Symptomatic xanthogranuloma of choroid plexus with unilateral hydrocephalus. Case report

Management of entrapped temporal horn: Literature review and operative technique for endoscopic fenestration

CONTEXT

Entrapment of the temporal horn (TH) is rare condition that can lead to increased intracranial pressure, but there is no consensus on a standard treatment. The aim of this study was to conduct a systematic literature review of the reported cases of TH entrapment and describe our operative technique for endoscopic fenestrations of the lateral ventricle into the basal cisterns.

METHODS

We searched the databases Pubmed and Google scholar to find all studies reporting cases of entrapped TH and the subsequent treatment. Additionally, we report two illustrative cases of endoscopic fenestration with a step-by-step description of our surgical technique.

RESULTS

Twenty-nine studies with a total of 67 patients were included in the analysis. The mean age was 36.5 years (SD± 21.9), and the female-to-male ratio was 1.5. The most frequent cause of TH entrapment was post-surgical scarring after tumor surgery (n= 30), and the most commonly reported treatment modality was endoscopic fenestration of the TH (n = 14). We observed an increasing use of endoscopic fenestration over time.

CONCLUSION

Entrapped TH is a rare condition often requiring surgical treatment. Neuronavigation-guided endoscopic fenestration of the ventricle into the basal cisterns appears to be a safe, efficient, and device-free technique that has gained importance over the past years.

Trapped temporal horn: From theory to practice, a systematic review of current understanding and future perspectives

Background

The Entrapped Temporal Horn (ETH) is characterized by localized enlargement of the temporal horn of the lateral ventricle of the brain. This study aimed to investigate the factors, development, prognosis, and effective treatment.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic search was conducted in major research databases. The inclusion criteria included patients of all ages with TTH diagnosis in cohort studies, case series, and case reports.

Results

Our study included 160 patients and 49 studies. The major causes of TTH were neoplastic lesions (42.3%), infections (22.3%), and cystic disease (13.08%). Of these cases, 71 were unrelated to cranial surgery, while 89 were unrelated to prior surgeries. Headache was the most common symptom (41.91%), followed by seizures (13.20%), drowsiness (12.50%) and memory loss (11.00%). Surgery was not required in 17 patients. Fenestration of the trapped temporal horn was performed in 24 patients, while VP/VA shunt surgeries were performed in the majority (57 patients) owing to favorable outcomes, lower revision rates, and extensive experience. However, TTH recurred in six of the 21 patients who underwent endoscopic ventriculocisternostomy. Tumors were the main cause, and isolated headache was the most frequent symptom. Ventriculoperitoneal shunts (VPS) are preferred because of their positive outcomes, lower revision rates, and wider expertise. Tumors near the trigonal area pose a higher risk.

Conclusion

Although TTH remains a rare condition, VPS continues to be the most widely preferred procedure among surgeons.

Symptomatic bilateral choroid plexus xanthogranuloma in a pediatric patient

INTRODUCTION

Central nervous system xanthogranulomas are uncommon clinical entities, and symptomatic bilateral choroid plexus xanthogranulomas are rare.

CASE PRESENTATION

We present the case of a 15-year-old male patient with bilateral choroid plexus xanthogranulomas with symptoms of increased intracranial pressure. Gross total resection of the tumor in the left lateral ventricle was performed. The patient improved, and asymptomatic right-sided tumor was monitored at follow-up.

CONCLUSION

The main treatment objective in these tumors is gross total resection. Asymptomatic tumors can be followed without intervention. However, surgery should be performed for symptomatic tumors that cause hydrocephalus or symptoms of increased intracranial pressure.

