Neuro-endoscopic management of intraventricular neurocysticercosis (NCC)

Summary Objective. Various approaches including endoscopy have been used for the treatment of intraventricular and cisternal NCC. We present our technique of Neuro-endoscopic management of intraventricular NCC. Methods. Twenty-one cases, 13 females and 8 males (age range 12–50 years; mean, 25.7 years), of intraventricular NCC [lateral (n = 6), third (n = 6), fourth (n = 10) ventricles including a patient with both lateral and third ventricular cysts] producing obstructive hydrocephalus formed the group of study. Gaab Universal Endoscope System along with 4 mm 0° and 30° rigid telescopes were used through a frontal burr-hole for removal of intraventricular including intra-fourth ventricular (n = 10) NCC. Endoscopic third ventriculostomy (ETV) was done for internal cerebrospinal fluid (CSF) diversion. Average follow up was 18 months. Results. Complete (n = 18) or partial (n = 2) removal of NCC was done in 20 patients, while a cyst located at foramen of Monro slipped and migrated to occipital or temporal horn in 1 patient. Thirty-degree 4-mm rigid telescope provided excellent image quality with ability to address even intra-fourth ventricular NCC through the dilated aqueduct using a curved tip catheter. No patient required further surgery for their hydrocephalus. There was no operative complication and post-operative ventriculitis was not seen in any case despite partial removal of NCC. Conclusion. Neuro-endoscopic surgery is an effective treatment modality for patients with intraventricular NCC. It effectively restores CSF flow and is capable of removing cysts completely or partially from accessible locations causing mass effect. Partial removal or rupture of the cyst does not affect the clinical outcome of the patients.     

Continuous intraventricular pressure monitoring for diagnosis of normal-pressure hydrocephalus

Summary Objectives. Normal-pressure hydrocephalus (NPH) syndrome is treatable by implantation of a cerebrospinal fluid (CSF) shunt. However, diagnosis of NPH by clinical and radiological findings alone is unreliable, and co-existing structural dementia can contribute to low success rates after shunt implantation. The aim of our study was to investigate whether long-term results after shunt implantation in NPH improve when surgical candidates are selected by continuous intraventricular pressure monitoring (CIPM). Patients and methods. Ninety-two consecutive patients who were admitted with suspected NPH received CIPM for 48 h including an intraventricular steady-state infusion test to determine the resistance outflow. With positive CIPM, shunt implantation was performed and the patients were prospectively followed up for 1 to 10 years (median 6.5 years). Results. CIPM was negative in 37 patients. Fifty-five patients had a positive CIPM and received CSF shunt. 96.1% of them improved from gait disturbance, 77.1% from cognitive impairment and 75.7% from urinary dysfunction. Clinical improvement remained during long-term follow-up in all but 3 patients who showed a decline at 4, 5 and 7 years, respectively. CIPM-related complications (ventriculitis) occurred in only one patient. Conclusion. CIPM is a safe and valuable tool to establish a reliable diagnosis of NPH and to identify promising surgical candidates.     

Management of haemorrhagic type moyamoya disease with intraventricular haemorrhage during pregnancy

Summary Moyamoya (“hazy puff-of-smoke”) disease represents a rare condition with progressive narrowing and occlusion of basal cranial vessels with secondary specific neoangiogenesis; we report on a 25-year-old primigravida with known moyamoya disease who suffered from acute bilateral intraventricular haemorrhage at 24 weeks gestation. She underwent bilateral external ventricular drainage and intraventricular recombinant tissue plasminogen activator (r-TPA) lysis was performed. At 34 weeks’ gestation, a healthy girl was delivered via Caesarean section. Encephalomyosynangiosis (EMS) and extra-intracranial (EC/IC) bypass surgery were performed six and eight months after delivery, respectively. The patient recovered almost completely and showed only mild residual deficits. Prompt diagnosis and immediate interdisciplinary treatment might have been the key for optimal maternal and neonatal outcome in our patient.     

Intraventricular craniopharyngiomas: topographical classification and surgical approach selection based on an extensive overview

Summary Background. This retrospective study analyzes the clinical, neuroradiological, pathological and surgical characteristics of well-described intraventricular craniopharyngiomas with the aims of: (i) critically to review the criteria used to affirm the diagnosis of an intraventricular location (ii) defining more accurately this topographical diagnosis preoperatively, and (iii) to investigate factors influencing the surgical outcome.Method. Clinical, neuroradiological, pathological and surgical objective data of 104 well-described intraventricular craniopharyngiomas (IVC) reported in the literature, in addition to a new case, were analyzed. On the basis of the proofs provided for third ventricle intactness, a new topographical classification for IVC was developed, distinguishing between: (i) strict IVC, with a proved third ventricle floor integrity and (ii) non-strict IVC, without any reliable proof confirming the intactness of the third ventricle floor. Following this classification, clinical features, pathology and surgical outcome for strictly and non-strictly IVC were compared.Findings. For 105 IVC compiled, 36 belonged to the strictly group and 69 to the non-strictly group. Two pathological features were associated with the non-strictly IVC group: a preferentially adamantinomatous pattern (p=0.106) and wider and tighter adherences to third ventricle margins (p=0.01). The non-strict topography was also associated with a worse postoperative outcome (p=0.046). There was a significant relationship between the surgical approach and the final outcome (p=0.05), being the translamina terminalis approach associated with the best outcome.Conclusions. Two different topographies might be considered among IVC: strict and non-strict intraventricular location. Non-strictly IVC have wider and tighter adhesions to third ventricle boundaries and this subtype is associated with a worse outcome.     

