Neuroepithelial cysts presenting with movement disorders: two cases

Symptomatic infratentorial ependymal cyst arising from the medulla: a case report with review of literature

BACKGROUND

Ependymal cysts (EC) typically present supra-tentorially near the lateral ventricle, juxta ventricular, or temporoparietal regions. Previous cases have also identified infratentorial EC of the brainstem, cerebellum, and subarachnoid spaces. They are mostly asymptomatic. In this paper, we present the first-ever case of a symptomatic medullary ependymal cyst treated with surgery, along with a comprehensive review of the literature on EC of other parts of the brain stem.

CASE DESCRIPTION

This 51-year-old female presented with hearing loss, dizziness, diplopia, and ataxia. Radiographic imaging indicated the presence of a non-enhancing lesion in the medulla with a mass effect on the brainstem. Pathological examination confirmed its characterization as an ependymal cyst. The patient underwent a suboccipital craniotomy for the fenestration of the medullary ependymal cyst under neuro-navigation, Intra-op ultrasound and intra-operative neuro-monitoring. Histopathological examination confirmed the diagnosis of an ependymal cyst. At one month follow-up, her KPS is 90, ECOG PS 1, and her ataxia has improved with complete resolution of diplopia.

CONCLUSION

Due to their rarity and potential similarity to other cystic structures, EC may be overlooked or incorrectly diagnosed resulting in mismanagement and surgical disaster. Therefore, a comprehensive understanding and awareness of their distinct characteristics are essential for accurate diagnosis and appropriate management.

Unusual presentation of a neuroepithelial cyst: A case report

Neuroepithelial cysts are benign, congenital, ependymal-lined cysts that constitute an infrequent cause of neurological symptoms among intracranial cystic lesions. We present Indonesian patient who underwent brain MRI depicting neuroepithelial cysts and pathological examination confirmed. Surgery was performed and yielded a satisfying result. Awareness of the entity and specific imaging features is key to making the diagnosis of neuroepithelial cyst and commencing appropriate treatment. This report is expected to aid in the diagnosis of neuroepithelial cysts, which are rare, and reduce the occurrence of misdiagnosis.

Cerebellar Glioependymal Cyst

Glioependymal cyst (GEC) is an uncommonly observed clinical entity in the posterior cranial fossa. A 36-year-old female with cystic lesion in the right cerebellum was hospitalized for evaluating headache and dizziness. Brain images showed a well-defined, ovoid mass adjacent to the fourth ventricle. After drainage and excision of the cyst, the patient became symptom free. Pathology examination disclosed low cuboidal epithelium and glial cells in the cyst wall. The radiological features, neurological manifestations, and the operations for GECs of the present localization are described in this short communication.

Endoscopic management of benign cystic lesions of the thalamus with fenestrated stent placement

Benign intracranial cystic lesions of the thalamus are an uncommon clinical entity rarely requiring operative decompression. In combination with cyst fenestration, cerebrospinal fluid (CSF) flow diversion or fenestrated stent placement may be performed at the time of surgery. We describe a method of treatment of these cysts using endoscopic cyst fenestration with fenestrated transventricular stent placement. Three patients with benign cystic lesions were treated with stereotactic-guided, endoscopic fenestration and fenestrated stent placement. All 3 had radiographic and clinical improvement. There were no complications. Endoscopic fenestration and transventricular fenestrated stent placement is a minimally invasive, effective, and safe method to decompress benign, symptomatic cystic lesions of the thalamus.

Transcranial endoscopic treatment of thalamic neuroepithelial cyst: case report and review of the literature

Thalamic neuroepithelial cysts are rare, benign lesions. Thirteen cases have been published in eight articles. The most frequent symptoms are headache, hemiparesis, tremor and related signs of hydrocephalus such as gait disturbance, confusion, and Paranaud's syndrome. Surgical interventions include endoscopic fenestration, open surgery and stereotaxic biopsy or aspiration. We report a case of a 63-year-old woman who had headache and right hemiparesis for 1 week, but no hydrocephalus. We treated her with transcranial neuronavigation-guided endoscopic complete resection. The patient recovered completely after cyst removal.