Entrapment of the temporal horn: case series and systematic review of literature

Entrapment of the temporal horn (ETH) is a form of focal, obstructive hydrocephalus. Etiology and clinical presentation are diversified. Though known since 1947, standard treatment has not yet been defined. The objective of our study was to perform a systematic review on ETH. Data from patients treated at our Institution from 2008 to 2019 were retrospectively collected and analyzed. A systematic PRISMA review of literature was also performed using PubMed and Google Scholar. 121 cases (mean age 41 years; M/F ratio 1/1) were analyzed. In 65 (vs 56) cases (53.7% vs 46.3%) ETH was not surgery related. Headache was the most common symptom (42%). "Major" treatments were (1) ventriculoperitoneal/ventriculoatrial shunt (42 cases, 34.7%), and (2) endoscopic ventriculocisternostomy (12 cases, 9.9%). In the first group, no perioperative complications were found, 39 patients (92.9%) had a favorable outcome, 3 patients (7.1%) died for the underlying disease, 4 cases (9.5%) went through revision; also considering the cases in which another procedure was performed as definitive treatment, shunt failures were 6 (13.6%). In the second group, 1 case (8.3%) developed a deep intracerebral hemorrhage, 11 cases (91.6%) had a favorable long-term outcome, 1 case (8.3%) had a favorable short-term outcome; also considering the cases in which another procedure was performed as definitive treatment, endoscopic ventriculocisternostomy failures were 6 (37.5%). Described as uncommon, ETH is probably underestimated. Early diagnosis and appropriate treatment are critical. VP shunt is still the most commonly performed treatment. Further randomized clinical trials are, however, needed to establish the gold standard.

Symptomatic xanthogranuloma of the lateral ventricle in a pregnant patient treated with delayed resection: A case report and systematic review

Intracranial xanthogranulomas (XG) are a rare benign histiocytic neoplasm and most often within the choroid. The majority are asymptomatic and are found incidentally on imaging or post-mortem examination or autopsy. We present a case of symptomatic XG in a pregnant patient who underwent a delayed transcortical, transventricular approach for lateral ventricle XG resection following the completion of her pregnancy. Four years post-operatively, the patient is neurologically intact and without recurrence. Our review of the literature showed differences among XG depending on location. The clinical and radiological features of XG are often indistinguishable from tumors arising from the choroid plexus and should be considered as a rare etiology in the differential of newly diagnosed intraventricular lesions.

Levodopa-responsive parkinsonism in a patient with corticobasal degeneration and bilateral choroid plexus xanthogranulomas

Corticobasal degeneration (CBD) has substantial overlap of clinical features with other neurodegenerative diseases including Parkinson's disease (PD). Its clinical diagnostic accuracy is the lowest among the common neurodegenerative diseases, and its antemortem diagnosis is more challenging when CBD is comorbid with another brain disease. We report an elderly male patient with multiple medical conditions and a family history of essential tremor. He presented with progressive tremor that was initially thought to be essential tremor and later diagnosed as PD despite head computerized tomography showing bilateral intraventricular masses and other minor changes. The clinical diagnosis of PD was supported by his responsiveness to low-dose levodopa. However, postmortem neuropathological examination revealed CBD and bilateral choroid plexus xanthogranulomas with mild ventricular enlargement and multifocal ependymal lining injury presumably due to mild hydrocephalus. CBD is typically levodopa-unresponsive, but hydrocephalus-associated parkinsonism is commonly levodopa-responsive. We raise awareness of the present comorbidity and atypical parkinsonism due to the choroid plexus xanthogranuloma-induced hydrocephalus for the clinical diagnosis and management of parkinsonism.

Neuronavigator-guided ventriculoscopic approach for symptomatic xanthogranuloma of the choroid plexus in the lateral ventricle

Xanthogranuloma of choroid plexus is an extremely rare, benign, and mostly asymptomatic intracranial lesion. We report a case of symptomatic lateral ventricular xanthogranuloma resected via a neuronavigator-guided ventriculoscopic approach. Then we review recent English medical literature and notice that craniotomies have been the most popular treatment. But our choice of a ventriculoscopic approach possesses unique advantages such as minimized neural tissue damage, shortened operative time, less blood loss, and safer access to central structures over conventional open surgeries. Informed consent has been obtained from the patient and his immediate family regarding this case report.

