[Treatment for Hydrocephalus Caused by Intraventricular Tumors]

Intraventricular tumors often cause hydrocephalus because their location in the ventricles affect cerebrospinal fluid circulation. Even small tumors can lead to acute hydrocephalus when they block the cerebrospinal fluid flow. They may also be found as large tumors occurring in large spaces, such as in lateral ventricles. Since various histological tumors occur in ventricles, it is important to consider the treatment strategy according to the expected histological type before treating hydrocephalus in the early stage. In addition, it is beneficial to predict and evaluate the site and size of the tumor, the cause of hydrocephalus, and the effect of postoperative chemotherapy and radiation therapy. Some tumors are sensitive to chemotherapy and radiation therapy, so there is an advantage in performing a biopsy at the same time as hydrocephalus treatment. Ventricular drainage and ventricular peritoneal shunts for patients with high intracranial pressure are at risk of developing ascending hernias, so we should be careful with the procedure.

Is This Truly A "Leave-Me-Alone" Lesion? An Unusual Case of Multiple Ring-shaped Lateral Ventricular Nodules

BACKGROUND

Ring-shaped lateral ventricular nodules (RSLVNs) are commonly considered as benign asymptomatic lesions, which are sporadically detected as incidental findings on routine brain magnetic resonance imaging scans. Despite their not irrelevant frequency, the exact biological nature of these lesions remains largely unknown due to the lack of histopathologic studies. Here we present the clinical, neuroradiologic, and histopathologic findings of an unusual case of symptomatic multiple RSLVNs.

CASE DESCRIPTION

A 44-year-old otherwise healthy man presented with a recent history of headache and retching. Neuroradiologic imaging revealed the presence of multiple RSLVNs, the largest of which, located in the cella media of the right lateral ventricle, exerted a mild to moderate mass effect on adjacent brain parenchyma. This latter nodule was successfully removed, with complete resolution of the symptoms. Histopathology revealed glial differentiation, and the specimen was diagnosed as subependymoma.

CONCLUSIONS

This report provides novel evidence characterizing RSLVNs as possible variants of subependymoma with a peculiar imaging appearance, also suggesting that, like subependymomas, they may occasionally grow large enough to cause mass effect-related symptoms, thus requiring neurosurgical intervention.

Hypothalamic relapse of a cardiac large B-cell lymphoma presenting with memory loss, confabulation, alexia-agraphia, apathy, hypersomnia, appetite disturbances and diabetes insipidus

A 37-year-old Hispanic man with a right atrial intracardiac mass diagnosed as diffuse large B-cell lymphoma (DLBCL) was successfully treated with surgery and chemotherapy. During 4 years, several total-body positron emission tomography and MRI scans showed no extracardiac lymphoma. On year 5 after the cardiac surgery, patient presented with sleepiness, hyperphagia, memory loss, confabulation, dementia and diabetes insipidus. Brain MRI showed a single hypothalamic recurrence of the original lymphoma that responded to high-dose methotrexate treatment. Correction of diabetes insipidus improved alertness but amnesia and cognitive deficits persisted, including incapacity to read and write. This case illustrates two unusual locations of DLBCL: primary cardiac lymphoma and hypothalamus. We emphasise the importance of third ventricle tumours as causing amnesia, confabulation, behavioural changes, alexia-agraphia, endocrine disorders and alterations of the circadian rhythm of wakefulness-sleep secondary to lesions of specific hypothalamic nuclei and disruption of hypothalamic-thalamic circuits.

A case report about oligodendrogliomas of the fourth ventricle

RATIONALE

Oligodendrogliomas are usually located in the frontal, parietal and the temporal lobe, with the ones in the fourth ventricle quite rare. Hence we want to introduce a case about the rare disease.

PATIENT CONCERNS

An eight-year old boy complained of progressive headache, dizziness and vomit for about 2 months. Then the slight ataxia was found by the physical examinations, with no sensory disturbances and other motor disturbances.

DIAGNOSES

Abnormal signals on the fourth ventricle were found by the preoperative brain computed tomography (CT) scan and magnetic resonance imaging (MRI) scan. So the patient accepted a gross total resection of the lesion with pathologically confirmed oligodendroglioma.

INTERVENTIONS

Radiotherapy was then delivered in 27 fractions at 2Gy per fraction after the operation, with one fraction daily for five days weekly. No other therapies were used for the patient.

OUTCOMES

The brain MRI was used for follow-up every three months until now when he has finished all therapies for more than one year. No progressive behaviors (for example, headache, dizziness, vomit and other symptoms about cerebellar tonsillar hernia) or images have been presented. And the follow-up will be continued.

LESSONS

Although oligodendrogliomas are usually located in the frontal lobe, with the ones of fourth ventricle extremely rare, they must be kept in mind all times. Treatments applied to our case may be provided as a reference for clinicians. Furthermore, the maximal range of resection, histologically proved oligodendroglioma and the 1p/19q loss of heterozygosity are associated with favorable prognosis.

Intraventricular Ganglioglioma Presenting with Spontaneous Hemorrhage

Intraventricular gangliogliomas presenting with spontaneous hemorrhage are rare. Due to high density of important tracts lateral to the ventricular atrium, the intraparietal trans sulcal approach is a good option to remove lesions in this location. These tracts are displaced and sometimes destroyed by the presence of large masses. A 33-year-old male presented with a sudden headache and a generalized seizure. He had a left visual field hemianopia and left visual field neglect. Brain computer tomography and magnetic resonance imaging revealed a hemorrhagic tumor located in his right atrium. With the help of tractography an optimal corridor to the tumor through the intraparietal sulcus was planned. Gross total removal of a ganglioglioma was possible with recovery of visual impairment and control of epilepsy. The efficacy in using tractography as a planning tool for safe tumor removal is demonstrated with clinical, imagiological and histological data, and a surgical video.

