discussed, focusing on the best timing for surgery. RESULTS Conservative management, marsupialization, or the placement of a T drain have been reported. The existing classifications describe the most correct approach for each clinical presentation, but scarce importance has been given to the delay from symptoms' onset to surgical treatment. CONCLUSION Although different cases have been described in the literature, this rare pathology remains unknown to most neurosurgeons.
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Affiliation(s)
| | - Alessandro Rapisarda
- Fondazione Policlinico Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy.
| | - Francesco Signorelli
- Fondazione Policlinico Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Mario Ganau
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Nicola Montano
- Fondazione Policlinico Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Filippo Maria Polli
- Fondazione Policlinico Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Massimiliano Visocchi
- Fondazione Policlinico Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
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Tuleasca C, Ducos Y, Knafo S, Levivier M, Aghakhani N, Parker F. Surgery for cyst dilatation of a ventriculus terminalis in adults: Keep it simple! Neurochirurgie 2020; 67:211-213. [PMID: 32504646 DOI: 10.1016/j.neuchi.2020.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 04/11/2020] [Indexed: 12/01/2022]
Affiliation(s)
- C Tuleasca
- Service de neurochirurgie, hôpitaux universitaires Paris Sud, CHU de Bicêtre, AP-HP, Le-Kremlin-Bicêtre, France; Faculté de médecine, Sorbonné Université, Paris, France; Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland; Faculté de biologie et de médecine (FBM), université de Lausanne (Unil), Lausanne, Switzerland; Signal Processing Laboratory (LTS 5), Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.
| | - Y Ducos
- Service de neurochirurgie, hôpitaux universitaires Paris Sud, CHU de Bicêtre, AP-HP, Le-Kremlin-Bicêtre, France
| | - S Knafo
- Service de neurochirurgie, hôpitaux universitaires Paris Sud, CHU de Bicêtre, AP-HP, Le-Kremlin-Bicêtre, France
| | - M Levivier
- Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland; Faculté de biologie et de médecine (FBM), université de Lausanne (Unil), Lausanne, Switzerland
| | - N Aghakhani
- Service de neurochirurgie, hôpitaux universitaires Paris Sud, CHU de Bicêtre, AP-HP, Le-Kremlin-Bicêtre, France
| | - F Parker
- Service de neurochirurgie, hôpitaux universitaires Paris Sud, CHU de Bicêtre, AP-HP, Le-Kremlin-Bicêtre, France
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Fletcher-Sandersjöö A, Edström E, Bartek J, Elmi-Terander A. Surgical treatment for symptomatic ventriculus terminalis: case series and a literature review. Acta Neurochir (Wien) 2019; 161:1901-1908. [PMID: 31278597 PMCID: PMC6704110 DOI: 10.1007/s00701-019-03996-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 06/25/2019] [Indexed: 11/05/2022]
Abstract
BACKGROUND Ventriculus terminalis is a cystic embryological remnant within the conus medullaris that normally regresses after birth. In rare cases, it may persist into adulthood and give rise to neurological symptoms, for which the optimal treatment remains uncertain. The aim of this study was to present our experience from a population-based cohort of patients with ventriculus terminalis and discuss our management strategy as compared to the existing literature. METHODS A retrospective review was conducted of all adult (≥ 15 years) patients with ventriculus terminalis who were referred to the Karolinska University Hospital between 2010 and 2018. RESULTS Fourteen patients were included. All patients were symptomatic at the time of referral, and the most common symptom was lower limb weakness (n = 9). Microsurgical cyst fenestration was offered to all patients and performed in thirteen. Postoperative imaging confirmed cyst size reduction in all surgically treated patients. No surgical complications were reported. Eleven of the surgically treated patients showed clinical improvement at long-term follow-up. One patient declined surgery, with progression of the cyst size and clinical deterioration observed at follow-up. CONCLUSIONS Surgery for ventriculus terminalis seems to be a safe and effective option for relief of symptoms. We propose that surgery should be offered to all patients with symptomatic ventriculus terminalis.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Solna, Sweden.