Symptomatic intraventricular xanthogranulomas

This article reviews symptomatic intraventricular xanthogranulomas, based on a case presentation. Bilateral xanthogranulomas of the choroid plexus were removed surgically from the lateral ventricles of a 12-year-old boy. At 9 years of age, he had evidence of increased intracranial pressure and was hospitalized. Dense enhancing masses were detected in computerized tomogram (CT) brain scan. The lesions were in the region of trigones with extension into the temporal horns and into the right occipital horn. The masses were brightly yellow and greasy. They measured 8.5 x 5.5 x 3.5 cm and 10 x 6.5 x 4.5 cm, respectively, and proved to be xanthogranulomas. Review of 35 reported symptomatic intraventricular xanthogranulomas revealed 11 lesions in the lateral ventricles in which six of them were bilateral. Twenty-two lesions were in the third ventricle, and two lesions were in the fourth ventricle. The lesion shows no significant sexual predilection. The patients’ average age is 37.6 years for males, 32.4 years for females, and 34.3 years for both sexes. The size of symptomatic lesions ranged from 1 to 3 cm in diameter but a few were large, up to 8 to 10 cm. The origin of foamy (xanthoma) cells in the xanthogranulomas arising in the choroid plexus is thought to be multicentric including the choroidal epithelium and stromal arachnoidal cells that have undergone xanthomatous changes. Increased intracranial pressure is the significant clinical feature of the intraventricular xanthogranulomas as in other mass lesions within the skull. Surgical extirpation is the treatment of choice if the lesion is accessible and the patient’s general condition is suitable.

Symptomatic Bilateral Xanthogranuloma of the Choroid Plexus

Xanthogranulomas (XGRs) of the choroid plexus are rare, asymptomatic, and benign lesions usually found incidentally. Here, we present a case of a 47-year-old male with bilateral XGR of the choroid plexus with periventricular edema and discuss our case in relation to a review of existing literature pertaining to the radiology of XGRs. To the best of our knowledge, this is the first reported case of bilateral trigonal XGR causing brain edema without ventricular dilatation. Despite the fact that they can cause hydrocephalus, XGRs are silent and benign lesions. Although the etiopathology of XGRs remains poorly understood, enhanced imaging analyses may provide additional information regarding edema and focal white matter signal changes.

Hydrocephalus caused by unilateral foramen of Monro obstruction: A review on terminology

Background:

Hydrocephalus caused by unilateral foramen of Monro (FM) obstruction has been referred to in literature by many different terminologies. Precise terminology describing hydrocephalus confined to just one lateral ventricle has a very important prognostic value and determines whether or not the patient can be shunt free after an endoscopic procedure.

Methods:

Aiming to define the best term for unilateral FM obstruction, 19 terms were employed on PubMed database (http://www.ncbi.nlm.nih.gov/pubmed) as quoted phrases.

Results:

A total of 194 articles were found. Four patterns of hydrocephalus were discriminated as a result of our research term query and were divided by types for didactic purpose. Type A - partial dilation of the lateral ventricle; Type B - pure unilateral obstruction of the FM; Type C - previously shunted patients with secondary obstruction of the FM; and Type D - asymmetric lateral ventricles with patent FM.

Conclusion:

In unilateral FM obstruction hydrocephalus, an in-depth review on terminology application is critical to avoid mistakes that may compromise comparisons among different series. This terminology review suggests that Type B hydrocephalus, i.e., the hydrocephalus confined to just one lateral ventricle with no other sites of cerebrospinal fluid circulation blockage, are best described by the terms unilateral hydrocephalus (UH) and monoventricular hydrocephalus, the first being by far the most popular. Type A hydrocephalus is best represented in the literature by the terms uniloculated hydrocephalus and loculated ventricle; Type C hydrocephalus by the terms isolated lateral ventricle and isolated UH; and Type D hydrocephalus by the term asymmetric hydrocephalus.

MRI and histopathologic study of a novel cholesterol-fed rabbit model of xanthogranuloma

PURPOSE

To develop a rabbit model of xanthogranuloma based on supplementation of dietary cholesterol. The aim of this study was to analyze the xanthogranulomatous lesions using magnetic resonance imaging (MRI) and histological examination.

MATERIALS AND METHODS

Rabbits were fed a low-level cholesterol (CH) diet (n = 10) or normal chow (n = 5) for 24 months. In vivo brain imaging was performed on a 3T MR system using fast imaging employing steady state acquisition, susceptibility-weighted imaging, spoiled gradient recalled, T1 -weighted inversion recovery imaging and T1 relaxometry, PD-weighted and T2 -weighted spin-echo imaging and T2 relaxometry, iterative decomposition of water and fat with echo asymmetry and least-squares estimation, ultrashort TE MRI (UTE-MRI), and T2* relaxometry. MR images were evaluated using a Likert scale for lesion presence and quantitative analysis of lesion size, ventricular volume, and T1 , T2 , and T2* values of lesions was performed. After imaging, brain specimens were examined using histological methods.