Endoscopic treatment of intraventricular ependymal cysts in children: personal experience and review of literature

OBJECT

Intracranial ependymal cysts are rare neuroepithelial cysts that occur less frequently than arachnoid cysts. The cysts are most often intraparenchymal, but they are rarely reported to be intraventricular. This study evaluates the role of endoscopy in the treatment of intraventricular ependymal cysts (IVECs).

METHODS

Twelve pediatric patients (mean age 4.3 years) with symptomatic IVECs were the subject of this study. The cyst was located inside the lateral ventricle in all cases (100%), it was present in trigone (10 patients, 83.3%), and in temporal horn (2 patients, 16.7%). Concomitant hydrocephalus was present in two patients (16.7%). All patients underwent operations through a purely endoscopic procedure. Communication of the cyst with the subarachnoid space was performed in six patients (50%); endoscopic cystocisternostomy was performed in four patients (33.3%), and endoscopic cystoventriculostomy in two patients (16.7%).

RESULTS

Postoperative clinical improvement associated with postoperative reduction in cyst size was encountered in ten patients (83.3%). Improvement of hydrocephalus occurred in both patients who had hydrocephalus (100%). There were no deaths or permanent morbidity. Among the follow-up period (mean 44.3 months), none of the patients required a repeat endoscopic procedure due to recurrence of symptoms or increase in cyst size.

CONCLUSION

Intraventricular ependymal cysts can be effectively treated by endoscopy. Endoscopic fenestration of the cyst wall into subarachnoid space, basal cisterns, or ventricular system can be used in the treatment of these patients with postoperative symptomatic improvement and reduction of cyst size. The procedure is simple, effective, minimally invasive, and associated with low morbidity and mortality rates.

Third Ventricular Cerebrospinal Fluid Cysts of Thalamic Origin: Review of Embryologic Origin, Presentation, and Management Strategies with a Case Series

OBJECTIVE

Third ventricular cerebrospinal fluid (CSF) cysts of thalamic origin are rare. The objective of this study is to review their possible pathogenesis, clinical presentation, and management strategies with a case series describing management via an endoscopic approach with fenestration using a single burr-hole technique.

METHODS

A systematic literature review of reported cases of thalamic cysts was conducted with further meta-analysis of CSF cysts that involve the third ventricle. The mode of presentation, pathologic analysis, surgical management, and outcomes were analyzed.

RESULTS

Twenty-two studies reported between 1990 and 2013 described 42 cases of thalamic cyst. Of those cases, 13 were consistent with CSF cyst that originated in the thalamus and involved the third ventricle. Eight cases (61.5%) were treated via endoscopic fenestration, 2 cases (15.4%) were surgically drained, 2 cases (15.4%) were stereotactically aspirated, and 1 case (7.69%) was observed. The most common presenting symptoms were gait disturbance (26.3%) and headaches (26.3%) followed by tremors (15.8%) and weakness (15.8%). In our series, a single burr-hole technique was a successful definitive treatment, with an average period of 23 months.

CONCLUSIONS

Third ventricular CSF cysts of thalamic origin most commonly present with hydrocephalus. They can be safely definitively treated via endoscopic fenestration to the CSF circulation using a single burr-hole technique. Long-term follow-up shows lasting improvement in symptoms without reaccumulation of the cyst.

Neuroendoscopic Approach to Intracranial Ependymal Cysts

BACKGROUND

Intraparenchymal cysts without communication to the ventricles or the subarachnoid space are named ependymal or epithelial cysts. The estimated ratio of their incidence compared with arachnoid cysts is 1:10. Neurologic deficit can occur when the cyst exerts mass effect on its surroundings. We evaluated the success rate of endoscopic fenestration of intracranial ependymal cysts.

METHODS

Our prospectively maintained endoscopy database was screened for all cases of ependymal cysts. The charts were retrospectively reviewed for symptoms, surgery, postoperative course, and complications. Magnetic resonance imaging scans performed before and after surgery were analyzed.

