Third ventricle cavernoma associated with venous angioma. Case report and review of the literature

A case of third ventricle cavernous angioma associated with venous angioma is reported. By a transventricular approach, the cavernoma was totally removed with successful preservation of the venous malformation. After review of the literature, the clinical characteristics and the surgical approach to third ventricle cavernous angioma are discussed; the importance of preservation of associated venous angioma is also underlined.     

A total removal case of cavernous angioma at the lateral wall of the third ventricle with interhemispheric trans-lamina terminalis approach

A case of cavernous angioma at the lateral wall of the third ventricle which was totally removed with interhemispheric trans-lamina terminalis approach is reported. A 40-year-old male had a slowly progressive onset of partial diabetes insipidus and headache with no neurological deficit . CT scan revealed a high density area at anterior third ventricle. The tumor was diagnosed ectopic pinealoma because of CT findings and clinical symptoms. Irradiation and chemotherapy ( RAFP therapy) was performed to this lesion. After two months, his clinical symptoms disappeared. CT scan showed decrease of the density of the region at this point. He was discharged with no symptom. After a half year, he suddenly complained of right homonymous hemianopsia with headache. CT scan showed that the high density area became larger to left posterior than that of half year before. Left carotid angiogram showed no mass lesion and no abnormal vessel. Operation was performed with interhemispheric trans-lamina terminalis approach using bifrontal craniotomy. Operative findings revealed that the tumor situated at the lateral wall of the third ventricle, had rough surface with reddish colour, and old and fresh blood clots inside the tumor. The tumor was carefully dissected without brain damage and was totally removed. The histological findings was compatible with cavernous angioma. Post-operative CT scan showed no high density area. He was discharged with no neurological deficit without right homonymous hemianopsia. Cavernous angioma of anterior third ventricle is very rare.(ABSTRACT TRUNCATED AT 250 WORDS)     

Anterior transpetrosal approach for pontine cavernous angioma--case report

A 58-year-old male patient presented with headache and unsteady gait. Magnetic resonance imaging revealed hemorrhage from a pontine cavernous angioma. The patient experienced stepwise aggravation of symptoms due to repeated hemorrhages. We decided to surgically remove the pontine cavernous angioma through an anterior transpetrosal approach, since the angioma and hematoma were located near the ventrolateral surface of the pons. The brain stem was incised at a site caudal to the trigeminal nerve and the hematoma and angioma were totally removed. No additional neurological deficits were observed following surgery. Brain stem cavernous angiomas are usually removed via a trans-fourth ventricle or lateral suboccipital approach. However, these approaches may not be appropriate if the angioma is located ventrally to the pons. We propose that the anterior transpetrosal approach is the method of choice for ventrally located pontine cavernous angioma.     

A surgical case of growing cavernous angioma at the pontomedullary junction

We described a surgical case of growing cavernous angioma located at the pontomedullary junction. This 52-year-old woman presented with symptoms caused by a small hemorrhage in the right cerebellopontine angle. Magnetic resonance images (MRI) suggested cavernous angioma as the underlying pathology. 9 months after the first episode, the second hemorrhage occurred with a deteriorated neurological state that disappeared under conservative treatment except for right facial paresis and hearing disturbance. During careful observation for 1 year, the size of the lesion gradually increased on MRI and additional neurological deficits including left hemiparesis and right abducent nerve palsy were diagnosed. The first operation was carried out through the right lateral suboccipital approach, but only partial removal of the cavernous angioma was accomplished due to the overlying seventh and lower cranial nerves. After more than 4 months, a third hemorrhagic episode was presented with a sudden onset of right cerebellar signs and facial numbness. The cavernous angioma grew in size to reach the ventrolateral corner of the 4th ventricle with dense hemosiderin deposition around the core lesion on MRI. An enhancement inside the lesion was also demonstrated after gadolinium-diethylenetriaminepenta-acetic acid administration. The second operation through the midline suboccipital approach was selected for the complete resection of the residual cavernous angioma. The lesion was too hard to resect without internal decompression. The pontine part of the lesion was almost totally resected, but manipulation for the medullary part to create a discrete layer between the lesion and surrounding neural tissues was unsuccessful and generated severe bradycardia, so this part of the cavernous angioma had to be left. The problems for the management of cavernous angioma in the brain stem should be discussed, especially focussing on the surgical indication in reference to our experience and previous literatures.     