Sellar tuberculoma: Report of two cases

Summary Hypophyseal tuberculomas are exceptionally rare. We report two patients with sellar tuberculoma but with no evidence of concurrent extrasellar disease. Although the lesion is often mistaken for adenoma, there are characteristic radiological features: intense enhancement on contrast CT and thickening of the pituitary stalk on MRI in 86% of cases. Accurate diagnosis is important because pituitary tuberculoma is curable.     

Primary intraventricular oligodendroglioma

This article reports a case of primary intraventricular oligodendroglioma that was successfully treated by ventriculoatrial shunting and radical removal by a transventricular approach. Oligodendrogliomas very rarely occur in the ventricles. The computed tomographic findings are pointed out.     

Hypertensive primary intraventricular hemorrhage due to a phaeochromocytoma

Primary intraventricular haemorrhage (IVH) is rare. We defined primary IVH as haemorrhage into the ventricles only as detected by computerized tomographic (CT) brain scan. This is in contrast with other intracerebral haemorrhages (e.g. basal ganglia/thalamic with intraventricular extension). The clinical condition of the patient ranges from minimal neurological deficits to coma/death. It also carries with it a poor prognosis of up to 80% when all four ventricles are involved. We present a 45-year-old Chinese female who presented with a hypertensive IVH which was managed successfully with ventricular drainage and intraventricular urokinase therapy. An adrenal phaeochromocytoma was diagnosed which was subsequently removed laparoscopically. The patient has recovered well in all aspects. This case report will discuss management of IVH and the importance of searching for secondary causes of hypertension.     

Abdominal tuberculoma mimicking a pancreatic neoplasm: Report of a case

We report herein a case of clinically solitary abdominal tuberculoma. A 28-year-old woman was admitted to hospital for treatment of an abdominal tumor shown to be located in the head of the pancreas and compressing the superior mesenteric vein by echosonography and computed tomography (CT). There were no clinical signs or symptoms of tuberculosis in the lungs or abdomen. Thus, under the diagnosis of a neoplasm of the pancreas, an exploratory laparotomy was performed which revealed tuberculosis. The patient made an excellent recovery on anti-tuberculous treatment, and no evidence of a tumor was seen on a CT scan performed 6 months after the initiation of treatment. Abdominal tuberculoma is often mistaken for a malignant neoplasm and the nonsurgical diagnosis of this entity continues to be a challange.     

Cavernous sinus tuberculoma: diagnostic difficulties in a personal case

BACKGROUND

Tuberculoma of the brain is rare, and its location in the cavernous sinus is exceptional. Many factors make the diagnosis difficult, necessitating a surgical procedure.

CASE DESCRIPTION

A 44-year-old woman complained of persistent headaches and diplopia. The examination revealed a right cavernous sinus syndrome. Radiologic investigation showed a growing process in the right cavernous sinus, overlapping the sella turcica. The diagnoses of metastasis, tuberculoma, and sarcoidosis were considered, but none of them could be confirmed. A biopsy of the lesion via a subtemporal approach revealed a tuberculoma. Antituberculous treatment led to complete resolution of her symptoms.

CONCLUSION

The diagnosis of a cavernous sinus tuberculoma is difficult; it is confirmed by biopsy. However, a trial of medical treatment, if the results are favorable, may obviate the need for a surgical procedure.     

Diagnostic challenges in a patient with myocardial tuberculoma: A case report

IntroductionTuberculosis can affect any organ of the body, including the heart.Presentation of caseAn 18-year old woman presented with a multifocal tuberculosis infection involving abdominal lymph nodes, a sternotomy wound, an abscess of the abdominal wall and most notably a myocardial tuberculoma. Establishing the diagnosis of the myocardial tuberculoma was challenging mainly due to the location within the heart. Initially a diagnostic percutaneous femoral vascular catheter guided biopsy of the right atrial mass was performed, but later open surgery involving median sternotomy was needed. The patient recovered fully after surgery and nine months treatment with anti-tuberculosis drugs.DiscussionThe optimal length of treatment for myocardial tuberculoma is unknown. Medical treatment for six months might be enough regardless whether surgery is performed or not.ConclusionMyocardial tuberculoma requires culture from the infected tissue for confirmed diagnosis and might be successfully treated with anti-tuberculosis drugs only. Indications for surgery include uncertain diagnosis, poor response to medical treatment or cardiac complications.     