RESULTS

We identified 6 patients harboring an intracranial ependymal cyst. The cyst location was frontoparietal, parietal, occipital, or mesencephalic. Patients presented with several symptoms according to the location of the cyst (i.e., epilepsy, hemiparesis, diplopia, hemianopsia). All patients were treated by navigation-guided endoscopic fenestration of the cyst to the ventricular system. Two complications occurred: a cerebrospinal fluid leak, which was managed surgically by wound revision without the need for cerebrospinal fluid shunting, and a chronic subdural hematoma, which occurred 6 weeks after surgery and required burr hole evacuation. Follow-up period ranged from 6 months to 9 years. Magnetic resonance imaging revealed that all cysts decreased in size. Symptoms improved in all patients.

CONCLUSIONS

Endoscopic fenestration of ependymal cysts to an adjacent ventricular cavity is a treatment option with excellent long-term results and minimal morbidity. It should be considered as the therapy of choice to avoid craniotomy and shunt dependence.

Endoscope-Assisted Microsurgical Removal of an Intraventricular Ependymal Cyst That Manifested with Tremor

BACKGROUND

Intraventricular ependymal cysts (ECs) are rare, histologically benign neuroepithelial cysts. Most of these cysts are clinically silent and discovered incidentally. Rarely, they become symptomatic, leading to obstruction of the cerebrospinal fluid circulation. ECs located inside the ventricles may manifest with signs of increased intracranial pressure.

CASE DESCRIPTION

A 32-year-old woman presented with a 6-year history of tremor affecting her left hand. In the last month, she had been experiencing headache as well, and the tremor of the left hand was affecting her quality of life. The patient demonstrated a fine resting and intention tremor of the left hand and a voice tremor. Magnetic resonance imaging revealed a large cystic, nonenhancing lesion within the right lateral ventricle. The fluid within the cyst was isointense to cerebrospinal fluid on all sequences. Because of the rapid progression of her symptoms and no response to medication, surgical decompression of the cyst was considered. The cyst was removed by an endoscope-assisted microsurgical technique. Her postoperative course was uneventful. A marked reduction in her tremor was noted in the immediate postoperative period. Histopathologic diagnosis was of an EC. During the follow-up period, the patient's tremor, although still present, had improved dramatically. At 6 months postoperatively, she could hold a drinking glass without spilling.

CONCLUSIONS

This is a unique case of an intraventricular EC that manifested with tremor, which improved by endoscope-assisted microsurgical removal of the cyst. This case also supports the important role of endoscopic surgery in the treatment of intraventricular cystic lesions.

Neuroepithelial cyst of the fourth ventricle

PURPOSE

Neuroepithelial cyst is considered an unusual differential diagnosis for cysts in the posterior fossa. Here, we present a paediatric case with such a pathology and review the pertinent literature.

METHODS

A 12-year old girl with headache, vertigo and disturbed gait was diagnosed with a cystic lesion in the fourth ventricle after brain MRI study. She was operated with the pre-operative diagnosis of arachnoid cyst.

RESULTS

A transparent, colourless cyst was observed intra-operatively. As frozen sections were consistent with endodermal cyst, total removal of the cyst was attempted. Definite histopathological studies and immunohistochemistry stains were in favour of neuroepithelial cyst. No regrowth of the cyst or recurrence of the symptoms was observed in her 2-year follow-up.

CONCLUSIONS

As neuroepithelial cyst is rarely encountered in the posterior fossa, the clinical, radiological and pathological characteristics of our case along with similar cases in the literature were reviewed and discussed.

[Intracerebral cysts revealed by extrapyramidal symptoms]

We report 3 cases of intracerebral cyst revealed by an unusual evolution of extrapyramidal symptoms. Diagnosis was based on MRI and the patients were treated by a cystoperitoneal or a cysto-atrial shunt. The surgical procedure was successful in the 3 cases, resulting in the rapid disappearance of symptoms.