RESULTS

In vivo MRI revealed that 6 of 10 CH-fed rabbits developed lesions in the choroid plexus. Region-of-interest analysis showed that for CH-fed rabbits the mean lesion volume was 8.5 ± 2.6 mm(3) and the volume of the lateral ventricle was significantly increased compared to controls (P < 0.01). The lesions showed significantly shorter mean T2 values (35 ± 12 msec, P < 0.001), longer mean T1 values (1581 ± 146 msec, P < 0.05), and shorter T2* values (22 ± 13 msec, P < 0.001) compared to adjacent brain structures. The ultrashort T2* components were visible using UTE-MRI. Histopathologic evaluation of lesions demonstrated features of human xanthogranuloma.

CONCLUSION

Rabbits fed a low-level CH diet develop sizable intraventricular masses that have similar histopathological features as human xanthogranuloma. Multiparametric MRI techniques were able to provide information about the complex composition of these lesions. J. Magn. Reson. Imaging 2016;44:673-682.

Symptomatic bilateral cerebellar mass lesions: an unusual presentation of intracranial xanthogranuloma

Xanthogranulomas are a group of benign lesions with an incidence of 1.6-7.0% in various autopsy series. Although the lateral ventricle is the most frequent intracranial site involved, most symptomatic cases occur in the choroid plexus, involving the third ventricle. Multicentric bilateral symptomatic cerebellar xanthogranuloma has not been reported previously. We describe a 35-year-old man who presented with a complaint of vertigo, with nystagmus and left-side cerebellar signs found on clinical examination. Radiological evaluation revealed bilateral cerebellar lesions abutting the cerebellopontine angle cistern. The left-side lesion was excised and diagnosed as xanthogranuloma up on histopathological examination. The right-side lesion was subsequently excised 4 years later when it became symptomatic. The role of histopathology cannot be overemphasized in the diagnosis of this rare lesion and long-term follow-up is advised in cases managed conservatively owing to the propensity of this tumor to grow over time.

Xanthogranuloma of the choroid plexus of the third ventricle: case report and literature review

Xanthogranulomas of the choroids plexus (XG) are benign tumours of debatable etiology which become rarely symptomatic. Only few cases have been studied with MRI. A new case of xanthogranuloma of the third ventricle showing unusual features in the CT and MRI studies in a 47-year-old man with a 2-month history of gait and urinary disturbances and cognitive impairment is reported. The literature concerning clinical and neuroradiological presentation of intracranial xanthogranulomas is reviewed.

Necrobiotic xanthogranuloma with cutaneous and cerebral manifestations

✓ Necrobiotic xanthogranuloma (NXG) is a rare inflammatory histiocytic disease of the skin. Xanthogranuloma of the central nervous system is rare and few cases have been reported. To the authors' knowledge, there has been no previously reported case of NXG in which an intracranial lesion was found.

This 52-year-old man, in whom NXG with all its cutaneous manifestations had been diagnosed, presented with three episodes of generalized tonic—clonic seizures. A contrast-enhanced computerized tomography scan of his brain revealed a bifrontal, dura-based mass lesion. The lesion was excised and reported to be an NXG that was similar, but not identical to the skin lesions. The patient was placed on a regimen of antiepileptic drug and chlorambucil after surgery.

Pineal xanthogranuloma

A 64-year-old man presented a large pineal cystic lesion manifesting as headache and exhibiting unusual neuroradiological findings. Magnetic resonance imaging showed a cystic lesion appearing as hyperintense on both T1- and T2-weighted images, and a nodular lesion which was hypointense on T1-and mixed intensity on T2-weighted images. The cystic mass was removed via a right occipital transtentorial approach. Histological examination disclosed that the inner surface of the cystic part consisted of bi-layered epithelial lining, portions of which had changed to stratified squamous epithelium. The solid part showed the characteristics of xanthogranuloma such as cholesterol clefts, hemosiderin-laden macrophages, and foreign body giant cells.

