Acute triventricular hydrocephalus caused by choroid plexus cysts: a diagnostic and neurosurgical challenge

Symptomatic intraventricular choroid plexus cysts. Illustrative case and systematic review

Although choroid plexus cysts are a frequent incidental neuroimaging finding, symptomatic ones are rare-a series of more than five cases are hard to find. In the absence of high-volume studies, there are no generally accepted algorithms for diagnosis and treatment for this pathology. Proposed surgical techniques include microsurgical excision or fenestration and endoscopic excision or fenestration with or without additional shunting. No definitive conclusions exist about the superiority of a certain technique. Here, we introduce an illustrative case of a patient with a symptomatic choroid plexus cyst in the trigone of the lateral ventricle and a systematic review of 65 additional published cases with the aim of identifying epidemiological features, variants of localization of the cysts, their symptoms, persistence of concomitant obstructive hydrocephalus, and treatment modalities. A PRISMA-based literature search was performed on the PubMed, MEDLINE, Scopus, and Web of Knowledge databases. We include in the review case reports and case series of symptomatic choroid plexus cysts with full texts or valuable abstracts available online in English and published by April 2023. All abstracts of retrieved studies were assessed by two independent researchers to avoid bias. Only descriptive statistics were used for the presentation of the results. A total of 48 studies (39 case reports and 9 case series) with 65 depicted cases met the eligibility criteria. The review showed a slight predominance of choroid plexus cysts in men. The most common localizations of cysts were the trigone and the body of the lateral ventricle. Obstructive hydrocephalus is often present in patients with choroid plexus cysts. The most common symptoms of cysts were signs of increased ICP: headaches and vomiting. The main treatment approaches for symptomatic choroid plexus cysts were microsurgical excision, microsurgical fenestration, endoscopic fenestration, and total endoscopic excision. The tendency has been noted to shift from microsurgical to endoscopic procedures over the past two decades. Some data on the classification of cysts of the central nervous system and the underlying mechanisms of the pathogenesis of choroid plexus cysts are also presented.Although symptomatic cases of choroid plexus cysts are rare, by summarizing currently available data, one could clarify their common features and identify a preferable treatment modality.

Utility of balanced steady-state field precession sequence in the evaluation of retinal and subdural hemorrhages in patients with abusive head trauma

Abusive head trauma is the leading cause of physical child abuse deaths in children under 5 years of age in the United States. To evaluate suspected child abuse, radiologic studies are typically the first to identify hallmark findings of abusive head trauma including intracranial hemorrhage, cerebral edema, and ischemic injury. Prompt evaluation and diagnosis are necessary as findings may change rapidly. Current imaging recommendations include brain magnetic resonance imaging with the addition of a susceptibility weighted imaging (SWI) sequence which can detect additional findings that suggest abusive head trauma including cortical venous injury and retinal hemorrhages. However, SWI is limited due to blooming artifacts and artifacts from the adjacent skull vault or retroorbital fat, which can affect the evaluation of retinal, subdural, and subarachnoid hemorrhages. This work explores the utility of the high-resolution, heavily T2 weighted balanced steady-state field precession (bSSFP) sequence to identify and characterize retinal hemorrhage and cerebral cortical venous injury in children with abusive head trauma. The bSSFP sequence provides distinct anatomical images to improve the identification of retinal hemorrhage and cortical venous injury.

Three-Dimensional Constructive Interference in Steady State (3D CISS) Imaging and Clinical Applications in Brain Pathology

Three-dimensional constructive interference in steady state (3D CISS) is a steady-state gradient-echo sequence in magnetic resonance imaging (MRI) that has been used in an increasing number of applications in the study of brain disease in recent years. Owing to the very high spatial resolution, the strong hyperintensity of the cerebrospinal fluid signal and the high contrast-to-noise ratio, 3D CISS can be employed in a wide range of scenarios, ranging from the traditional study of cranial nerves, the ventricular system, the subarachnoid cisterns and related pathology to more recently discussed applications, such as the fundamental role it can assume in the setting of acute ischemic stroke, vascular malformations, infections and several brain tumors. In this review, after briefly summarizing its fundamental physical principles, we examine in detail the various applications of 3D CISS in brain imaging, providing numerous representative cases, so as to help radiologists improve its use in imaging protocols in daily clinical practice.

Acute hydrocephalus caused by a gelatin-sponge material: a case report

Third ventricle lesions, especially those located proximally to the foramen of Monro, generally present with obstructive hydrocephalus symptoms. In this report, we present a case with acute obstructive hydrocephalus secondary to a gel-foam material. The patient has previously underwent an endoscopic cystectomy. At postoperative third month, she admitted to our hospital with the complain of headache. Neuroradiological imaging revealed triventricular hydrocephalus. A second endoscopic operation was performed, and a piece of gelatin-sponge material was detected at the level of cerebral aqueduct, which obstructed the flow of cerebrospinal fluid (CSF). The CSF flow was immediately restored after removing this material, and an additional third ventriculostomy was performed.