Surgical removal of large cavernous angioma in the pontomedullary junction: a case report]

Recent advances in neuroradiology have enabled us to approach cavernous angioma in the brain stem. A case of large cavernous angioma, which was located in the pontomedullary junction, was removed surgically. A 24-year-old female was admitted with occipitalgia, dizziness, nausea, gait disturbance. On neurologic examination, the patient had right hemiparesis, slight right facial palsy and paresthesia, right hemiparesthesia, dysphagia. T1 weighted Gd enhanced MRI revealed a mixed intensity lesion. These findings were thought to be consistent with a cavernous angioma. Follow up MRI findings demonstrated progressive increase in cavernous angioma. Vertebral angiograms showed a mass sign and a venous angioma in the midline of the pontomedullary junction. Therefore, the operation was performed in an attempt to remove the cavernous angioma through the midline of the fouth ventricle. The operation was performed under monitoring of electromyogram of facial muscle and external ocular muscle. The cavernous angioma was removed totally, and addition neurogical deficits were minimal.     

Colloid cyst of the third ventricle

Summary The clinical and x-ray features of 28 cases of colloid cyst of the third ventricle are described. Colloid cyst is one of the most favourable space-occupying lesions of the brain for successful surgical removal, because an exact pre-operative diagnosis is possible. The surgical approach for colloid cyst of the third ventricle is discussed and the frequency of postoperative seizure is reviewed in 28 cases and compared with the literature.     

Brain stem hemorrhage associated with venous angioma: report of two cases

The incidence of hemorrhage associated with venous angioma has been considered to be rare. We here report two cases of brain stem venous angioma which also showed brain stem hemorrhage. Case 1; a 15-year-old female had experienced weakness in the left upper extremity 8 months prior to admission. She developed dysfunction of the left cranial nerves, and magnetic resonance imaging (MRI) showed a huge enlarging hematoma in the pons. Cerebral angiography showed venous angioma penetrating through the pons. Evacuation of the hematoma was performed through the fourth ventricle and many small vessels were found in the hematoma. Although all symptoms were partially resolved after the operation, a re-hemorrhage occurred 1 month after the operation. Case 2; a 50-year-old man had suddenly developed headache and vertigo several days prior to admission. Computed tomography (CT) and MRI showed a small hematoma in the lesion with venous angioma adjacent to the hematoma. All symptoms gradually resolved with conservative therapy.     

Cerebral venous angioma of the pons complicated by nonhemorrhagic infarction. Case report

The authors emphasize an unusual complication of venous angiomas in the brain: venous infarction. The patient in this case is a 32-year-old man who presented with a clinical history of headache followed by a worsening of his neurological status. Neuroimaging studies demonstrated a brain infarct in the posterior fossa, which was related to thrombosis of the draining vein of a cerebral venous angioma. A conservative treatment approach without anticoagulation therapy was followed and the patient completely recovered. Nonhemorragic venous infarction caused by thrombosis of a venous angioma is exceptional and only nine previous cases have been reported in the literature.     

Forth ventricle hematoma in a eight-year-old child

We report the case of a 4th ventricle hematoma due to rupture of an angioma localized in the cerebellar vermis, in an eight-year-old child. Only seven cases of a vascular malformation in such a localization, angiographically and/or pathologically verified, have been previously reported. The girl died, in spite of prompt surgical treatment. Also the clinical presentation of this kind of case is very rare.     

Intraventricular hemorrhage in a term neonate secondary to a third ventricular AVM. Case report

An initially healthy infant born of an uncomplicated full-term gestation was brought for evaluation of the acute onset of vomiting, irritability, lethargy, and opisthotonus at 14 days of age. Computerized tomography demonstrated an intraventricular hemorrhage. Arteriography defined an angioma on the roof of the third ventricle which was successfully removed via the transcallosal interfornicial approach on the 34th day of life. Other than an easily controlled seizure disorder, the postoperative course was uneventful. At 8 months of age the child is developing normally. Arteriovenous malformations should be considered in the differential diagnosis of intraventricular hemorrhage in full-term neonates without predisposing trauma or bleeding diathesis. High-speed digital subtraction arteriography may be used to screen for this diagnosis. The transcallosal interfornicial exposure offers a satisfactory approach for excising third ventricular angiomas in young infants.     

Diencephalic syndrome of emaciation in an adult associated with a third ventricle intrinsic craniopharyngioma: case report

OBJECTIVE AND IMPORTANCE: Diencephalic syndrome of emaciation (DS) is seen almost exclusively in infants and young children, and only two cases of DS in adults have been reported previously. We describe a case of DS associated with a third ventricle intrinsic craniopharyngioma in an adult patient. CLINICAL PRESENTATION: A 54-year-old man presented with profound emaciation, disorientation, memory loss, and psychological disorders. Computed tomographic scanning and magnetic resonance imaging of his brain disclosed a tumor within the third ventricle. The preoperative endocrinological examination indicated an elevated growth hormone level and a decreased somatomedin C level. INTERVENTION: The patient underwent partial resection of the tumor, which was adherent to the floor of the third ventricle but not to the ventricle wall, by an interhemispheric-transcallosal approach. The histological examination revealed a squamous papillary-type craniopharyngioma. The patient received 50 Gy of radiotherapy, which resulted in 90 to 95% reduction of the tumor size within 6 months, as indicated by the magnetic resonance images presented. The psychological disorders, memory disturbance, and severe emaciation improved gradually thereafter. CONCLUSION: Although extremely rare, DS can occur in an adult harboring a tumor in the anterior hypothalamus.     

