Intraventricular cryptococcal cysts masquerading as racemose neurocysticercosis

BACKGROUND: Cryptococcal infections of the CNS are infrequent in immunocompetent hosts. When present, they usually present as meningitis and hydrocephalus or as fungal masses called cryptococcomas. We report a case in which intraventricular cryptococcal cysts clinically and radiologically simulated the racemose form of neurocysticercosis. CASE DESCRIPTION: A 23-year-old man presented to the emergency department with a 1-week history of severe headache, dizziness, nausea, vomiting, and some lethargy. A computed tomography scan revealed significant hydrocephalus. The patient was admitted to the hospital and immediately underwent a right ventriculostomy tube placement. CSF examination showed a meningitic pattern. Magnetic resonance imaging, including FLAIR images, showed multiple large cysts in the temporal horns of both lateral ventricles in addition to hydrocephalus. When an endoscopic left temporal cyst fenestration failed to decompress his trapped right temporal horn, he underwent placement of a left lateral ventricle to peritoneal shunt and a right temporal cyst to peritoneal shunt. ELISA test results for HIV-1 and -2 antibodies in the patient's serum were negative. His CD4 and CD8 counts were within normal limits. Multiple tests for CSF anticysticercal antibody using IgG ELISA gave unequivocally negative results. Latex agglutination tests detected Cryptococcus neoformans antigen in his CSF in titers of 1:1024, which progressively decreased in response to antifungal therapy. The patient underwent treatment with IV amphotericin B for 7 weeks, IV 5-FC for 2 weeks, and oral fluconazole for 5 weeks. At discharge, 3 consecutive CSF cultures were negative for bacteria and fungi. His neurologic status returned to baseline. CONCLUSIONS: Cryptococcal CNS infections in immunocompetent hosts can mimic the intraventricular form of racemose neurocysticercosis. Distinguishing between the two is essential because the medical management of the 2 conditions is distinct from each other.     

Brain abscess and ventriculitis associated with entrapment of the lateral ventricle appearing more like remarkable brain edema than ventricular dilatation--a case report

We present a case with brain abscess associated with entrapment of the lateral ventricle appearing more like remarkable brain edema in the temporo-occipital lobe than ventricular dilatation. A 72-year-old man suffering from headache and vomiting visited our clinic. CT and MRI showed brain abscess in the right parieto-occipital lobe, associated with ventriculitis. Lumbar puncture also revealed purulent meningitis. Both symptoms and CSF findings improved after administration of antibiotics. The improved condition continued for two months after admission, but disturbed consciousness and left hemiparesis than appeared. MRI and CT showed entrapment of the lateral ventricle and brain edema of the right temporo-occipital region without ventricular dilatation. Because brain edema was thought to be caused by transudate of the CSF through the ventricular wall, lobectomy of the right temporal lobe and opening of the temporal horn were carried out. Although left hemiparesis and disturbed consciousness and brain edema disappeared after the operation, subdural effusion appeared. Using a subdural-peritoneal shunt, the subdural effusion was prevented and disappeared. In this case, we thought Hounsfield Unit (HU) of the brain edema caused by transudate of CSF through the ventricular wall (12.6) was markedly lower than that of so-called vasogenic edema (25.1) due to active inflammation. Measurement of the HU seemed to be a useful means to differentiate the types of brain edema in this situation from that of vasogenic edema caused by brain abscess, and thus a means for selection of the appropriate treatment.     

Access to the posterior medial temporal lobe structures in the surgical treatment of temporal lobe epilepsy

The authors describe a surgical technique that allows access to the posterior temporal horn of the lateral ventricle with preservation of the most functional lateral temporal cortex. Development of the technique was stimulated by the need to resect posteromedial temporal lobe structures in patients with intractable complex partial epilepsy and well-identified unilateral posterior hippocampal foci. This technique has also been of value in the resection of some lateral ventricular and posteromedial temporal lobe masses. The operation consists of three steps. No more than 4.5 cm of the anterolateral temporal lobe is removed en bloc such that the most anterior aspect of the temporal horn is entered. An incision is carried from the floor of the temporal horn through the inferior longitudinal fasciculus to the middle fossa dura mater and posteriorally into the lateral ventricular atrium. The lateral temporal cortex and white matter are then elevated with a self-retaining retractor. This exposes the posteromedial temporal horn or intraaxial mass for excision or allows en bloc resection of the entire hippocampus and medial temporal lobe structures while preserving the functional association areas of the lateral temporal cortex, including speech and visual spatial function.     