Mesencephalic ependymal cysts: treatment under pure endoscopic or endoscope-assisted keyhole conditions

OBJECT

Primary intracranial ependymal cysts are extremely rare. Similar to congenital intraparenchymal cysts in the mesencephalon they usually occur with symptoms of an occlusive hydrocephalus or symptoms like Parinaud syndrome, dizziness, or gait disturbance. The objective of this study was to evaluate the surgical methods for the treatment of these cysts and the clinical outcome of the patients.

METHODS

The authors present the clinical records of 8 patients who were treated in their department for symptomatic mesencephalic ependymal cysts in the past 10 years. The patient age ranged from 22 to 60 years with a mean age of 44 years. In 4 cases the authors performed a suboccipital infratentorial supracerebellar approach by using endoscope-assisted microsurgery. The other 4 patients underwent a pure endoscopic procedure over a frontal bur hole trepanation.

RESULTS

Four patients became symptom free, and the remaining 4 improved significantly after a mean follow-up duration of 38.5 months (range 5-119 months). One patient underwent 2 operations: first a ventriculocystostomy and 4 months later endoscopic third ventriculostomy because of recurrent hydrocephalus. In 1 case a second surgery was necessary because of a wound infection. In all of the patients an adequate fenestration of the cyst was achieved.

CONCLUSIONS

A symptomatic mesencephalic ependymal cyst is an indication for neurosurgical intervention. These cysts can be treated successfully and most likely definitively by a pure endoscopic or endoscope-assisted keyhole neurosurgical technique. There were no morbid conditions or death due to the procedures in this group of 8 patients. Therefore, the authors regard these surgical procedures to be good alternatives to treatments such as shunt placement or stereotactic aspiration of the cysts.

Obstructive hydrocephalus due to a third ventricular neuroepithelial cyst

Cysts occupying the third ventricle are rare lesions and may appear as an unusual cause of obstructive hydrocephalus. Various types of lesions occur in this location, and they generally have an arachnoidal, endodermal, or neuroepithelial origin. The authors present a case of acute hydrocephalus following minor trauma in a child due to cerebrospinal fluid outflow obstruction by a third ventricular cyst. Definitive diagnosis of this cystic lesion was possible only with contrast ventriculography and not routine computed tomography or magnetic resonance imaging. The investigation, treatment, and pathological findings are discussed.

Impact of surgical treatment on tremor due to posterior fossa tumors

Object

The object of this study was to investigate the impact of surgical treatment on tremor caused by posterior fossa tumors.

Methods

The authors performed a retrospective evaluation of 6 cases involving patients with tremors due to posterior fossa tumors. Patients who had been treated with neuroleptic medication or had a family history of movement disorders were excluded. All patients had postural or kinetic tremors. Tremor was mainly unilateral. The study group included 5 women and 1 man. Mean age at surgery was 59 years. Five patients underwent total or subtotal tumor resection, and 1 patient underwent stereotactic biopsy only. The histological diagnosis was epidermoid tumor in 2 patients, metastasis in 2 others, and vestibular schwannoma and low-grade glioma in 1 each.

Results

Two patients had no improvement of tremor, postoperatively. In both of these patients the tumor (low-grade glioma in 1, metastasis in the other) involved the dentate nucleus directly. In the other patients, a compressive effect on the dentate nucleus or the dentatothalamic pathways was present without invasion of the cerebellar structures, and immediate or gradual amelioration of the tremor was observed postoperatively.

Conclusions

The prognosis of tremor due to posterior fossa tumors appears to depend mainly on the involvement of tremor-generating structures. The prognosis appears to be favorable in those patients with compression of these substrates, whereas primary invasion by tumor has a poor prognosis. Caution must be used in generalizing the findings of this study because of the small number of cases in the series.

Microanatomy of the intrachoroidal vasculature of the lateral ventricle

OBJECTIVE

Intraventricular surgery requires a detailed knowledge of the microanatomy of the choroid plexus vasculature.

METHODS

Twenty choroid plexuses were microdissected, and two additional plexuses were prepared for microscopic examination.