Ventricular Central Neurocytoma: Rate of Shunting and Outcome 2 Years After Total and Subtotal Excision

BACKGROUND

Central neurocytoma is an intraventricular tumor that affects young adults. It has a favorable prognosis after adequate surgical intervention; however, an aggressive course may take place in some cases.

OBJECTIVE

The objective of the study was to evaluate the rate of shunting and the outcome of control measures in patients with central neurocytoma submitted to total and subtotal excision.

METHODS

Twelve patients were included in this study, with a follow-up of 24 months. Data collected included: age, sex, clinical presentation, early morbidity and mortality, radiological findings (tumor location, features, residual, recurrence, and hydrocephalus). All patients underwent surgery for total or subtotal excision through a transcortical approach. External Ventricular Drain (EVD) was inserted then removed or replaced by a shunt. Histopathology and the MIB index were used to confirm diagnosis and guide the follow-up; adjuvant radiotherapy or Gamma Knife radiosurgery were used for residual tumor or recurrence.

RESULTS

The ages of the patients ranged from 14 to 48 years. Two patients died early, after total and subtotal excision, from sepsis and thalamic infarction, respectively. Six patients (60 %) had a total excision; two of them had a high MIB index and showed small recurrence at 12 months and 18 months, respectively, and received Gamma Knife radiosurgery. One of the six patients with total excision needed a shunt, and no shunt was needed in the four otherpatients; a subtotal excision was done for four patients (40 %). An early shunt was inserted for two of these patients, radiosurgery-controlled for one patient, while radiotherapy was used for control in the other three patients; radiotherapy control failed in one patient, who underwent a second surgery at 18 months.

CONCLUSION

Central neurocytoma may have a favorable prognosis, with a lower incidence of shunt insertion throughout its course than that for other intraventricular tumors, if total removal is achieved.

Chordoid glioma of the third ventricle: a patient presenting with SIADH and a review of this rare tumor

INTRODUCTION

Chordoid glioma of the third ventricle is a rare and recently described tumor characterized by a unique histomorphology and exclusive association with the suprasellar/third ventricular compartment. Its clinical, radiological and histological features may vary. Despite the fact that chordoid glioma is a low-grade tumor, its prognosis has been relatively poor because of its insidious presentation and the difficulty in obtaining complete surgical resection.

MATERIALS AND METHODS

Here, we report on a new case of chordoid glioma occurring in a 48-year-old woman, presented with hyponatremia, and on the initial work-up with a diagnosis of hyponatremia due at least in part to SIADH. We review the current literature on this rare pathology, discuss the radiological and histopathologic findings, and discuss the optimal management of chordoid glioma in general.

CONCLUSION

Based on this new case and the previous literature reports, we suggest that chordoid glioma should be included in the differential diagnosis of uncommon masses of the third ventricle, especially in middle-aged women, and we emphasize current management guidelines.

Neurodevelopmental long-term outcome in children with hydrocephalus requiring neonatal surgical treatment

PURPOSE

To assess long-term neurodevelopmental outcome in children with hydrocephalus requiring neurosurgical treatment during the neonatal period.

METHODS

This prospective longitudinal population-based study included 43 children with neonatal shunted hydrocephalus. The 43 children were prospectively reviewed in the presence of their parents at the outpatient clinic. Cognitive and motor outcomes were assessed respectively using different Wechsler scales according to age and Gross Motor Function Classification System (GMFCS). Postoperative MRI was routinely performed.

RESULTS

The mean gestational age at birth of the 43 consecutive children with neonatal hydrocephalus (sex ratio M/F: 1.39) was 34.5±5.4 weeks of gestation. At mean follow-up of 10.4±4 years, mean total IQ was 73±27.7, with equivalent results in mean verbal and mean performance IQ. Of the 33 children with IQ evaluation, 18 presented an IQ≥85 (41.9%). Efficiency in walking without a mobility device (GMFCS≤2) was obtained in 37 children (86%). Only severity of postoperative ventricular dilation was significantly associated with unfavorable outcome (Evans index>0.37; odds ratio: 0.16, P=0.03).

CONCLUSION

This information could be provided to those families concerned who often experience anxiety when multi-disciplinary management of neonatal hydrocephalus is required.

Neuropsychiatric Manifestations of Colloid Cysts: a review of the literature

Colloid cysts account for approximately 2% of primary brain tumours and the majority of cases are identified in the fourth and fifth decade. They are small, gelatinous neoplasms lined by a single layer of mucin-secreting columnar epithelium that are thought to arise from errors in folding of the primitive neuroepithelium. They develop in the rostral aspect of the third ventricle in the foramen of Monro in 99% of cases and despite their benign histology carry a poor prognosis, with a mortality greater than 10% in symptomatic cases. The location of colloid cysts within the ventricular system results in obstruction of the foramen of Monro as the cyst grows, disrupting the circulation of cerebrospinal fluid (CSF) and causing hydrocephalus. This is the mechanism behind the most common presenting symptoms of postural headache, nausea and vomiting - a clinical picture synonymous with hydrocephalus and intracranial pathology. In addition to these classical neurological symptoms, there is a high prevalence of psychiatric symptoms in the patient population, with symptoms ranging from anterograde amnesia to gustatory hallucination. These symptoms can occur with or without the presence of hydrocephalus, and are thought to be secondary to compression of connecting pathways between the mesocortices and subcortical limbic regions. These symptoms have been shown to be comparative in frequency to the classical symptoms, yet are rarely the reason for referral to a neurological or neurosurgical service for investigation.