Choroid plexus cyst causing acute hydrocephalus and transtentorial herniation: report of a rare case and its successful neuroendoscopic treatment

Choroid plexus cysts (CPC) are a frequent incidental neuroimaging finding and completely asymptomatic in the vast majority of cases. We hereby describe a rare case of acute hydrocephalus secondary to a CPC, atypical in size, location and presentation, which required urgent neuroendoscopic management. There are very few reported cases of CPC causing obstructive hydrocephalus. The authors present the case of a previously healthy 2-year-old boy with severe symptoms of acute intracranial hypertension, triventricular hydrocephalus, and left ventricle exclusion after placement of a right external ventricular drain. Magnetic resonance imaging (MRI) showed a very subtle gadolinium enhancement in the anterior region of the third ventricle and foramen of Monro (FM). An emergency neuroendoscopic exploration was performed, where a big cyst was found in the choroid plexus near the FM. The foramen was completely unblocked by thoroughly fenestrating and coagulating the cyst, and a preventive endoscopic septum pellucidotomy was done in the same procedure. The patient completely resolved his symptoms, without neurological morbidity or requirement of a cerebrospinal fluid shunt placement. It is important to consider this infrequent presentation in cases of acute or intermittent obstructive hydrocephalus without apparent cause, bearing in mind its difficult detection in neuroimaging studies and the possibility of effective neuroendoscopic treatment.

Incidental Intracranial Cysts in Children

With increasing use of intracranial imaging, the diagnosis of benign intracranial cysts is becoming more frequent in the pediatric population. These lesions are usually incidentally discovered during the work-up of unrelated symptoms. Most do not require treatment and many do not even require imaging follow-up. When symptomatic, symptoms of these lesions are usually caused by local mass effect. Symptomatic lesions warrant neurosurgical evaluation, and may require surgical intervention in rare, well-selected cases. This article describes three common benign intracranial cysts found in the pediatric population: arachnoid cysts, choroid cysts, and pineal cysts.

Giant choroid plexus cysts with calvarial erosion: a case report and literature review

Choroid plexus cysts rarely grow to be symptomatic. Few large choroid plexus cysts have been reported in the pediatric population. The authors report a 15-month-old boy with increased head circumference and a bony deformity in the left parietal region due to mass effect from a giant choroid plexus cyst. The child had a craniotomy for open resection of the cyst, and made an excellent recovery. The differential diagnosis for intraventricular cysts and the literature surrounding choroid plexus cysts are discussed.

Migrating Lateral Ventricle Choroid Plexus Cyst into the Fourth Ventricle Causing Acute Hydrocephalus

Choroid plexus cysts consist of abnormal folds of the choroid plexus that typically resolve prior to birth. Rarely, these cysts persist and may cause outflow obstruction of cerebrospinal fluid. In this article, we presented a 5-month-old male child patient who presented with lethargy, vomiting, and a bulging anterior fontanelle. Magnetic resonance imaging showed one large choroid plexus cyst had migrated from the right lateral ventricle through the third ventricle and cerebral aqueduct into the fourth ventricle causing outflow obstruction. The cyst was attached to the lateral ventricle choroid plexus by a pedicle. The cyst was endoscopically retrieved from the fourth ventricle intact and then fenestrated and coagulated along with several other smaller cysts. Histologic examination confirmed the mass was a choroid plexus cyst. The patient did well after surgery and did not require any cerebrospinal fluid diversion. Nine months after surgery, the patient continued to thrive with no neurological deficits. This case is the first we have found in the literature of a lateral ventricular choroid plexus cyst migrating into the fourth ventricle and the youngest of any migrating choroid plexus cyst. Only three other cases of a migrating choroid plexus cyst have been documented and those only migrated into the third ventricle. New imaging advances are making these cysts easier to identify, but may still be missed on routine sequences. High clinical suspicion for these cysts is necessary for correct treatment of this possible cause of hydrocephalus.

Management of multiloculated hydrocephalus in children with emphasis on role of CT ventriculography

OBJECTIVE

The authors performed a retrospective review of children diagnosed with multiloculated hydrocephalus (MLH) in our institute. The goal was to analyze the different diagnostic and therapeutic modalities used with special emphasis on CT ventriculography (CTV).

METHODS

Male and female patients below the age of 18 years diagnosed with MLH were included. Cases of uniloculated hydrocephalus like entrapped temporal horn or isolated fourth ventricle were excluded. We used iohexol for CTV and gadodiamide for MR ventriculography. Neuroendoscopic procedures performed were endoscopic fenestration, endoscopic third ventriculostomy (ETV), endoscopic septostomy, endoscopic aqueductoplasty, or a combination of the above. The cohort was divided into two groups (endoscopic or shunt) based on initial surgical intervention.