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Sweden.
| | - Erik Edström
- Department of Neurosurgery, Karolinska University Hospital, Solna, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Sweden
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Solna, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Sweden
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Neurosurgery, Karolinska University Hospital, Solna, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Sweden
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Lotfinia I, Mahdkhah A. The cystic dilation of ventriculus terminalis with neurological symptoms: Three case reports and a literature review. J Spinal Cord Med 2018; 41:741-747. [PMID: 29791269 PMCID: PMC6217512 DOI: 10.1080/10790268.2018.1474680] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
CONTEXT The ventriculus terminalis (VT) is a very small ependymal-lined residual lumen in the conus medullaris. It is normally present in all subjects during fetal development. VT in adults appears as an unusual pathology with an uncertain pathogenesis. FINDINGS In this paper, we described three case reports of symptomatic fifth ventricle cystic dilations. All of them were female and their mean age was 59 years. We treated them surgically and all three patients were improved based on clinical and imaging assessments. CONCLUSION Our cases suggested that surgical decompression was a safe and effective treatment in symptomatic patients and the neurosurgeons should be aware of such rare situations. A complete list of differential diagnosis about other cystic dilations of the conus medullaris should be emphasized to select the correct clinical approach.
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Affiliation(s)
- Iraj Lotfinia
- Professor of Neurosurgery Department of Neurosurgery, Tabriz University of Medical Science, Tabriz, Iran
| | - Ata Mahdkhah
- Assistant Professor of Neurosurgery Department of Neurosurgery, Urmia University of Medical Science, Urmia, Iran
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Severino R, Severino P. Surgery or not? A case of ventriculus terminalis in an adult patient. JOURNAL OF SPINE SURGERY 2017; 3:475-480. [PMID: 29057360 DOI: 10.21037/jss.2017.06.22] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The ventriculus terminalis (VT) is an intramedullary cavity containing cerebrospinal fluid (CSF), usually located at the conus, and represents an unsuccessful regression of a normal embryological phase of the development of the neural tube. Symptoms are not univocal and may vary from aspecific signs to sphincter dysfunctions and focal neurological deficits. The correct management of this condition is still an object of debate due to its rarity and its unpredictable behaviour in adult patients. Two different studies have proposed a distinction for patients with cystic dilatation of VT based on their symptoms, suggesting that only those patients with neurological deficits clearly related to the terminal ventricle could benefit from surgery. We describe a case of an adult patient with a progressive dilatation of a diagnosed VT that we treated surgically. A management flowchart for this condition is also proposed based on our experience and a review of the literature.
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Affiliation(s)
- Rocco Severino
- Department of Neurosurgery, Anthea Hospital, Bari, Italy
| | - Paolo Severino
- Department of Neurosurgery, Anthea Hospital, Bari, Italy
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Zeinali M, Safari H, Rasras S, Bahrami R, Arjipour M, Ostadrahimi N. Cystic dilation of a ventriculus terminalis. Case report and review of the literature. Br J Neurosurg 2017; 33:294-298. [PMID: 28618974 DOI: 10.1080/02688697.2017.1340585] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The ventriculus terminalis (VT) is a small ependyma-lined cavity within the conus medullaris that is in direct continuity with the central canal of the spinal cord. Cystic dilatation of the ventriculus terminalis on its own is an extremely rare pathological event in adults whose pathogenesis is uncertain. VT has been described in children as a normal developmental phenomenon. These lesions are often diagnosed incidentally during imaging and are in most cases asymptomatic, especially in children. Symptomatic dilatation of VT in adults is a rare condition with 61cases being reported to date. Symptomatic dilatation of VT in children has not been reported till now. We present a 5 year-old-boy with a sphincteric and walking disorder. The patient was assessed by clinical, electrophysiological and urodynamic investigations as well as magnetic resonance imaging (MRI) of the lumbar-sacral segment with and without gadolinium enhancement. Lumbar-sacral MRI demonstrated the presence of a cystic lesion containing cerebrospinal fluid (CSF), which did not enhance after gadolinium, compatible with the diagnosis of the ventriculus terminalis dilation.The patient underwent laminectomy and the cyst wall was fenestrated with a midline myelotomy. In 6-month of follow-up, urinary problems and gait disturbance improved.