[Symptomatic xanthograuloma of the lateral ventricle]

Xanthogranulomas of the choroid plexus in the lateral ventricle are usually asymptomatic lesions found incidentally at autopsy. Symptomatic cases are rare. We present the case of a 30-year-old woman with a xanthogranuloma of the right lateral ventricle who showed intracranial hypertension and visual disturbance. Plain T1-weighted magnetic resonance images disclosed a isointense right temporal lesion in the ventricular horn which showed decreased signal intensity on T2-weighted images and massive enhancement on T1-weighted images after gadolinium injection. She was operated on through a right temporal craniotomy with total excision. We review the literature and discuss radiological findings on MRI.

Symptomatic solitary xanthogranuloma occupying the cavernous sinus. Case report

The authors report the first case of a solitary xanthogranuloma of the cavernous sinus without systemic manifestation. A 43-year-old woman experienced decreased visual acuity on the right side in association with papilledema and a visual field defect. She was alert and no other neurological sign was observed. She had no family history of hyperlipoproteinemia and no cutaneous and/or systemic xanthomatous lesions. Skull x-ray films showed an enlarged right superior orbital fissure. Computerized tomography revealed a low-density oval mass 2 x 3 cm in diameter in the right cavernous region that was compressing the right optic nerve in the lateral to medial direction. This mass exhibited isointensity on T1-weighted and mixed-pattern hyperintensity on T2-weighted magnetic resonance images with diffuse contrast enhancement. Cerebral angiography demonstrated fine staining in the margin, originating from the right middle meningeal artery. These neuroimaging findings closely mimicked those associated with trigeminal neuroma. The lesion was partially removed via a right-sided zygomatic approach, and her symptoms improved. Clinical characteristics and histopathological features of this rare case are discussed.

Diagnostic imaging of choroid plexus disease

Disorders of the choroid plexus, a central nervous system structure, are rare, but can pose diagnostic difficulties. The purpose of this review is to illustrate the computed tomography and magnetic resonance imaging findings of a wide spectrum of lesions that affect the choroid plexus. The areas covered include (1) neoplasms (papilloma, leukaemia, meningioma, lymphoma and metastases); (2) infections (bacterial, fungal and viral); (3) cysts; (4) haemorrhage; (5) congenital abnormalities (Sturge-Weber syndrome, Klippel-Trenaunay-Weber syndrome and vascular malformations); and (6) non-infectious inflammatory disorders (xanthogranulomas, inflammatory pseudotumour, neurosarcoidosis, rheumatoid nodule and villous hypertrophy). Few of the patterns of choroid plexus involvement are specific for a particular pathological process. Guermazi, A. (2000) Clinical Radiology 55, 503-516.

Tumours of the lateral ventricle. A retrospective review of 112 cases operated upon 1970-1997

Between the years 1970 and 1997, 112 patients with tumors of the lateral ventricle were operated on at the University of Ankara, School of Medicine, Department of Neurosurgery. Seventy-one patients (63.4%) were male and 41 patients (36.6%) female. Headache (35.7%), nausea and vomiting (22.3%) were the most common presenting complaints. Papilloedema (42.9%), motor and sensory loss (25%) were the most common findings at neurological examination. Complete tumor removal was accomplished in 38.4% of the patients. Histopathologically, the most commonly seen types of the tumor were ependymoma (25%) and astrocytoma (21.4%). Among the various approach, the anterior transcortical (53.6%) and the posterior transcortical (16%) were the most commonly used. Eleven patients were reoperated for tumor recurrence. After surgery, radiation therapy was also performed on fourty-two patients. The morbidity and mortality rates were considerably higher before 1976 when the use of microneurosurgical techniques was introduced. After this, our morbidity and mortality rates decreased dramatically. The overall surgical mortality rate was 7.1% before 1976; during the last 10 years (n:46), it was 6.5%. In this report, our choice of operative approaches and the results will be discussed.

Xanthogranuloma with massive hematoma in the third ventricle: case report

OBJECTIVE AND IMPORTANCE

Symptomatic xanthogranulomas of the ventricular system are rare entities. No case of a massive hematoma in the xanthogranuloma, which may cause sudden deterioration, has been reported. This is the first report of a massive hematoma arising from a xanthogranuloma in the third ventricle.