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.

Symptomatic subependymomas of the ventricles. Review of twenty consecutive cases

BACKGROUND AND PURPOSE

Intraventricular subependymomas are rare benign tumors, which are often misdiagnosed as ependymomas. To review the clinicopathological features of subependymomas. PATIENT SELECTION AND METHODS: Retrospective clinical analysis of intraventricular subependymomas and systematic review of histological slides operated on at our center between 1985 and 2005.

RESULTS

Twenty subependymomas presented at the median age of 50 years (range 19-77). Two (10%) were found in the third, three (15%) in the forth, and 15 in the lateral ventricles. There was male preponderance (12 vs. 8). Ataxia (n=13) and papilledema (n=7) were the most common clinical presentations. Fifteen patients underwent gross total resection, and five had subtotal resection. None of the cases showed mitotic figures, vascular endothelial proliferation or necrosis. Cell proliferation marker MIB-1 activity (percentage of positive staining tumor cells) ranged from 0 to 1.4% (mean 0.3). Two cases were treated with preoperative radiation therapy (50 Gy) before the CT era, three other patients received postoperative radiation therapy for tumors originally diagnosed histologically as low grade ependymomas. Three patients (15%) died of surgical complication between one and three months postoperatively, and three patients died of unrelated causes in eight, 26 and 110 months. Fifteen patients were alive without evidence of tumor recurrence at a median follow-up time of 10 years.

CONCLUSION

Subependymomas are low-grade lesions and patients do well without adjuvant radiotherapy. Small samples from more cellular areas may be confused with low grade ependymomas, and unnecessary radiotherapy may follow. Recurrences, rapid growth rates should warrant histological review, as hypocellular areas of ependymomas may also be a source of confusion.

[Neuroendoscopic surgery for intra- and para-ventricular tumors:impacts on biopsy and hydrocephalus treatment]

In this report, the authors retrospectively review and discuss their results for neuroendoscopic surgery for intra- and para-ventricular tumors. This study included 28 patients who were admitted to our hospital for intra- or para-ventricular tumors between January 2005 and March 2013. There were 17 males and 11 females, and their age varied widely from 1 to 75 years. Using a neuroendoscopic technique, tumor biopsy was attempted in all 28 patients. Biopsy was possible in 25 patients(89.3%)but not in the other 3(10.7%)because of hypervascularity or tumor bleeding. Of these 25 patients, pathological diagnosis was possible in 23(92%), but not in other 2(8%)because of incomplete sampling. In 18 of 28 patients, various forms of hydrocephalus were observed. Neuroendoscopic procedures were quite useful to improve cerebrospinal fluid dynamics in 13 of these patients, including endoscopic third ventriculostomy(ETV)in 9(except for 1 patient with ETV failure), septostomy with ventriculoperitoneal shunting(VPS)in 3, and cystostomy in 1. Simple VPS was performed in the other 4 patients. These results suggest that neuroendoscopic surgery is valuable as a minimally invasive procedure for pathological diagnosis and hydrocephalus treatments in patients with intra- and para-ventricular tumors. Further development of neuroendoscopic equipment is warranted to accurately diagnose tumors with hypervascularity and subependymal tumors.

[Incomplete Horner's syndrome as a presenting sign of fourth ventricle ependymoma]

CASE REPORT

The case of 44 year old male patient with palpebral ptosis and trigeminal neuralgia as presenting sign of fourth ventricle ependymoma is reported. After surgical treatment, the patient developed a residual paresis of the sixth cranial nerve.

DISCUSSION

Horner's syndrome occurs due to an alteration of the sympathetic innervations of the eye and adnexa. Some tumours may be the cause, in our case an ependymoma of the fourth ventricle, which onset exceptionally with blepharoptosis and involvement of the ophthalmic division of trigeminal nerve, due to the proximity of these nerve fibres at the brainstem.

[Subependymoma of the lateral ventricle. A case report]

INTRODUCTION. Intracranial subependymomas are rare, slow-growing, noninvasive, benign tumors. They are most often located in the fourth ventricle. Most of these tumors are discovered incidentally during autopsy. Routine medical checkups using neuroimaging techniques have increased their diagnosis. Subependymomas may present with symptoms related to cerebrospinal fluid obstruction or mass effect. CASE REPORT. A 52-year-old man presented with severe headache and mental deterioration with memory disturbances and bradypsychia. Computed tomography and magnetic resonance imaging revealed a mass in the right lateral ventricle causing obstructive hydrocephalus. The tumour was totally removed through a right frontal transcortical approach. Histological examination showed a typical subependymoma. A complete neurological recovery was achieved after surgery. CONCLUSIONS. Subependymomas are rare low-grade glial neoplasm that commonly arise in the ventricular system. They have a low-proliferative potential but in these locations they can cause symptomatic hydrocephalus. Surgical removal of the mass and the restoration of the normal cerebrospinal fluid pathways constitute the optimal management strategy.