A case of intraventricular cyst associated with normal pressure hydrocephalic condition

A case of intraventricular cyst associated with normal pressure hydrocephalic condition (NPHC) is reported. A 72 year-old female, with 2-year-history of slowly progressing dementia and gait disturbance, was admitted to our hospital on September 19, 1989. On admission, she had mild dementia, unsteadiness of gait, and at times urinary incontinence. Cerebrospinal fluid (CSF) pressure was found to be 90mmH2O by lumbar tap. Plain computed tomographic (CT) scan and T1-weighted magnetic resonance image (MRI) showed asymmetrical enlargement of the trigon and posterior horn of the right lateral ventricle. CT cisternography showed a cyst in the trigon and in the posterior horn of the right lateral ventricle. T1-weighted MRI with Gd-DTPA demonstrated no enhancement of the cyst wall, and there was superior and posteromedial displacement of the choroid plexus at the trigon of the right lateral ventricle. The patient was diagnosed as having an intraventricular cyst in the right trigon with NPHC. Ventriculo-peritoneal shunt and partial removal of the cyst were performed. Histological examination of the cyst wall revealed collagenous strands and no epithelial cells. Developmental intracranial cysts, especially arachnoid or ependymal cysts, occasionally lack an epithelial layer, so their histological diagnosis is difficult. This case was considered to be an arachnoid cyst because there was adhesion between the cyst and the choroid plexus in the right trigon, and superior, posteromedial displacement of the choroid plexus, which indicated extension of the cyst from the extracerebral to the intracerebral region. NPHC was considered to be due to disturbance of CSF circulation caused by gradual expansion of the cyst.     

Intraventricular arachnoid cyst appearing with attacks of orbital pain: case report and review of the literature

While there have been 5 cases of intraventricular arachnoid cyst published in the literature, the occurrence in the anterior horn of the lateral ventricle has not been reported. We report a case of intraventricular arachnoid cyst of the anterior horn causing attacks of orbital pain. A 30-year-old man was admitted with frequent attacks of orbital pain on his right side. Neurological examination revealed no abnormality. Plain CT showed a cystic dilatation of the anterior horn of the right lateral ventricle, and enhanced CT showed a deviation of the septal veins to the left side. T1-weighted MRI demonstrated a low-intensity mass in the anterior horn of the right lateral ventricle, and T2-weighted image demonstrated the mass as having high intensity. PEG in the sitting position showed no filling of air into the right lateral ventricle due to obstruction of the right foramen of Monro. The patient underwent an operation under a diagnosis of intraventricular benign cyst. The cyst wall was subtotally removed and the right foramen of Monro was opened. Histological examination of the specimen showed an arachnoid membrane with prolific collagen fibers. From an embryological point of view, the arachnoid membrane is derived from the arachnoid cell. We think intraventricular arachnoid cysts to originate from the remnants of the arachnoid cell on the tela choroidea or on the choroid plexus like intraventricular meningiomas.     

Caplike double-horned double-outlet right ventricle. Report of two cases.

Two patients with a rare form of double-chambered, double-outlet right ventricle (DORV) are described. Both patients had associated pulmonary stenosis, ventricular septal defect, and a large tricuspid valve whose chordal attachments crossed the right ventricular outflow tract. The angiocardiographic, echocardiographic, and operative findings were distinctive. The right ventricle was positioned as a "cap" sitting atop the ventricular septal defect at the cephalad end of the left ventricle. The right ventricle, with its two "horns," was likened to a rider straddling a saddle. Tricuspid chordal attachments extended into each of the two right ventricular "horn." No repair was performed in the asymptomatic patient. The other repair involved closure of the tricuspid orifice and insertion of a valved extracardiac conduit from the right atrium to the pulmonary artery.     

