Cystic dilation of the conus ventriculus terminalis presenting as an acute cauda equina syndrome relieved by decompression and cyst drainage: case report

Cystic dilatation of the ventriculus terminalis: A narrative review

Introduction

The terminal ventricle, also known as the fifth ventricle, is a tiny relic cavity in the conus medullaris of the human spinal cord. Our purpose in bringing attention to this condition is to get the word out about the signs and symptoms, diagnostic hurdles, and therapeutic options available for it.

Methods

All relevant studies involving patients diagnosed with ventriculus terminalis (VT) were retrieved from PubMed, Google Scholar, and Scopus. Studies published in complete English language reports were included. The terms VT, terminal ventricle, and 5th ventricle. Age, gender, presenting symptoms, magnetic resonance imaging findings, treatment, and outcome of patients with ventriculus terminalis were all included and recorded.

Results

The average age of the patients was 39 years, and there were 13 men among them (14.4%). Motor deficits and sciatica were the most commonly reported symptoms in 38 and 34 patients (42.2%, 37.7%), respectively. In 48 patients (53.3%), cyst fenestration was performed, and in 25 patients (27.7%), myelotomy was performed. Fifty-eight patients (64.4%) saw a reduction in cyst size after surgery. The majority of patients reported an improvement in their symptoms in 64 cases (51.1%), with only three cases (3.3%) reporting a worsening.

Conclusions

In cases where the VT is the source of symptoms such as motor, sensory, or bladder dysfunction, surgical intervention is recommended. This review compiles information from the available literature to shed light on the anatomy, clinical presentation, imaging, and treatment options for this variant. It also aims to pinpoint any potential drawbacks or restrictions connected to the surgical techniques.

Toward the End of the Funnel: The Ventriculus Terminalis-The State of Art of an Ancient Entity with a Recent History

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.

Recurrent terminal ventricle cyst: a case report

The terminal ventricle (TV) of Krause is a rare cystic dilation of the conus' central canal. Due to limited understanding surrounding its pathophysiology, optimal management remains controversial. We report a 25-year-old female presenting with acute paraparesis. Magnetic resonance imaging spine revealed a cystic conus medullaris lesion in keeping with an incidental TV cyst. However, the patient experienced a rapid resolution of symptoms. We hypothesize that the TV cyst spontaneously ruptured and auto-decompressed. To our knowledge, this is the first reported case of an enlarging symptomatic TV cyst with spontaneous rupture and resolution of symptoms, highlighting the variable natural history of this condition.

Cystic dilation of the ventriculus terminalis

The ventriculus terminalis (VT) is a virtual cavity of the conus medullaris that appears during embryonic life. We presented a case with the cystic dilation of the ventriculus terminalis (CDVT) in a symptomatic patient. A 66-year-old female suffered from disturbance while walking evolving for the past 2 years. An MR image revealed a cystic dilatation of ventriculus terminalis. The patient experienced marked improvement of lower extremity strength by a fenestration of cyst and cyst-subarachnoid shunt. Treatment for asymptomatic patients seems to be the best conducted conservatively, whereas patients with focal neurological deficits seem to be best handled surgically.

Surgical treatment for symptomatic ventriculus terminalis: case series and a literature review

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.

The cystic dilation of ventriculus terminalis with neurological symptoms: Three case reports and a literature review

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.

Surgery or not? A case of ventriculus terminalis in an adult patient

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.

Cystic dilation of a ventriculus terminalis. Case report and review of the literature

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.

Cystic Dilation of the Ventriculus Terminalis: Report of 6 Surgical Cases Treated with Cyst-Subarachnoid Shunting Using a T-Catheter

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.

The Slowly Enlarging Ventriculus Terminalis

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.

Massive cystic dilatation within a tethered filum terminale causing cauda equina compression and mimicking syringomyelia in a young adult patient

BACKGROUND

The ventriculus terminalis (VT) is formed during early embryonic development of the spinal cord and can only be identified histologically in both children and adults. Cystic dilatation of the VT can be seen in young children, but it rarely persists through adulthood.

CLINICAL CASE

We describe a 27-year-old female with paraparesis secondary to a massive and tethered cystic dilatation of the VT mimicking syringomyelia. Symptoms appearing in early childhood were ignored, probably leading to the much prominent presentation in early adulthood. The preoperative presentation and surgical treatment are discussed in relation to childhood history.

CONCLUSIONS

Although extremely rare, symptomatic dilatation of the VT can be seen in young adults, usually with previous manifestations in early childhood. This entity should be considered while treating tethered cord spectrum.

Ventriculus terminalis in adults: unusual magnetic resonance imaging features and review of the literature

OBJECTIVE

The ventriculus terminalis (VT) in adults is a rare pathology. We report various MR imaging features of the adult VT.

MATERIALS AND METHODS

Ten patients were included in this retrospective review.. All patients had undergone magnetic resonance (MR imaging with a surface coil that used two different 1.5T MR systems. All patients had undergone initial and follow-up MR imaging with contrast enhancement using gadopentate dimeglumine. Three patients underwent additional MR imaging using the echocardiogram-gated spatial modulation of magnetization (SPAMM) technique. If a shift in tagging band during the systolic phase was less than half of the band space, it was defined as a "non-pulsatile fluid". Two neuroradiologists independently reviewed these images, while clinical symptoms and outcomes were statistically analyzed between the treated and non-treated group.