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Affiliation(s)
- Masoud Zeinali
- a Department of Neurosurgery , Ahvaz Jundishapur University Of Medical Sciences , Ahvaz , Iran
| | - Hosein Safari
- a Department of Neurosurgery , Ahvaz Jundishapur University Of Medical Sciences , Ahvaz , Iran
| | - Saleh Rasras
- a Department of Neurosurgery , Ahvaz Jundishapur University Of Medical Sciences , Ahvaz , Iran
| | - Reza Bahrami
- a Department of Neurosurgery , Ahvaz Jundishapur University Of Medical Sciences , Ahvaz , Iran
| | - Mahdi Arjipour
- a Department of Neurosurgery , Ahvaz Jundishapur University Of Medical Sciences , Ahvaz , Iran
| | - Nima Ostadrahimi
- a Department of Neurosurgery , Ahvaz Jundishapur University Of Medical Sciences , Ahvaz , Iran
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Zhang L, Zhang Z, Yang W, Jia W, Xu Y, Yang J. Cystic Dilation of the Ventriculus Terminalis: Report of 6 Surgical Cases Treated with Cyst-Subarachnoid Shunting Using a T-Catheter. World Neurosurg 2017; 104:522-527. [PMID: 28512052 DOI: 10.1016/j.wneu.2017.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/03/2017] [Accepted: 05/04/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cystic dilation of the ventriculus terminalis (CDVT) is a rare anatomic variation that and may become symptomatic. Literature regarding CDVT is limited, and thus the clinical characteristics and management strategy of CDVT are unclear. Here we report 6 cases of CDVT seen in our institution, and provide a review of the current literature. METHODS The study cohort comprised 6 patients with CDVT seen at Beijing Tiantan Hospital between September 2010 and June 2015. All 6 patients were managed surgically. Data on age, sex, clinical presentation, radiologic features, operative methods, and surgical outcomes were reviewed retrospectively. We evaluated the clinical outcomes and postoperative radiologic changes of these patients and compared them with findings of similar previous reports. RESULTS All 6 patients were female, with a median age of 50.0 years (interquartile range [IQR], 25.8-54.0 years). Surgical management of cyst-subarachnoid shunting using T-catheter after myelotomy was successfully performed in all patients. During an average follow-up of 41 months, relief of clinical symptoms, especially low-back pain and sciatica, were observed in all 6 patients. No patients experienced symptom recurrence during follow-up, and postoperative magnetic resonance imaging revealed no regrowth of the lesion. Patients with focal neurologic deficits and sphincter disorders also achieved symptom relief from the procedure. CONCLUSIONS CDVT is an extremely rare cause of conus medullaris syndrome with an unclear treatment strategy. Our successful surgical management of 6 cases through cystic-subarachnoid shunting using a T-catheter for CDVT drainage provides a potential option for treating CDVT.
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Affiliation(s)
- Liang Zhang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University No. 6, Tiantan Xili, Beijing, People's Republic of China
| | - Zhifeng Zhang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University No. 6, Tiantan Xili, Beijing, People's Republic of China
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wenqing Jia
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University No. 6, Tiantan Xili, Beijing, People's Republic of China.
| | - Yulun Xu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University No. 6, Tiantan Xili, Beijing, People's Republic of China
| | - Jun Yang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University No. 6, Tiantan Xili, Beijing, People's Republic of China
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Woodley-Cook J, Konieczny M, Spears J. The Slowly Enlarging Ventriculus Terminalis. Pol J Radiol 2016; 81:529-531. [PMID: 27867442 PMCID: PMC5102252 DOI: 10.12659/pjr.895669] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 04/24/2016] [Indexed: 11/09/2022] Open
Abstract
Background A cerebral spinal fluid (CSF) cavity within the conus medullaris has been described by the term ventriculus terminalis (VT) or the fifth ventricle. The finding of a VT on MRI imaging of the lumbar spine is often incidental but may be found in patients with low back pain or neuromuscular deficits. These lesions, when identified, are thought to regress or remain stable in terms of size, although some have been described to enlarge in the presence of post-traumatic meningeal hemorrhages or deformities of the vertebral canal. Case Report We describe a case of a slowly growing VT in a patient with progressing lower limb weakness without any history or imaging findings of trauma or spinal canal abnormalities. Conclusions We present an intriguing case of a slowly growing VT in a woman with progressive neurological symptoms. Surgical fenestration provided complete symptomatic relief and follow-up imaging two years after surgery demonstrated no evidence of recurrence. This, to our knowledge, is the first described case of a slowly enlarging VT independent of any other imaging findings.