A case of the development of cavum vergae after head trauma

We report a case of the development of cavum septi pellucidi and cavum Vergae after head trauma in a 29-year-old female patient. After the accident, cavum septi pellucidi and cavum Vergae gradually expanded. Using magnetic resonance imaging, we followed up the patient for 33 months after the head trauma. Preoperatively, metrizamide CT cisternography was performed in order to investigate CSF flow between the cavum septi pellucidi/cavum Vergae and the subarachnoid space. Using neuroendoscopy, we succeeded in opening the wall of the cavum septi pellucidi via anterior horn of the right lateral ventricle. Cystography was performed during the operation. The volume of the cavum septi pellucidi/cavum Vergae decreased remarkably. In this case, our CSF flow studies revealed that CSF flowed into the posterior part of the cavum Vergae from the third ventricle and did not flow backward to the third ventricle. Therefore, we considered that the development of cavum septi pellucidi/cavum Vergae was related to a one-way valve mechanism between the posterior part of the cavum Vergae and the third ventricle.     

Delayed appearance of posttraumatic cerebrospinal fluid fistula

A case of CSF fistula, formed as a result of old fracture of the anterior cranial fossa, presented with recurrent meningitis and CSF rhinorrhea due to herniation of markedly dilated right frontal horn of lateral ventricle into the right ethmoid sinus through fractures of right frontal bone, cribriform plate of ethmoid and roof of orbit is reported. Attention was drawn to the CSF fistula only after recurrent meningitis and detailed imaging studies. Using a right frontal craniotomy approach, successful repair of the CSF fistula was performed and patient was discharged symptom-free.     

Microsurgical anatomy of the choroidal fissure

The microsurgical anatomy of the choroidal fissure was examined in 25 cadaveric heads. The choroidal fissure, the site of attachment of the choroid plexus in the lateral ventricle, is located between the fornix and thalamus in the medial part of the lateral ventricle. The choroidal fissure is divided into three parts: (a) a body portion situated in the body of the lateral ventricle between the body of the fornix and the thalamus, (b) an atrial part located in the atrium of the lateral ventricle between the crus of the fornix and the pulvinar, and (c) a temporal part situated in the temporal horn between the fimbria of the fornix and the lower surface of the thalamus. The three parts of the fissure are the thinnest sites in the wall of the lateral ventricle bordering the basal cisterns and the roof of the third ventricle. Opening through the body portion of the choroidal fissure from the lateral ventricle exposes the velum interpositum and third ventricle. Opening through the temporal portion of the choroidal fissure from the temporal horn exposes the structures in the ambient and crural cisterns. Opening through the atrial portion of the fissure from the atrium exposes the quadrigeminal cistern, the pineal region, and the posterior portion of the ambient cistern. The neural, arterial, and venous relationships of each part of the fissure are reviewed. The operative approaches directed through each part of the fissure are also reviewed.     

Excision of a large pineal region hemangiopericytoma (angioblastic meningioma,hemangiopericytoma type)

A large hemangiopericytoma was located posterocentrally. The patient presented with headaches and papilledema. Surgical management consisted of total gross excision by a combined right occipital transtentorial and right occipitoparietal transfalcine approach under magnification in three stages over a 6-week period. Removal was aided by dilatation of the right temperooccipital horn (“trapped ventricle”) and meningioma-like encapsulation allowed separation of the tumor from the brain and surrounding structures after internal debulking of the tumor. Subsequent peritoneal shunting of the trapped ventricular horn and 5000 rads of radiotherapy were given to the patient. She remains well with an inferior quadrantanopsia on the left side more than 1 year after treatment. Meningiomas of the pineal region, the relationship of meningioma to hemangiopericytoma and malignant mesenchymal tumors (sarcomas) are considered in reference to presumed cells of origin.     