Interhemispheric approach through the lamina terminalis to tumors of the anterior part of the third ventricle

Operative approaches to tumors of the third ventricle, mainly the bifrontal approach through the lamina terminalis, are discussed. The latter approach has several advantages. First, the main arteries can be exposed and the operative field is sufficiently wide to render the operative procedure safe. Second, cortical incision or excision is unnecessary. By cutting the lamina terminalis, which is usually thin and expanded as a result of hydrocephalus, even a large tumor can be removed. In addition, lethal complications are avoided, because this approach has less possibility of damage to the lateral wall of the third ventricle. Seventeen cases of tumor in the third ventricle underwent operation via this approach. The operative technique for the bifrontal approach through the lamina terminalis and three representative cases are reported. This approach can be applied not only to tumors, but to arteriovenous malformations or giant aneurysms adjacent to the third ventricle.     

Radical surgery on cavernous angioma of the brainstem

Four cases of cavernous angioma of the brainstem are reported. Three patients had angiomas of the pons; one had a lesion extending from the third ventricle to the hypothalamus. In the three patients directly operated upon the entire lesion was excised. The lesions were delimited by reactive scar tissue, so that by means of a careful technique severe associated disorders were avoided postoperatively. The importance of computed tomography for postoperative observation and the effectiveness of nuclear magnetic resonance-computed tomography have been demonstrated. It is thought that henceforth surgical treatment of brainstem lesions will be found appropriate in a far greater number of cases.     

Cavernous angioma in the fourth ventricle

A cavernous angioma in the fourth ventricle of a 47-year-old man is reported. Because of a progressive clinical course and a ring-like enhancement on computed tomography, a brain tumor, rather than a vascular disease, was suspected. The lesion was removed totally and verified histologically as a cavernous angioma.     

CT finding is an index in assessment of outcome in patients with diffuse traumatic brain swelling

Objective:To assess the relationship between the prognosis of the patients with diffuse traumatic brain swelling (DTBS) and the changes of the ventricles and the cisterns in CT scans.Methods:The outcome of the patients with DTBS and the changes of the vertricles and the cisterns in CT scans were studied and analyzed in a group of 268 cases.We focused on the changes of the third ventricle and the basal cistern,age and Glasgow Coma Scale(GCS).Results:Of 268 cases,there were changes of the third ventricle and/or the basal cistern in 124,65 died.In 18 cases,the third ventricle and the basal cistern were both absent and 16 died(88.9%).The third ventricle changed significantly in 59 cases,33 died(55.9%),while the basal cistern changed in 47 cases and 16 died (34%).Of the 124 patients with changes of the third ventricle and/or the basal cistern,26 were children,8 died;98 adults,57 died.Conclusions:For patients with DTBS,the outcome was in direct correlation with the change of the third ventricle and/or the basal cistern,the change of the third ventricle was much more important in assessment of the outcome than that of basal cisterns.There is no significant difference in,the incidence of DTBS between children and adults while the outcome of children is much better than that of adults.The patients with the changes of the third vertricle and the basal cistern accompanied with lower GCS scores have poor outcome.     

Experimental study on destruction of the third ventricle floor in the midline:--examination for the trans-third ventricle approach

Surgery of a basilar bifurcation aneurysm is a very difficult operation in neurosurgery. For the treatment of this lesion, two methods are widely used at present: one is the subtemporal approach developed by Drake and the other is the pterional approach by Yasargil. With either approach, however, the treatment of a basilar bifurcation aneurysm accompanied by megadolichobasilar anomaly is difficult and hazardous due to the necessity for excessive retraction of the brain, nerves and vessels. Recently we successfully treated two cases of ruptured basilar bifurcation aneurysm complicated with megadolichobasilar anomaly by the trans-third ventricle approach. The floor of the third ventricle was already partly destroyed by aneurysmal rupture in both cases. It was required to make a small split in the third ventricle floor in order to get a wider operative field. Postoperatively, however, no influence from the splitting of the floor was seen. An experimental study was carried out in dogs to determine the influence from the destruction of the floor of the third ventricle. Using microsurgical techniques, the third ventricle floor was opened along the midline. Dogs were sacrificed 30 days after surgery. The following items were evaluated before, during, and after surgery: clinical symptom, blood pressure, pulse, body temperature, serum electrolytes, serum osmotic pressure, pituitary hormones (anterior lobe), cortisol, ADH (2.5mol NaCl loading test), electroencephalogram, cerebral blood flow and pathological change. No significant abnormalities could be detected in endocrine and metabolic functions, and no histological changes were seen around the hypothalamus. In conclusion, it is justified to split the third ventricle floor along the midline if it is indicated.     