Unusual appearance and presentation of supratentorial subependymoma in an adult patient

We report a case of a large, heterogeneously enhancing, pathologically proven, supratentorial subependymoma in a 31-year-old male patient presenting with headache, nausea and vomiting as well as gait disturbances. Although most supratentorial subependymomas have distinctive MR features, our case demonstrated imaging findings that made it indistinguishable from other more aggressive malignant supratentorial intraventricular lesions. It is of paramount importance to consider supratentorial subependymomas in the differential diagnosis of supratentorial lesions, even if their radiological features were atypical.

Supratentorial intraventricular hemangioblastomas

A 33-year-old male presented with a headache. He had a history of a previous surgical procedure for excisions of cervical spine hemangioblastomas 13 years prior He had a family history of von-Hippel Lindau (VHL) disease, and a VHL mutation was identified. Brain magnetic resonance imaging showed enhanced mass lesions in both the third and right lateral ventricles as well as in the cerebellum. The lesion in the right lateral ventricle also had a cystic component. Two-staged resections of the tumors in the third and right lateral ventricles and ventriculo-peritoneal shunt were performed. A histopathological specimen was compatible with a hemangioblastoma. Supratentorial intraventricular hemangioblastomas are extremely rare. We reviewed the literature and discussed the features.

[Subependymomas of lateral ventricle. Analysis of our series and review of literature]

Subependymoma is a benign lesion, slow-growing neoplasm, representing 0.2 to 0.7 % of intracranial tumors. They are often clinically silent, incidentally discovered at autopsy. These symptoms are related to big volume. They are attached to the septum pellucidum, leading to hydrocephalus by Monro foramen obstruction. Overall mean age at diagnosis is 39 years with more males than females. At CT-scan, subependymoma shows a slightly low attenuation compared to gray matter. There is no or mild enhancement following contrast injection. On MR T1-weighted imaging, subependymoma is isointense and hyperintense on MR T2-weighted imaging. Intramural calcifications and cystic components are noted in 20 to 30 % of patients. Peritumoral oedema is absent. Immunohistochemicals studies show intense positivity for S-100 and GFAP. The treatment is surgical with an excellent prognosis.

[Pediatric intraventricular tumors]

Pediatric intraventricular tumors present a well circumscribed group from surgical point of view. These tumors growing in the ventricular system cause hydrocephalus in most of the cases, the presenting symptoms are the signs of raised intracranial pressure. The mass lesion may remain silent for a long period, especially in infancy due to compensatory mechanisms, and the tumor might reach extreme size making the surgery a real challenge. This group has very specific postoperative problems resulting from the disturbance of CSF circulation. In this study we present the retrospective analysis of 55 patient operated for intraventricular tumor in the National Institute of Neurosurgery between 1991 and 2006. Data were analysed regarding histological type, presenting symptoms, type of surgical approach, radicalitiy of the resection and postoperative complications. In addition to our own results brief presentation of the specific histological groups is given based on the available literature.

Bruns syndrome caused by intraventricular tumor

The Bruns syndrome is an unusual phenomenon, characterized by attacks of sudden and severe headache, vomiting and vertigo, triggered by abrupt movement of the head. The presumptive cause of the Bruns syndrome is a mobile deformable intraventricular lesion leading to an episodic obstructive hydrocephalus resulted from an intermittent or positional CSF obstruction with elevation of intracranial pressure due to a ball-valve mechanism. Although the old neurological literature recognized tumors as well as neurocysticercosis as causes of the Bruns syndrome, during the last 60 years only intraventricular neurocysticercosis was reported to cause this symptom-complex. Here, we report a 38-year-old woman with relapsing attacks of headache, vertigo, nausea, vomiting, and ataxia provoked by head rotation corresponding to the classical Bruns syndrome. The cranial MRI revealed a tumor in the third ventricle and a further tumor in the fourth ventricle, which could cause a transient obstruction of the CSF pathways. This unusual observation of the Bruns syndrome in a non-parasitary disease of the CNS adds the syndrome to the differential diagnosis of paroxysmal vertigo.

Colloid cyst: a case study

A colloid cyst, also called a neuroepithelial cyst, is a slow-growing, benign tumor that occurs in the anterior third ventricle. The cyst typically blocks the foramen of Monro, causing obstructive hydrocephalus involving only the lateral ventricles. The most common presenting sign and symptom of a colloid cyst is headache. Less common presenting signs and symptoms include nausea, vomiting, memory loss, mental status changes, gait disorder, and visual disturbances. Surgical resection is the recommended treatment. Meticulous baseline and ongoing neurological assessments are of paramount importance in the care of a patient with a colloid cyst to promote optimal patient outcomes.

Discharge management of an adolescent female with posterior fossa syndrome: a case report

Posterior Fossa Syndrome (PFS) is a constellation of neurological, behavioural and psychological symptoms occurring in pediatric patients following surgical resection of posterior fossa brain tumours. The clinical presentation of PFS typically includes cerebellar mutism, bulbar dysfunction, ataxia, cranial nerve palsies, flaccid hemiparesis and emotional lability. The intent of this paper is to (a) provide an overview of PFS, (b) explore the case of a 16-year-old adolescent who presented with PFS following surgical resection of a fourth ventricle medulloblastoma, (c) reveal the complexity of her discharge, and (d) describe a discharge management framework used by the authors to guide the discharge process from a general pediatric unit in a tertiary care hospital.