Saccular aneurysm of the distal anterior choroidal artery--case report.

The authors report a case of a distal anterior choroidal artery aneurysm in a 75-year-old female who presented with nausea, vomiting, and severe headache. Computed tomographic (CT) scans revealed a hematoma in the right lateral ventricle and a subarachnoid hemorrhage in the right parasellar-Sylvian cistern. Cerebral angiography showed a saccular aneurysm at the right distal anterior choroidal artery. The authors intended to operate at the chronic stage, and carried out conservative management. After 1 month her condition suddenly worsened and she died, although a CT scan showed no remarkable changes. At autopsy, a pulmonary artery thrombosis was considered the cause of death. The aneurysm was identified in the temporal horn of the right lateral ventricle, and was a true aneurysm.     

A Case of Difficult Management of Fluid-electrolyte Imbalance in Choroid Plexus Papilloma

A 22-month-old boy presented with nausea and gradual deterioration of gait disturbance. Computed tomography (CT) demonstrated an intraventricular mass lesion in the right lateral ventricle. He was referred to our department 3 weeks after onset. Acute hydrocephalus gradually proceeded 4 days after admission, and external ventricular drainage (EVD) was performed. EVD revealed cerebrospinal fluid (CSF) overproduction (800–1,500 mL/day) under constant pressure of 10 cm H₂O above external auditory meatus. Magnetic resonance imaging showed a multi-lobular mass in the inferior horn of the right lateral ventricle. A choroid plexus tumor was suspected. The ratio of blood urea nitrogen:creatinine (BUN:Cre) remained between 30 and 40, and hemoglobin was between 14.0–17.0 mg/dL, suggesting marked dehydration. Serum sodium varied between 117 and 140 mmol/L, and serum potassium between 2.2 mmol/L and 6.9 mmol/L. The amount of EVD was unstable and fluid balance management was difficult. Hypotonic fluid with sodium chloride supplement was used to adjust thefluid and electrolyte imbalance. Surgical removal of the tumor was performed6 days after EVD and tumor was grossly and totally removed. The high BUN:Cre ratio decreased to about 15 and hemoglobin recovered to 7.5–9.0 mg/dL after removal. Electrolytes returned to the normal range. Overproduction of CSF also markedly improved to < 300 mL/day. Histopathological examination diagnosed choroid plexus papilloma.We experienced a case of choroid plexus papilloma associated with fluid-electrolyte imbalance due to over-drainage after EVD, which could not be effectively controlled before tumor removal. Cautious fluid management and emergent surgical resection might be required to managethe overproduction of CSF and fluid-electrolyteimbalance.     

Primary endodermal sinus tumor of the fourth ventricle (author's transl)

A case, a 18-year-old male, of an endodermal sinus tumor (yolk sac tumor) in the fourth ventricle, was reported. The patient had a month history of headache, vomiting and gait disturbance prior to the hospitalization, when he admitted to our service he was in lethargic condition with left cerebellar ataxia and horizontal nystagmus. Lumbar tap revealed clear CSF under normal pressure of 110 mm H2O with the CSF protein of 432.5 mg/dl and cell count of 147/3. The vertebral angiography demonstrated space occupying lesion in the posterior fossa. Plain CT demonstrated only disappearance of the fourth ventricle and slightly dilated bilateral ventricles and third ventricle. However diffuse high density area around the fourth ventricle was demonstrated and the wall of bilateral anterior horn was slightly enhanced, after injection of contrast media. There was no other abnormal findings around the pineal region. Suboccipital craniectomy was performed and the tumor was totally removed macroscopically. The tumor was situated in th floor of the fourth ventricle and infiltrated into the fourth ventricular wall and th adjacent cerebellar tissue. The tumor was with soft, greyish color and extremely vascular. Histologically the tumor was diagnosed as endodermal sinus tumor according to Teilum's classification. There were stellate cells arranged in a loose with vacuolated network which formed cystic cavities and a complicated network of honeycomb appearance with a system of communicating cavities and channels. Various size of intra- and extracellular PAS-positive hyaline globules were also seen. Glomerular-like structure (Schiller-Duval body) was not observed. Immunoperoxidase study clearly demonstrated the presence of intra- and extracytoplasmic alpha-fetoprotein granules in the tumor tissue. The amount of the serum alpha-fetoprotein, measured by radioimmunoassay, showed 400 ng/ml. After irradiation in the posterior fossa (5000 rad) the patient was discharged. Three months later, follow up CT demonstrated small high density area in the anterior horn of the left lateral ventricle, so he was rehospitalised. Irradiation in the whole brain was again administered. The tumor was very radiosensitive. CT, after 800 rad, demonstrated complete disappearance of the tumor. After irradiation totally (3000 rad), he discharged with left cerebellar ataxia.     