RESULTS

A total of 52 patients were included, with 43 boys and 9 girls. The average age of presentation was 7.7 months. The most common predisposing factor for MLH was neonatal meningitis seen in 30 patients. Mean duration of follow-up was 39 months. CTV was used in 26 patients and MR ventriculography in three patients. In one patient, the diagnosis of MLH was ruled out after ventriculography. Patients who underwent ETV only had the best outcome with 71.4% success rate. At the end of follow-up, 14 patients (27%) were shunt independent.

CONCLUSIONS

The present study indicates that CTV helps to accurately define the anatomy of the ventricles and determine the site of physiological CSF obstruction. This helps in therapeutic planning and in avoiding misdiagnoses. Further, neuroendoscopy has the potential to lead to shunt independence in some patients.

Choroid Plexus Cyst of the Fourth Ventricle Associated with Intermittent Obstructive Hydrocephalus

BACKGROUND

Choroid plexus cysts (CPCs) are a type of neuroepithelial cysts, benign lesions located more frequently in the supratentorial compartment. Symptomatic CPCs in the posterior fossa are extremely rare and can be associated with obstructive hydrocephalus.

CASE DESCRIPTION

A previously healthy elderly woman suffered intermittent attacks of headache and vomiting associated with gait instability. Magnetic resonance imaging documented a large cystic lesion occupying all the fourth ventricle. An endoscope-assisted fenestration of the lesion through a telovelar approach determined only temporary improvement, hence a second surgery with gross total resection of the cyst was performed, with successful long-term clinical and radiologic resolution. Histology revealed CPC.

CONCLUSIONS

Fourth ventricle symptomatic CPCs are extremely rare lesions, especially in the elderly. Their presence must be carefully evaluated as a possible rare cause of intermittent obstructive hydrocephalus. Even though cyst fenestration with restoration of the cerebrospinal fluid pathway represents the best treatment in the majority of cases, a more aggressive resection is sometimes necessary.

Symptomatic lateral ventricular cystic lesion in a young cat

Case summary

A 1.5-year-old male neutered Persian cat was referred for acute deterioration of chronic left head tilt and ataxia. A lateral intraventricular cystic lesion, closely associated with the left choroid plexus, was identified on MRI. The intralesional signal intensity and cytological analysis of the fluid revealed a liquid similar to cerebrospinal fluid. After trepanation, an endoscopic-assisted fenestration and aspiration of the cyst were performed to temporally relieve the high intracranial pressure while waiting for surgical cystoperitoneal shunt placement. Three weeks after surgery, clinical relapse and recurrence of the lesion were noted on the pre-cystoperitoneal shunting MRI. During anaesthesia, the cat arrested. Cardiac resuscitation was successfully performed and cystoperitoneal shunting was postponed. Global brain ischaemia was then suspected, based on major forebrain clinical signs and MRI abnormalities. During a 6-month recovery period, a further three fine-needle CT-guided aspirations of the lesion were required, owing to clinical recurrence and increased cyst size. Cystoperitoneal shunting was eventually performed, allowing persistent reduction of the lesion and long-term improvement of the cat’s neurological status.

Relevance and novel information

This is the first report of a symptomatic lateral intraventricular cystic lesion in a cat. A left lateral intraventricular choroid plexus cyst was suspected based on the MRI features. Our case suggests that endoscopic fenestration and CT-guided aspiration are not adequate treatments for long-term management. Cystoperitoneal shunting may be a safe procedure, allowing significant and stable reduction of the cystic lesion, associated with improvement in the cat’s neurological status by preventing high intracranial pressure.

A case of a mobile choroid plexus cyst presenting with different types of obstructive hydrocephalus

Background

Although it is well known that most choroid plexus cysts (CPCs) are asymptomatic, previous studies have reported that they can infrequently cause progressive hydrocephalus along with their increasing sizes. Among those cases, some patients needed cyst fenestration or cerebrospinal fluid (CSF) diversion to recover neurological deterioration. Meanwhile, some CPCs revealed spontaneous resolution, and in rare cases, they developed re-accumulation. Some reports have described series of radiological findings about their changes in location.

Case Description

We present a 47-year-old male with CPC manifesting obstructive hydrocephalus. Radiological findings of the lateral and the third ventricles changed along with their different obstructive points, leading to their own symptoms. Because the patient's symptoms were not resolved completely, he underwent endoscopic fenestration for the cyst at the third ventricle. We could perform near-total resection, resulting in recovery of normal CSF flow. Postoperatively, the size of the ventricles decreased, with histological confirmation of a CPC. His symptoms resolved clearly without any complications.

Conclusions

It seems quite unusual that shift of the CPC location in the ventricle systems could induce not only different types of hydrocephalus but also their own symptoms. We need to consider that the location of CPCs might change when patients present with fluctuating symptoms over time.