Bruns syndrome caused by intraventricular tumor

The Bruns syndrome is an unusual phenomenon, characterized by attacks of sudden and severe headache, vomiting and vertigo, triggered by abrupt movement of the head. The presumptive cause of the Bruns syndrome is a mobile deformable intraventricular lesion leading to an episodic obstructive hydrocephalus resulted from an intermittent or positional CSF obstruction with elevation of intracranial pressure due to a ball-valve mechanism. Although the old neurological literature recognized tumors as well as neurocysticercosis as causes of the Bruns syndrome, during the last 60 years only intraventricular neurocysticercosis was reported to cause this symptom-complex. Here, we report a 38-year-old woman with relapsing attacks of headache, vertigo, nausea, vomiting, and ataxia provoked by head rotation corresponding to the classical Bruns syndrome. The cranial MRI revealed a tumor in the third ventricle and a further tumor in the fourth ventricle, which could cause a transient obstruction of the CSF pathways. This unusual observation of the Bruns syndrome in a non-parasitary disease of the CNS adds the syndrome to the differential diagnosis of paroxysmal vertigo.

[Band atrophy of the optic disc secondary to ventricular subependymoma compression]

CASE REPORT

A 42-year-old man was diagnosed with band or "bow tie" optic atrophy with a right homonymous hemianopia. Computerized tomography (CT) revealed a calcified lesion in the left hippocampus. Craniotomy and tumor resection were performed. The biopsy revealed a subependymoma of the temporal horn of the left ventricular system.

DISCUSSION

Optic tract lesions are uncommon clinical entities, in which homonymous hemianopia and contralateral band optic atrophy are characteristic. Subependymomas are infrequent and benign tumors that are typically associated with the ventricular system.

Successful treatment with voriconazole of Aspergillus brain abscess in a boy with medulloblastoma

Invasive aspergillosis is an increasing problem in immuno-incompetent patients after prolonged steroid therapy, cancer radio-chemotherapy, and bone marrow or solid organ transplantation. Cerebral aspergillosis is a well-described complication of the invasive aspergillosis but only in rare cases, the brain is the sole site of infection. Despite increasing availability of antifungal drugs, the prognosis of cerebral aspergillosis is poor. We report on an 11-year-old boy with medulloblastoma in the area of the fourth ventricle. Following tumor surgery and radio-chemotherapy, several abscess-like structures occurred in the operating field. After incomplete abscess, resection histology and culture confirmed a localized Aspergillus fumigatus infection. The initial treatment of the Aspergillus fumigatus infection with conventional amphotericin B failed, and treatment with the triazole voriconazole was started. Intravenous treatment with voriconazole resulted in a reduction of the Aspergillus fumigatus abscess. After switching to oral ambulatory therapy, the Aspergillus fumigatus abscess increased in size. To improve treatment, voriconazole dosage was adapted to reach drug concentrations in cerebrospinal fluid (CSF) above the minimal fungicidal concentration and plasma specimens. During the concentration-controlled voriconazole therapy for a period of 18 months, a complete response was achieved.

Ectopic craniopharyngioma of the fourth ventricle: case report

BACKGROUND

Ectopic craniopharyngioma is an uncommon entity. We report the first case of ectopic craniopharyngioma confined purely within the fourth ventricle, exophytic from pons.

CASE DESCRIPTION

A 12-year-old girl presented with 2 months history of headache and recent evidence of raised intracranial pressure and left abducent palsy. Magnetic resonance imaging suggested intra-fourth ventricular mass with hydrocephalus. The patient underwent midline posterior fossa craniotomy and tumor excision, with prompt relief of gaze palsy. Histologic examination proved the lesion to be craniopharyngioma. We found no evidence to correlate this tumor to the suprasellar region.

CONCLUSION

Craniopharyngioma may not always be in primary communication with suprasellar tumor.

Subependymoma revisited: clinicopathological evaluation of 83 cases

OBJECT

Subependymomas are rare ependymal neoplasms. To date, a large clinicopathologic study of these benign neoplasms treated with modern neurosurgical techniques has not been reported.

METHODS

Eighty-three cases of subependymoma were retrieved from the files of the Armed Forces Institute of Pathology. Clinicopathological features were reviewed; chromogenic in situ hybridization analysis for chromosome 22 was performed (n = 8), and patient follow-up was obtained (n = 34). Overall, the patients included 68 males and 15 females, 1.5 to 85 years of age (mean, 51.0 years). Twenty-seven cases were discovered at autopsy and the remaining were surgical specimens (n = 56). Tumors arose in the posterior fossa (n = 43), lateral ventricles (n = 37), spinal cord (2) and only one arose in the temporal horn. Tumors ranged in size from 2.0 mm to 60 mm in greatest dimension (mean, 23.0 mm). Eighteen-percent (15/83) of subependymomas exhibited a mixed histologic pattern; that is, subependymoma together with another glial tumor. The most common mixture (13/15) was subependymoma and ependymoma. Surgical excision was used in all symptomatic patients; 10 patients received radiation. Four patients developed a recurrence due to incomplete excision. All patients were without evidence of disease at the last follow-up: alive (n = 28) or dead (n = 8).

CONCLUSIONS

Age is the only variable found to be significantly associated with survival. Currently, surgical methods result in an excellent long-term clinical outcome. Subependymomas do not appear to be associated with NF2 mutations.