RESULTS

All cases presented an intramedullary cystic lesion in the conus medullaris and showed the same signal intensity as CSF. Three VTs had intracystic septation and cord edema, which were pathologically confirmed after surgery; two of these were associated with kyphotic deformity and spinal arteriovenous malformation. SPAMM-MRI of 3 patients demonstrated non-pulsatile fluid motion within the VT. In the treated group, clinical symptoms improved better than the non-treated group.

CONCLUSION

The adult VT shows some unusual imaging features, including septation, cord edema, and coexistence of a spinal AVM, as well as the typical findings. Surgical maneuvers may be considered as a treatment option in adult VT with progressive neurological symptoms.

Cystic dilation of the ventriculus terminalis

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.

Intramedullary lesions of the conus medullaris: differential diagnosis and surgical management

The medullary conus represents a distinct entity of the spinal cord regarding its anatomical, clinical and microsurgical features. An overview of the pathologic processes of this region is provided. Epidemiological, clinical and neuroradiological characteristics of neoplastic (glial tumors, non-glial tumors, metastasis, primary melanomas) and non-neoplastic lesions (granulomatous lesions, abscess, parasitic infections, vascular, demyelinating and dysembryogenetic lesions) are discussed. Main MR imaging characteristics used to differentiate neoplastic from non-neoplastic lesions consist in pathological spinal cord expansion, gadolinium-enhancement and tumoural cyst formation. Management strategies differ substantially, depending on the kind of lesion. According to the suspected pathological entity radical resection, biopsy or conservative treatments are reasonable options. Intraoperative electrophysiological monitoring is a fundamental part of the surgical setting.

Cystic lesion of the ventriculus terminalis: proposal for a new clinical classification

The ventriculus terminalis is a small cavity inside the conus medullaris that is formed during the embryonic development. Previous reports regarding cystic lesion of the ventriculus terminalis (CLVT) in adults have detailed a broad and diversified distribution in terms of clinical symptoms, clinical evolution, neurological findings, and treatment. Therefore, nonstandardized management has led to unsatisfactory outcomes. Thus, the authors propose a new classification system in which the clinical presentation is taken into account to standardize the cases and facilitate the proper management of these lesions. Two more cases are described. The literature was reviewed, dividing the patients into 3 groups by clinical presentation as follows: CLVT Type I, patients with nonspecific neurological symptoms or nonspecific complaints; CLVT Type II, presence of focal neurological deficit; and CLVT Type III, presence of sphincter disturbances (bowel or bladder dysfunction). Two patients were classified as CLVT Type I, 3 as CLVT Type II, and 12 as CLVT Type III. In Type I, no improvement was observed in clinical evaluation after surgery, and stable symptoms were achieved with clinical management. In Type II, 2 patients had total improvement and 1 had subtotal improvement after surgery. Finally, in Type III, 92% of the patients improved postoperatively; among these 33% presented with total improvement. Only 1 case in this group was handled conservatively and no improvement was documented. This new classification is useful to group the patients into 3 clinical types to provide guidance as to the best management options. Treatment for the Type I lesion seems to be best conducted conservatively, whereas Types II and III seem to be best handled surgically.

Cystic dilation of the ventriculus terminalis in adults

✓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 anterior portion of the spinal cord. Normally, such a cavity is identifiable only histologically in children and adults and can be visualized using common neuroradiological techniques only after dilation. Currently, the mechanisms of isolated dilation are not documented. The present work describes 2 cases of VT in elderly patients. Data from a histological and ultrastructural study of a case of VT dilation are reported, and the results are compared with those obtained from the VT of 5 fetuses to explain the nosological aspects of nontumoral VT lesions. Our data suggest that the site, age, and histological characteristics of the lesion allow us to define VT dilation as a nosological entity distinct from other cystic dilations of the conus medullaris.

Isolated filar cyst on lumbar spine sonography in infants: a case-control study

BACKGROUND

Simple cysts found within the filum terminale of infants on lumbar spine sonography are relatively common, but no study has established their clinical significance.

OBJECTIVE

To obtain information on the sonographic features of isolated filar cysts and determine their clinical significance in comparison with age- and sex-matched controls.

MATERIALS AND METHODS

We performed a retrospective review of 644 consecutive spine sonograms in patients younger than 8 months. Gestational age- and sex-matched controls with normal lumbar sonograms were taken from the same period. We obtained short-term clinical follow-up of motor milestones for each group.

RESULTS

The incidence of filar cyst was 78 of the 644 (11.8%) and was inversely related to age. Developmental follow-up of the study patients compared with control population showed no statistically significant difference in the ages at which the infants were able to turn over, crawl and walk. Follow-up MR imaging of 13 study patients (19%) failed to demonstrate filar cysts previously identified on sonography.

CONCLUSION

No significant difference was found in the short-term outcome of infants with isolated filar cysts on lumbar sonography compared with that of a control population. Filar cysts should be considered a normal variant when found in isolation on lumbar sonography.