Prognosis in traumatic intraventricular haemorrhage

Summary Traumatic intraventricular haemorrhage (TVH) is rare. The clinical profile and prognosis in 16 patients with traumatic intraventricular haemorrhage after blunt head injury are evaluated. Majority of the patients (94%) had low Glasgow coma score (<8) on admission and none had a lucid interval. CT showed haematoma adjacent to the foramen of Monroe in 5 patients and localised to the frontal horn or the body of the lateral ventricle in six. The mortality was 62.5% in this subgroup of patients with head injury. Our findings are compared to those of previous reports in the literature.The poor prognosis of cases with TVH reflects the severity of trauma and general brain damage and is probably not related only to the intraventricular bleeding.     

Persistent intraventricular hematoma following ruptured aneurysm

It is well known that intraventricular hematomas disappear within three weeks, as documented by computed tomography (CT). Recently we encountered a patient with an intraventricular hematoma, caused by rupture of an aneurysm of the anterior communicating artery, that persisted as a visible lesion on CT scans two months following the hemorrhage.     

Traumatic primary intraventricular hemorrhage

Two patients with primary intraventricular hemorrhage following mild head injury are presented. Both patients experienced a rapid loss of consciousness after a lucid interval following the head injury. Conray ventriculography or computerized tomography revealed intraventricular hematoma originating in the third ventricle and causing an obstructive hydrocephalus. Both patients made good recoveries promptly after ventricular drainage.     

神经内窥镜治疗原发性脑室出血

目的：探讨用微创技术治疗原发性脑室出血的新方法。方法：应用Karl-Storz硬质神经内窥镜治疗原发性脑室出血31例,其中单侧侧脑室为主的出血16例,双侧侧脑室为主的出血14例,三脑室合并四脑室出血1例。并发急性梗阻性脑积水者24例。结果：手术时间30-60min,平均43.4min。24例单、双侧脑室血肿清除90％以上,其余7例血肿清除50％-90％。术后明显好转和好转25例,无变化4例,死亡2例。1例术后并发脑积水。结论：应用神经内窥镜清除脑室内血肿,具有直视下操作、手术时间短、创伤小、血肿清除率高和术后疗效好等优点。     

Pre- and post-operative hydrocephalus in supratentorial intraventricular tumours

Summary Post-operative problems of hydrocephalus which occur in a high percentage of intraventricular tumours are infrequently discussed. Our experience, however, showed many problems in the treatment of hydrocephalus associated with supratentorial intraventricular tumours. In a series of 40 supratentorial intraventricular tumours different types of management were used and reviewed retrospectively. It is concluded that certain types of management are disadvantageous, like primary shunt insertion. As a result the recommended form of treatment is: primary temporary external CSF-drainage followed by tumour surgery. Post-operative assessment of ventricular compartments and tolerance of drainage withdrawal. Shunt insertion only if compartmentilization or drainage dependency were manifest.     

正常成人侧脑室与第四脑室的CT测量

通过采用CT扫描测量了422例正常成人侧脑室的脑室颅腔比(VCR),第四脑室前后径和横径大小.按年龄和性别分组进行测量,测量的结果经统计学分析表明:各年龄组的VCR均值,第四脑室前后径及横径均值,以及每组男女相应均值之间的差异均无显著性.根据Mohr氏法,VCR正常范围为0.089～0.137;根据Shapira氏法,第四脑室前后径为0.344～0.898cm,横径为0.789～1.430cm.     

Intramedullary spinal tuberculoma presenting as a conus tumor: a case report and review of the literature

Intramedullary spinal tuberculoma is a rare form of central nervous system tuberculosis. Although tuberculosis is unusual in the west, it is still prevalent in Asia and Africa. We report a case in which the diagnosis was made histologically without evidence of symptoms of systemic tuberculosis. The lesion, located in the conus medullaris, mimicked a conus tumor. The patient was a 20-year-old man who presented with a history of progressive leg weakness, urinary urgency, and impotence. There was no history of, or recent contact with, tuberculosis. A diagnosis of an intramedullary tumor in the conus medullaris was made by MRI. The patient underwent a T11-L1 laminectomy and total resection of the lesion with microsurgical technique. Histologic examination revealed a granulomatous lesion containing Langhans’ giant cells, inflammatory cells, and caseating necrosis. Antituberculous medication was instituted as soon as the diagnosis was made. Neurologic symptoms and signs slowly improved postoperatively. A combination of microsurgical resection and antituberculous chemotherapy should be the choice of treatment for intramedullary tuberculomas. Received: 11 January 1997 Revised: 1 April 1997 Accepted: 17 April 1997     

Removal of intraventricular craniopharyngiomas through the lamina terminalis

Summary Radical, but subtotal, removal of four craniopharyngiomas, three of which were primarily within the third ventricle, has been carried out by an approach beneath the frontal lobe and through the lamina terminalis. A good result was obtained in two cases, and in two other cases the patients were left with considerable disability from hypothalamic damage. The technique, and the indications for radical surgery on these lesions are discussed.