Exceptional symptomatology of a lipoma beneath the third ventricular floor and successful neuroendoscopic treatment

The aim of this paper is to present the exceptional case of a lipoma located beneath the floor of the third ventricle in front of right mamillary body manifesting with psychiatric symptoms and treated by navigated neuroendoscopy. A 58-year-old male was referred for neurosurgical treatment because of paroxysmal disturbances of consciousness accompanied by aggressive behaviour. Because electroencephalographic evaluation failed to confirm the epileptic origin of the presenting symptoms, the final psychiatric diagnosis was syndrome of amentia. However, when the MRI investigation revealed two tiny lipomas with one of them located in front of the right mamillary body, a hypothesis was established that this lipoma might be the cause of the clinical symptoms. After a thorough analysis of the patient's symptoms and taking into special consideration the functional role of hypothalamic structures the decision to remove the lipoma endoscopically was accepted. After stereotactic planning and functional correlation using digital stereotactic atlases, the lipoma located in front of the right mamillary body was endoscopically removed. The clinical course after navigated neuroendoscopic surgery proved complete disappearance of symptoms and problems supported by the results of imaging techniques, psychological investigations and neurological findings. Detailed anatomic analysis with pathophysiological consideration substantiated the excellent result of minimally invasive endoscopic surgery for lipoma removal.

The role of neuroendoscopy in the management of solid or solid-cystic intra- and periventricular tumours

OBJECTS

The purpose of this study was to describe the surgical strategies of neuroendoscopic treatment in patients with solid or solid-cystic peri- and intraventricular tumours. Analysis of the postoperative histopathology and complication of neuroendoscopic interventions was also performed.

BACKGROUND

A number of intracranial tumours do not ultimately require aggressive surgical intervention. Either definite or palliative treatment for the intra- and periventricular lesions could be accomplished using various neuroendoscopic techniques, depending on the histopathological diagnosis and aim of therapeutic intervention.

MATERIALS AND METHODS

Between 1994 and 2004, 46 patients with newly diagnosed solid or solid-cystic peri- and intraventricular tumours underwent neuroendoscopic procedures Twenty patients had associated hydrocephalus requiring the cerebrospinal fluid diversion procedures. Since 1997, neuronavigation has been applied to selected cases.

RESULTS

Obstructive hydrocephalus was treated sufficiently by endoscopic third ventriculostomy or endoscopic stent placement. Partial or total extirpation of solid tumour was achieved in four cases. The majority of pathological examinations revealed astrocytoma (23), craniopharygioma (7) and metastasis (2). Subsequent mode of treatment such as chemotherapy, radiation therapy or microscopic surgery was determined according to the pathological findings. There were three transient morbidities and one permanent deficit, but no operative mortality.

CONCLUSION

Transventricular endoscopic approach is an effective and reliable alternative treatment of newly diagnosed peri- and intraventricular lesions. Neuroendocopic procedures offer the opportunity to combine tumour biopsy and treatment of hydrocephalus. In selected patients, partial or total tumour removal could be performed.

Papilledema in obstructive hydrocephalus caused by giant cell astrocytoma of tuberous sclerosis

A 5-year-old girl with progressive hemiparesis and headache was found by brain imaging to have a large tumor centered at the foramen of Monro, blocking cerebrospinal outflow and producing massive lateral ventriculomegaly. Total excision of the mass led to a pathologic diagnosis of giant cell astrocytoma. Dermatologic abnormalities had been detected shortly after birth but were unexplained. Abdominal imaging disclosed renal cysts, and ophthalmologic examination disclosed papilledema and retinal plaques. On this basis, a diagnosis of tuberous sclerosis (TS) was finally made. Two months after surgery, papilledema had resolved, and visual function appeared to be normal. Although the patient apparently escaped visual loss, other reports affirm that giant cell astrocytoma, a common tumor in TS, may go undetected for long enough to produce irreversible optic neuropathy from chronic papilledema. Because patients with TS may not report visual loss, they should undergo periodic ophthalmologic screening.

First report of occurrence of choroid plexus papilloma and medulloblastoma in the same patient

INTRODUCTION

Choroid plexus papilloma is a benign epithelial brain tumour showing a striking predilection for infants and occurring most frequently in the lateral and fourth ventricles. Medulloblastoma, on the other hand, is a primitive neuroectodermal tumour and is the most frequent malignant brain tumour of the posterior fossa in children. In this study, we report a metachronous occurrence of choroid plexus papilloma and medulloblastoma in the same patient, which has not been reported before to the best of our knowledge.

CASE REPORT

The authors describe the case of a girl who presented with an atypical choroid plexus papilloma on the posterior wall of the left lateral ventricle at 3 months of age that was resected completely. She was followed up regularly after surgery and made good progress with normal development. At 8 years of age, she presented with right cerebellar medulloblastoma.

DISCUSSION

The authors review literature for incidence and aetiology of the two tumours.

Endoscopic biopsy for intraventricular tumors in children

OBJECT

Endoscopy is a useful technique for obtaining biopsy samples of intraventricular tumors, and it offers the advantage of simultaneous treatment of obstructive hydrocephalus through endoscopic third ventriculostomy (ETV). Figures in the literature on the diagnostic yield of endoscopic biopsy, its complication rate, and the success rate of ETV in this context vary significantly. The authors performed a retrospective analysis of biopsy accuracy, complication rate, and success rate of ETV in a series of 31 endoscopic biopsy procedures.