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Affiliation(s)
- Joel Woodley-Cook
- Department of Diagnostic Imaging, The Scarborough Hospital, Scarbrorough, ON, Canada
| | - Magdalena Konieczny
- Department of Diagnostic Imaging, The Scarborough Hospital, Scarbrorough, ON, Canada
| | - Julian Spears
- Department of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
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Yang T, Wu L, Deng X, Yang C, Fang J, Zhao L, Wang G, Yang J, Xu Y. Clinical characteristics and surgical outcomes of spinal intramedullary ependymal cysts. Acta Neurochir (Wien) 2014; 156:269-75. [PMID: 24322584 DOI: 10.1007/s00701-013-1964-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 11/28/2013] [Indexed: 11/26/2022]
Abstract
OBJECT Intramedullary ependymal cysts are exceedingly rare lesions, and have been previously reported in the literature as case reports. The aim of this study was to discuss the clinical presentation and the outcomes of microsurgery for these benign lesions. METHODS The authors retrospectively reviewed the records of ten patients who underwent microsurgery for intramedullary ependymal cysts. All patients had preoperative and postoperative magnetic resonance imaging. The surgical treatment included gross total resection and biopsy plus a cyst-subarachnoid shunt. The diagnosis of intramedullary ependymal cysts was based on radiological and pathological criteria. All patients were followed up, with a mean duration of 47.6 months. RESULTS Intramedullary ependymal cysts were hypointense on T1-weighted images and hyperintense on T2-weighted images. Contrast-enhanced T1-weighted images showed no enhancement. Gross total resection was achieved in one case. Biopsy of the cyst wall plus cyst-subarachnoid shunt placement was achieved in nine cases. Long-term neurological function was improved in eight patients. No recurrence was observed on magnetic resonance imaging. CONCLUSIONS Ependymal cysts should be considered in the differential diagnosis of intramedullary cysts. For symptomatic patients, early surgery should be performed before neurological deficits deteriorate. Complete decompression and cyst-subarachnoid shunt placement is the optimal treatment and the outcome may be favorable.
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Affiliation(s)
- Tao Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.6 Tiantan Xili, Dongcheng District, Beijing, 100050, China,
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Ganau M, Talacchi A, Cecchi PC, Ghimenton C, Gerosa M, Faccioli F. Cystic dilation of the ventriculus terminalis. J Neurosurg Spine 2012; 17:86-92. [DOI: 10.3171/2012.4.spine11504] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The ventriculus terminalis, an embryological remnant consisting of the ependymal-lined space of the conus medullaris, can occasionally become symptomatic after cystic dilation. In the existing literature, consisting of 32 cases, the preferred type of management (conservative vs surgical) is still debated. The object of this study was to report the surgical results in a consecutive series of 10 adult patients with cystic dilation of the ventriculus terminalis (CDVT), to match them with data retrieved from the relevant literature, and specifically to validate a new recent clinical classification.
Methods
The authors reported 13 new cases of CDVT treated in the Department of Neurosurgery at University Hospital in Verona, Italy. Treatment modalities and clinical and radiological outcomes, both early and at follow-up, were analyzed and compared with a preoperative classification of clinical presentation, as established by de Moura Batista and colleagues (2008).
Results
Surgical treatment seemed to guarantee the resolution of CDVT. Dorsolumbar laminotomy, myelotomy, and cystic drainage were performed in 10 patients. Patients with Type I symptoms (nonspecific complaints) often presented with comorbidities (herniated disc or facet hypertrophy) confusing their clinical status. The surgical treatment of patients with Type I symptoms promoted good results only if the diagnosis of CDVT was definitive and symptoms had rapidly evolved. In patients with Type II (focal neurological deficits) and III (sphincter disturbances) symptoms, surgical treatment sustained improvement even at the late follow-up.
Conclusions
While confirming the usefulness of de Moura Batista and colleagues' classification in its impact on prognosis, the authors propose a revision of the classification with subgroups Type Ia (nonspecific symptoms without clear relation to CDVT), which is best treated conservatively, and Type Ib (rapid onset and invalidating unspecific complaints without comorbidities), which may benefit from surgical evacuation.
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Affiliation(s)
- Mario Ganau
- 1Section of Neurosurgery, Department of Neuroscience, University of Verona
| | - Andrea Talacchi
- 1Section of Neurosurgery, Department of Neuroscience, University of Verona
| | | | | | - Massimo Gerosa
- 1Section of Neurosurgery, Department of Neuroscience, University of Verona
| | - Franco Faccioli
- 4Department of Neurosurgery, University Hospital, Verona; and
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