Long-term results after Fontan procedure and its modifications

The Fontan procedure is an effective method of treatment for patients with tricuspid atresia, univentricular heart, and other complex lesions. Modifications of the Fontan procedure have been developed to treat various anatomic malformations. From 1975 to 1984, 31 patients (17 male and 14 female) have undergone 35 Fontan operations. The youngest patient was 4 and the oldest 26 years of age (average 12.2 years). Sixteen patients had tricuspid atresia, and 15 univentricular heart. Twenty-three patients had undergone 37 palliative operations before the Fontan procedure. The original Fontan procedure was performed in 10 patients until 1977, and there were three early deaths (30%). After that time, the operative technique was modified and the early mortality dropped to 12% (3/25 patients). A valved prosthetic conduit was used in 11 patients (right atrium to pulmonary artery in five; right atrium to right ventricle in six), a valveless conduit in 14 patients (right atrium to pulmonary artery in nine; right atrium to right ventricle in five), and direct anastomosis (right atrium to pulmonary artery) in 10 patients. Postoperative cardiac catheterization was performed in 20 patients and revealed excellent results in 15. The remaining five had reduced oxygen saturation; three of them had had a Glenn anastomosis 8 and 10 years before the Fontan procedure, and one had an anomaly of the coronary sinus with a shunt to the left atrium. This patient required reoperation. Three other patients underwent reoperation because of calcified stenotic and/or outgrown conduits. Postoperative mean right atrial pressure varied from 10 to 20 mm Hg. The hemodynamic ventricular parameters were within the normal range. We conclude that in patients with tricuspid atresia, univentricular heart, and other complex cardiac lesions, inactivating the right ventricular pump function by means of the Fontan procedure does not adversely affect the systemic ventricle. Although the response to exercise was abnormal, the clinical condition of these patients was good to excellent.     

Diagnosis and treatment of 52 cases of cardiac myxoma

43 patients with cardiac myxoma had undergone surgical removal of the tumors under CPB 38 tumors were located in the left atrium, 5 in right atrium, and 1 in right ventricle respectively. The sites of attachment of the tumor stalk observed during operation were as follows: 34 left atrial myxomas were attached to the interatrial septum and 4 left atrial myxomas to the atrial wall. 5 right atrial myxomas were attached to the interatrial septum and 1 right ventricular myxoma to the ventricular wall. 1 patient with a right ventricular myxoma which had been removed one year ago appeared new one in the left atrium and the tumor was cut too. The diagnosis of cardiac myxoma was confirmed by 2D-echo-cardiography in all of our cases. Mitral valve replacement was done in 1 patient in this series. There was one death postoperatively. Besides these 43 cases, there were 9 patients who had not been operated upon, because of refusal of operation in 5, sudden death from cardiac arrest before operation in 2, coma from cerebral thrombosis in 1, and serious pulmonary tuberculosis in another one respectively.     