METHODS

All data regarding tissue and cerebrospinal fluid sampling, endoscopy-related complications, procedures performed for hydrocephalus treatment, tissue diagnosis, and further management were reviewed. The accuracy of the biopsy findings was graded on a four-level scale: Level I, fully diagnostic; Level II, diagnostic with some reservation; Level III, pathological categorization problematic; and Level IV, not interpretable. Failure of ETV was defined as the need for any further operation for the treatment of hydrocephalus. Tissue diagnosis was graded as Level I or II in 23 cases. One Level I diagnosis differed from the diagnosis made following craniotomy. During the study period one patient underwent endoscopy without biopsy because the tumor could not be visualized. Consequently, the percentage of successful biopsies was 69% (22 of 32 endoscopic procedures). Complications occurred in six cases (19%), of which two (6%) were significant. Three patients (10%) suffered hemorrhagic complications. When combined with biopsy, the ETV procedure was successful in nine (64%) of 14 patients.

CONCLUSIONS

Endoscopic biopsy of intraventricular tumors is a useful technique for establishing a tissue diagnosis and is associated with an acceptable complication rate. The biopsy does not affect the success rate of simultaneous ETV.

Choroid plexus acinar adenoma: a case report

Mucus-secreting adenomas or acinar adenoma of the choroid plexus are very rare. We report the case of a 79-year-old male with a 3-year history of occipital headaches with vomiting, ataxia and cerebellar signs. He was first seen due to difficulty while walking. He was admitted to the hospital with significant tumor expansion and clinical deterioration. CT and MRI revealed obstructive hydrocephalus secondary to a large fourth ventricular cyst mass, which enhanced markedly on contrast administration. Pathological findings were consistent with an acinar choroid plexus adenoma. The tumor was attached to the ependymal lining and was strongly adhered to the walls and floor of the IV ventricle. Post-operative bleeding complicated partial removal of this tumor. The patient died 6 h after surgery.

[Congenital spinal cord malformation concurrent with ependymoma of the third brain ventricle]

This paper describes a very rare case of congenital spinal cord malformation as two tumoroid masses of spinal cord rudiments and located in the area of the cauda equina. In addition, ependymoma of the third brain ventricle was detected in a male child aged 2 years and 4 months.

A growth in bipolar disorder?

OBJECTIVE

This case report suggests that screening of patients with psychiatric symptoms using modern neuroimaging can help identify organic causes of mental illness.

METHOD

A single case study was reported.

RESULTS

We report the case of a 25-year-old woman with a recent diagnosis of bipolar II disorder having an magnetic resonance imaging (MRI) scan as part of a research project that reveals an intraventricular brain tumour. The latter is most likely the cause of her irritability and 'hypomanic' symptoms and is defined anatomically using diffusion tensor imaging and structural and functional imaging using MRI and positron emission tomography.

CONCLUSION

The lesion in this individual case most probably produces mood symptoms by impinging upon the fornix, a component of the limbic system. However, more generally, the increase in diagnosis of bipolar disorder has to be tempered against alternate causes of similar symptoms and necessitates vigilance of potential organic mechanisms.

Childhood dermatomyositis associated with intracranial tumor and liver cysts

We present a girl with dermatomyositis, liver cysts and choroid plexus papilloma who was treated and followed for 7 years. Muscle histology revealed an inflammatory muscle disease and similar changes were detected in a brain tumor that was surgically removed at onset. Western blot analysis of the muscle revealed severely reduced calpain-3 protein. She was treated with pulse methylprednisolone treatment (800 mg i.v. for 4 days) followed by oral prednisone treatment (16 mg on alternate day) for 14 months, which improved muscle strength. Moreover, the cystic liver formations disappeared during steroid treatment. This is an unusual association of muscular disorder, steroid-responsive liver cysts, intracranial tumor and secondary calpain-3 deficiency. We speculate that this association is not coincidental, but mediated by an autoimmune attack against an antigen that is shared among the target tissues.

[Clinicopathologic study of subependymal giant cell astrocytoma]

OBJECTIVE

To study the clinicopathologic features of subependymal giant cell astrocytoma.

METHODS

The clinical and pathologic characteristics of 18 cases of subependymal giant cell astrocytoma were retrospectively analyzed.

RESULTS

Amongst the 18 cases studied, there was a male predominance (male-to-female ratio = 2:1). The age of patients ranged from 7 to 54 years (mean age = 18.2 years). The tumor often occurred in the lateral ventricles (16/18, 88.9%). Most patients presented with headache and vomiting (11/18, 61.1%), followed by visual disturbance (3/18, 16.7%). Eleven patients (61.1%) had clinical features of tuberous sclerosis, usually in the form of facial angiofibroma (8/18, 44.4%). Computerized tomography was performed in 10 cases, in which 7 cases were of high density and 5 cases showed contrast enhancement. MRI revealed isointense mass lesion on T1WI (7/11, 63.6%), highly intense lesion on T2WI (10/11, 90.9%) and contrast enhancement in some cases (9/11, 81.8%). Four patients had follow-up information available and all of them were alive from 1 to 5 years (mean = 3.5 years). Histologically, there were bundles of spindle cells mixed with clusters of gemistocytes and ganglion-like cells. The spindle cells showed immunoreactivity for glial fibrillary acidic protein (18/18, 100%), while the gemistocytes and ganglion-like cells expressed synaptophysin (14/18, 77.8%). Most of the cases (16/18, 88.9%) had MIB-1 index <or= 1%.

CONCLUSIONS

Subependymal giant cell astrocytoma is a benign brain tumor with distinctive histopathologic features. The tumor typically affects children and young adults. It is associated with a favorable clinical outcome, especially if completely excised.