Intraventricular solitary fibrous tumor: an unusual tumor with radiological, ultrastructural, and immunohistochemical evaluation: case report

OBJECTIVE AND IMPORTANCE: Intracranial solitary fibrous tumors have been described previously, but intraventricular solitary fibrous tumors are extremely rare. We present what is, to our knowledge, the first reported case of solitary fibrous tumor in the third ventricle. CLINICAL PRESENTATION: A 63-year-old man presented with weakness of his lower extremities and headaches. Computed tomography and magnetic resonance imaging of the brain revealed an enhancing mass in the posterior part of the third ventricle. INTERVENTION: The tumor originated from the wall of the left internal cerebral vein and extended to the posterior part of the third ventricle. Nearly total excision was performed via an infratentorial-supracerebellar approach. CONCLUSION: The differential diagnosis of intracranial solitary fibrous tumors includes fibroblastic meningioma, meningeal hemangiopericytoma, neurofibroma, and schwannoma. The differential diagnosis in the present case was greatly helped by the immunohistochemical and ultrastructural findings, along with a disease-free 3.5-year follow-up. These findings are presented with reference to previous reports.     

经胼胝体-穹窿间入路显微手术切除第三脑室肿瘤

目的探讨经胼胝体-穹窿间入路显微手术切除第三脑室肿瘤的方法，并对相应的显微解剖学基础加以讨论。方法经胼胝体-穹窿间入路显微手术切除第三脑室肿瘤12例，其中突入第三脑室颅咽管瘤8例，丘脑内侧型胶质瘤2型，室管膜瘤1例，畸胎瘤1例。结论10例在手术显微镜下肿瘤全切，2例次全切除，全切除率83．3％，其中8例颅咽管瘤中7例全切，术后复查头颅MR未见肿瘤残留及复发。无死亡病例，近期并发症主要为多饮、多尿、电解质紊乱。经处理后1-2周消失。远期并发症为2例脑积水，其中1例半年后行脑室腹腔分流，2例硬膜下积液，3月后自行吸收。全组病例随访最短2个月，最长2年半，1例颅咽管瘤大部切除8月后复发，1例丘脑胶质瘤术后1年复发，其余10例中9例生活正常，1例生活自理。结论经胼胝体-穹窿间入路显微手术切除第三脑室肿瘤系通过胚胎组织残留的组织间隙进入第三脑室，几乎不损伤正常脑组织，手术视野大，直视下操作，可切除第三脑室前、中、后各部位肿瘤，肿瘤全切除率高，并发症少。     

Ganglioglioma in the third ventricle: report on two cases

Gangliogliomas are uncommon central nervous system (CNS) tumors composed of a mixture of glial and neuronal elements. Although these tumors can occur in any portion of the central nervous system, involvement of the ventricular system is rare. We herein report on two cases of gangliogliomas in the third ventricle in a 34-year-old woman and in a 52-year-old man. One patient presented only with headaches, and the other presented symptoms associated with panhypopituitarism and diabetes insipidus. In the first case the tumor in the middle portion of the third ventricle was successfully removed by a transcallosal subchoroidal approach. In the second case the hemorrhagic tumor was located in the anterior floor of the third ventricle and was removed by an anterior inter-hemispheric trans-lamina terminalis approach. To date, follow-ups of both patients have involved no adjuvant therapy, and there have been no signs of tumor recurrence on magnetic resonance images. The nature, radiological findings, and treatments of these tumors are discussed.     

Transcavum septum pellucidum interforniceal approach for the colloid cyst of the third ventricle Operative nuance

BACKGROUND: Despite their unfavorable locations, lesions of the third ventricle can be successfully removed via an interhemispheric, transcallosal approach. In cases with normal ventricular anatomy, this approach requires unilateral or bilateral identification of the foramen of Monro. TECHNIQUE: However, in the presence of abnormal ventricular configuration such as cavum septum pellucidum (CSP), this basic knowledge needs to be modified. After routine callosotomy, there may be a confusion while entering the CSP due to the invisualization of ventricular landmarks such as the foramen of Monro, thalamostriate vein, and choroid plexus. The floor of the CSP is formed by the fornices, and a direct approach to the interforniceal area is easier via the CSP. But the interforniceal approach is not a routine way to reach the third ventricle, which has higher risks than other modalities. CONCLUSION: This approach should be planned and used in selected cases of the CSP. Opening of the walls of CSP is recommended both to expose both the foramen of Monro and to gain safe access to the third ventricle before manipulating the interforniceal area.