Neonatal brain abscess with intracystic hemorrhage--case report

The authors describe the case of an 11-day-old boy with high fever and signs of meningeal irritation in whom computed tomography demonstrated a large brain abscess with intracystic hemorrhage in the right temporal lobe. Cerebrospinal fluid analysis indicated purulent meningitis caused by Escherichia coli. After aspiration of the abscess contents, the entire ventricular system gradually enlarged. Despite repeated ventricular drainage and ventriculoperitoneal shunting, the lateral horn of the left lateral ventricle remained dilated. The isolation of the lateral ventricle may have resulted from septation due to the inflammatory reaction. This fluid was also shunted to the peritoneal cavity.     

Right ventricular myxoma with syncopal attach; report of a case

Cardiac myxoma of right ventricle is rare. We report a 16-year-old girl who underwent an emergent surgical resection of right ventricular myxoma. She had syncopal attach in going to school and was referred to our hospital in emergency. There were no abnormal findings in brain computed tomography (CT) and electroencephalogram, but Levine IV/VI systolic ejection murmur was heard. Echocardiography and magnetic resonance imaging (MRI) revealed the presence of large mass in the right ventricle which was floating into the pulmonary artery. The tumor was removed completely through the both of main pulmonary artery and right atrium using cardiopulmonary bypass. The tumor was attached to the right ventricle free wall by a pedicle, which was 5 x 3 cm in size and was diagnosed as myxoma by histopathological examination.     

Ossified choroid plexus papilloma--case report

While the calcification has been documented radiologically in 4 - 25 percent of the cases with choroid plexus papilloma, the ossification of choroid plexus papilloma has been reported only in 3 cases on literature. In this paper, we present a case of large ossified choroid plexus papilloma in the right lateral ventricle. A 35-year-old man was admitted with left hemiparesis and headache. Skull X-rays showed an abnormal calcified mass (25 mm x 23 mm x 14 mm) in the right temporal region. CT scan revealed an abnormal high density area protruding into the right lateral ventricle, and a low density area at the right corona radiata. Operation was carried out with a right temporal craniotomy. The mass was yellowish-elastic hard and protruded into the right inferior horn of the lateral ventricle. The histological examination of surgical specimen showed an ossified choroid plexus papilloma with some bone marrow formation and numerous calcification. Calcification of choroid plexus papilloma is found frequently, but ossification is a very rare neuropathological abnormality. Bone and/or cartilage formation in neuroepithelial neoplasms is an unusual event histopathologically. Several mechanisms have been proposed, such as (1) metaplasia of connective tissue, (2) transformation of neuroepithelial cells to mesenchymal tissue, (3) teratomatous nature, (4) heteroplasia, (5) mixed mesenchymal-neuroepithelial nature, and (6) ossification as an end stage of mucoid degeneration. In our case, it was considered that the bone formation resulted from metaplasia of connective tissue of choroid plexus papilloma.     

Trigonal cavernous angioma presenting with selective ventricular exclusion

We present a case of a patient with an intraventricular cavernous angioma originating from the splenium of the corpus callosum presenting with intracranial hypertension syndrome. In our case the growth of the lesion from the corpus callosum toward the ventricular spaces determined the direct exclusion of the occipital and temporal horn of the left lateral ventricle.     

Dermoid cyst of the lateral ventricle associated with ethmoidal dermal sinus. Report of a case

We report a case of a ventricular dermoid cyst associated with a dermal sinus connected with the ethmoidal cells in a patient who developed rapid symptoms of raised intracranial pressure. Computed tomography showed a cystic mass in the right lateral ventricle with a hydrolipidic image in the left frontal horn of the ventricle and associated hydrocephalus. Magnetic resonance imaging showed a heterogeneous T1 hyperintense mass with a fistulous tract communicating with the ethmoid cells. A cerebrospinal fluid ventriculo-peritoneal shunt was initially established, which required further revision. A right sided transventricular approach was undertaken in a second stage, allowing resection of a dermoid cyst. Obliteration of the dermal sinus tract was obtained using pericranial duraplasty. Clinical and imaging features are discussed. The need for total resection including the tumor capsule and occlusion of the fistula are emphasized if recurrence and infection are to be prevented.