Subependymal giant cell astrocytoma

Subependymal giant cell astrocytomas (SEGAs) are slowly growing tumours corresponding to WHO grade I. They are intraventricular and usually occur in the setting of tuberous sclerosis complex. They often result in obstructive hydrocephalus. Treatment is usually restricted to surgical resection, recurrences are rare and long term prognosis is excellent. We present a series of three cases.

Congenital cranial and spinal dermal sinuses: a report of 3 cases

Three cases of congenital dermal sinus are presented--2 female and 1 male. Frontal, thoracic, and lumbosacral congenital dermal sinuses were explored. All patients presented with skin findings, but no neurologic deficits. The case with frontal localization was associated with a corpus callosum lipoma and dermoid tumor, and the patient presented with recurrent meningitis. The case with sacral localization was associated with an epidermoid tumor. Morphogenetic, clinical, and radiologic aspects of these cases are discussed. The midline should be carefully examined whenever a child suffers from meningitis. Dermal sinus tracts should be excised prophylactically.

Pilomyxoid astrocytoma in a patient with neurofibromatosis

Pilomyxoid astrocytoma (PMA), a recently described variant of low-grade astrocytoma is associated with a high rate of recurrence and a propensity for CSF seeding. While cases of PMA have been reported in infants and young children, there has been no report of PMA in patients with neurofibromatosis. The first reportable case of PMA occurring in a child with neurofibromatosis type 1 (NF1) is described. Following presentation with obstructive hydrocephalus, the patient underwent a partial resection of a third ventricular tumor. Histology confirmed the typical features of PMA. The patient demonstrated a partial response to chemotherapy. The authors review the literature on PMA and discuss the specific issues associated with this diagnosis in the context of a child with neurofibromatosis.

Intraventricular neurocytoma with massive brain stem involvement in a 5-year-old child

INTRODUCTION

Central neurocytoma is a tumor of neuronal origin that should be taken into consideration in the differential diagnosis of intraventricular neoplasms. Reports of neurocytomas with an extraventricular localization are rare: to our knowledge, the case described here is the first in which a neurocytoma developed within the ventricles but also invaded the brain stem.

CASE REPORT

The authors describe the unusual case of a 5-year-old boy with an intraventricular neurocytoma presenting with massive involvement of the basal nuclei and the brain stem. The patient underwent first biopsy and then surgery for ventricular-peritoneal shunting and partial removal of the tumor. Histology showed the tumor to be a typical neurocytoma with Mib-1 <2%. The postoperative course was uneventful. At 3 years' follow-up, the patient's clinical condition is stable and there are no signs of disease progression.

DISCUSSION

The literature is reviewed and the characteristics of this unusual tumor are discussed.

Neuropsychological findings in patients with intraventricular tumors

BACKGROUND

Intraventricular tumors are quite rare and become symptomatic with hydrocephalus-related signs such as headache, double vision, and seizures. Also, most of the patients show neuropsychological deficits, especially memory problems and lack of attention.

METHODS

We reviewed the charts and computed tomographic/magnetic resonance images of 15 patients with tumors of the lateral and third ventricle, who were also examined by a neuropsychologist pre- and postoperatively. Neuropsychological testing included tests of attention, memory, executive functions, and concentration.

RESULTS

Between 1995 and 2003, 7 patients with colloid cysts of the third ventricle (3 men, 4 women; mean age, 38 years), 5 patients with meningiomas of the lateral ventricle (2 men, 3 women; mean age, 51 years), and 3 patients with astrocytomas and ependymoma (2 men, 1 woman; mean age, 38 years) were treated. All patients with colloid cysts and meningiomas showed mental changes, especially attention and memory deficits. Symptoms improved markedly after surgical intervention. The 3 patients with astrocytoma and ependymoma showed normal results pre- and postoperatively.

CONCLUSION

Neuropsychological testing is very useful in patients with intraventricular lesions and important for follow-up examinations. It should be included in every workup examination in this small patient group.

Rapid expansion of a previously asymptomatic subependymoma

✓ This 39-year-old man presented with a 6-month history of occipital headaches. Magnetic resonance imaging revealed an irregularly shaped fourth ventricle mass. One month after his initial presentation, he was admitted to the hospital with significant tumor expansion and clinical deterioration. A posterior fossa craniectomy was performed and the mass was resected. Histopathological analysis of this tumor showed central necrosis with associated edema in an otherwise typical and benign-appearing subependymoma. To the authors' knowledge, this is the first reported case of rapid, nonhemorrhagic expansion associated with necrosis in a previously asymptomatic subependymoma.

Central neurocytoma presenting with intraventricular hemorrhage: case report and review of literature

We report a case of a 25 year old man presenting with acute headache, vomiting and nuchal rigidity. Computed Tomography (CT) scan and MRI without contrast showed a right ventricular hemorrhage surrounding a mass lesion. The tumor and hematoma were completely removed by neurosurgical transcortical-transventricular approach. Anatomopathological analysis revealed a central neurocytoma. Central neurocytoma seldom present with hemorrhage. We review 16 cases of neurocytoma with hemorrhage. It is important to recognize central neurocytoma as a cause of intraventricular hemorrhage, especially in adolescents and young adults. Outcome is often favorable when the tumor is completely removed. In some patients the clinical course is more aggressive and additional treatment such as radiotherapy, radiosurgery or chemotherapy is needed.