CLINICAL PRESENTATION

A 35-year-old woman was referred to our hospital with a 1-month history of progressively deteriorating consciousness. Neuroradiological findings revealed a mass in third ventricle and obstructive hydrocephalus.

INTERVENTION

Bilateral external ventricular drainage was performed as an emergency treatment. Two weeks later, the mass was removed totally via the transcallosal-transforaminal approach. The disturbance of consciousness completely disappeared 2 weeks after the second operation. The pathological diagnosis was xanthogranuloma causing massive hematoma.

CONCLUSION

The pathogenesis, clinical and radiological features, differential diagnosis, and treatment of this rare benign tumor are discussed. The hypothalamic dysfunction caused by a massive hematoma in the lesion of the third ventricle may cause sudden deterioration and death, whether the obstructive hydrocephalus exists. The risk of hemorrhage and hydrocephalus still remains after aspiration alone because of the presence of the cyst wall. Radical extirpation should be the choice of treatment for xanthogranulomas or colloid cysts of the third ventricle.

Huge Langerhans cell histiocytosis granuloma of choroid plexus in a child with Hand-Schüller-Christian disease. Case report

In the literature, only two previous cases of presumed Langerhans cell histiocytosis (LCH) granuloma involving choroid plexus have been reported in patients with Hand-Schüller-Christian (HSC) disease, but those cases were not verified by immunohistochemistry or electron microscopy. The authors report a case of LCH granuloma of the choroid plexuses of bilateral lateral ventricles and the fourth ventricle in a child affected by HSC disease. This disease was confirmed by the presence of Birbeck granules on electron microscopy and positive reactivity to S-100 protein. Clinical, radiographic, and histological features are discussed. This case illustrates that LCH granuloma should be considered in the differential diagnosis of intraventricular masses.

Third ventricular xanthogranulomas clinically and radiologically mimicking colloid cysts. Report of two cases

Two cases are reported of third ventricle masses that were clinically and radiographically indistinguishable from pure colloid cysts. A 21- and a 36-year-old man presented with a 5-year and 10-day histories of headache, respectively. Magnetic resonance (MR) imaging revealed smooth, homogeneous masses in the anterior third ventricle that were iso- to hyperintense on T1-weighted MR images and hyperintense on T2-weighted images. There was little enhancement with intravenous contrast material. In both patients, craniotomies were performed and histopathological examination revealed xanthogranulomas of the choroid plexus with only microscopic foci of colloid cyst-like structures. These cases illustrate that xanthogranulomas of the third ventricle may clinically and radiologically mimic pure colloid cysts, that a range of MR imaging signals can be seen, and that craniotomy rather than stereotactic aspiration is the indicated treatment.

Intracranial xanthogranuloma of the dura in Hand-Schüller-Christian disease. Case report

The authors describe a 37-year-old man with the classic clinical features of Hand-Schüller-Christian disease. He presented with symptoms of increased intracranial pressure due to obstructive hydrocephalus secondary to a huge xanthogranuloma involving falx cerebri and tentorium cerebelli. Immunohistochemical and ultrastructural studies failed to demonstrate Langerhans histiocytes, however. The implication of this finding is discussed in light of the recent relevant literature.

Giant bilateral xanthogranulomas in a child: case report

Symptomatic xanthogranulomas are rare lesions that most commonly occur in adults. A case of giant bilateral xanthogranulomas in a 6-year-old boy, who remains without tumor recurrence 9 years after resection, is presented. The operative management of these unusually large lesions is discussed. The pathogenesis of xanthogranulomas is reviewed as it relates to the presentation of these lesions in the pediatric population.

Surgery of tumours of the lateral ventricle

Tumours of the lateral ventricle in most cases enlarge significantly before signs and symptoms are exhibited. In the years between 1980 and 1991 we encountered 55 patients of all age groups with tumours of the lateral ventricle. All were diagnosed either by CT or MRI, and in lesions with good enhancement on CT additional angiography was performed. All 55 tumours were operated upon using microsurgical techniques. The approach was chosen according to the location of the tumour, preferably transcortical. In selected cases large tumours were removed in a two-stage operation. Only in one frontal horn and Cella media tumour an interhemispheric transcallosal approach was used. Postoperative or surgically related mortality was experienced in 3 cases. Life expectancy and morbidity were dependent upon histology.