RESULTS

The choroid plexus was perfused primarily by the anterior choroidal artery (AChA) and the lateral posterior choroidal artery (LPChA). The AChA, which averaged 650 microm in diameter, most often (in 75% of cases) divided into the medial and lateral trunks, which averaged 450 microm in diameter. The medial trunk gave off the bush-like intrachoroidal branches, whereas the lateral trunk divided into the parallel arteries. The inferior LPChA was present in 50% of the hemispheres, both the inferior and superior LPChAs in 40%, and their common trunk in 10%. In 40%, the LPChA, which averaged 670 microm in diameter, divided into the terminal trunks, with a mean diameter of 490 microm. The anastomoses involving the trunks of the LPChA and other choroidal arteries averaged 310 microm in diameter. All primary intrachoroidal branches of the AChA and LPChA were divided into three groups. The parallel branches, which averaged from 220 to 230 microm in diameter, coursed along the lateral part of the choroid plexus. The tortuous glomus vessels, which averaged 310 microm in size, originated from the AChA (45%), the LPChA (15%), or both (40%). The bush-like vessels, with a mean diameter between 155 and 190 microm, ramified into smaller twigs, up to the intrachoroidal capillaries.

CONCLUSION

The data obtained on the microanatomy of the intrachoroidal vasculature may have certain neurosurgical implications.

Thalamic ependymal cyst presenting with tremor

CASE REPORT

We report the case of a 6-year-old boy presenting with intention tremor. CT and MR scanning showed a large thalamic cyst.

TREATMENT

Stereotactic tapping of this cyst was carried out as the first step in surgical management. Following drainage of the cyst the tremor disappeared, but recurred 18 months later. Repeat MRI showed that the thalamic cyst had refilled. As the initial tapping of the cyst had resulted in effective but only transient clinical improvement a cysto-peritoneal shunting procedure was performed.

OUTCOME

The clinical symptoms again disappeared and the child has now remained tremor free for 3 years.

Endoscopic treatment of thalamic neuroepithelial cysts

✓ Thalamic neuroepithelial cysts are rare lesions of the central nervous system. Surgical management of these lesions has varied and yielded mixed results. The authors identified 10 reported cases in the literature, five of which involved symptomatic lesions. The authors present three unique cases of symptomatic thalamic neuroepithelial cysts associated with hydrocephalus, which were all successfully treated using endoscopic third ventriculostomy and fenestration of the cyst into the third ventricle.

Microanatomy of the subependymal arteries of the lateral ventricle

BACKGROUND

Scarce information about the anatomy of the subependymal arteries (SEAs) is present in the scientific literature.

METHODS

Twenty cerebral hemispheres with injected arteries were microdissected, and the magnetic resonance imaging scans of 100 patients with lacunar infarcts were examined.

RESULTS

The SEAs were found to range in diameter from 40 to 490 microm (mean, 149 microm) and in number between 3 and 12 (average, 5.2). Of these, numbers from 1 to 3 originated from the anterior choroidal artery (AChA), between 1 and 10 from the lateral posterior choroidal artery (LPChA), 1 from the medial posterior choroidal artery (MPChA), and 1 from the internal carotid artery. The SEAs most often arose from the choroidal branches (90%) and less frequently from the thalamic (30%), caudate (35%), or thalamocaudate twigs (20%). The SEAs of the AChA supplied the walls of the temporal horn (100%), the occipital horn (85%), and the atrium (35%). Those of the LPChA perfused the walls of the occipital horn (15%), the atrium (65%), the body of the ventricle (100%), and partially the frontal horn. The SEAs of the MPChA partially nourished the body and the frontal horn (10%). The SEAs may also occasionally supply the caudate nucleus (20%) and the stria terminalis. The anastomoses involving the SEAs were absent. In spite of this, ischemia in the territory of a single SEA was noticed in only 1% of our patients.

CONCLUSIONS

The SEAs are tiny vessels that supply the walls of the lateral ventricle, as well as the caudate nucleus and the stria terminalis occasionally. The obtained anatomic data can have important neurosurgical implications in intraventricular operations.