Cyst of the choroid plexus in the lateral ventricle: case report and review of the literature

We report an intraventricular cyst in a 2-year-old boy who had myoclonic jerks of the extremities. The cyst had no communication with the ventricular system or subarachnoid space. Total removal of the cyst adhering to the choroid plexus was accomplished. The glial cyst wall was lined in part by flattened or cuboidal epithelium. The preoperative and postoperative computed tomographic scans and magnetic resonance images are presented, and congenital benign cysts in the lateral ventricle are reviewed and discussed.     

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.     

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.     

Selection of surgical approach for quadrigeminal cistern arachnoid cyst

Preoperative magnetic resonance imaging of 4 cases of quadrigeminal cistern arachnoid cyst were retrospectively reviewed and patterns of extension to surrounding cisterns from the quadrigeminal cistern were examined. Relationship between patterns of extension to surrounding cisterns and selected surgical approach were evaluated. In 2 cases, the cyst extended anteriorly and compressed the quadrigeminal plate. These two cases had hydrocephalus due to aqueductal stenosis. The anteroirly extending cyst was treated with endoscopic ventriculocystocisternostomy via the lateral and third ventricles. In one case, the cyst extended superiorly to the velum interpositum cistern, and was treated with endoscopic ventriculocystocisternostomy via the lateral ventricle. In one case, the cyst extended laterally to the ambient cistern and compressed the posterior horn of the lateral ventricle. This case had loculated hydrocephalus of the inferior horn. The laterally extending cyst was treated with resection of the wall of the arachnoid cyst via an infratentorial supracerebellar approach assisted by endoscope. All cysts were successfully treated. Injury of the foramen of Monro occurred during a procedure using a flexible endoscope in a case with an anterior extending cyst. Exact analysis of the preoperative imaging and selection of appropriate surgical approach are key factors for successful treatment of a quadrigeminal cistern arachnoid cyst.     

Spontaneous disappearance of two asymptomatic arachnoid cysts in two different locations.

We report two children with asymptomatic arachnoid cysts which resolved spontaneously without any surgical intervention and history of major head and body trauma. The first child was a 10-year-old boy with an arachnoid cyst in the right sylvian fissure. The second child was a 1-year-old girl with a right cerebral convexity arachnoid cyst. Both of them were asymptomatic. Arachnoid cysts spontaneously disappeared within 2 years following initial diagnosing. There was no major head and body trauma except usual home, school and sports activity. We speculated that the cysts ruptured into cerebrospinal fluid circulation by the mechanical effects of some forced activities to the brain tissue and cyst, such as excessive breathing, coughing and sport activities. These factors may change the balance between intracystic and pericystic pressure and facilitate the rupturing of the cyst into subdural, subarachnoid and intraventricular spaces. These cases demonstrate that neurosurgical intervention of asymptomatic arachnoid cysts is not absolutely indicated in the paediatric age group. Close follow up with computerized tomography (CT) and magnetic resonance imaging (MRI) is a treatment option in the patient with arachnoid cysts located in the middle cranial fossa and cerebral convexity.     

Ventricular diverticula in obstructive hydrocephalus secondary to tumor growth

OBJECTIVE: The association of ventricular diverticula with intra- and paraventricular tumors causing obstructive hydrocephalus has rarely been reported. METHODS: Records and imaging findings for 57 patients with obstructive hydrocephalus caused by tumors who were treated at our institution were reviewed for the presence of ventricular diverticula. For the anatomic study of ventricular diverticula, data were collected from five cadaveric heads. RESULTS: Ventricular diverticula were identified on magnetic resonance imaging scans in five cases. Diverticula were similarly located in the quadrigeminal cistern but originated from the medial wall of the atrium of the lateral ventricle in three cases and from the superior portion of the fourth ventricle in two cases. Regression of diverticula occurred in all cases after either insertion of a shunt or removal of the obstructing tumor. The cadaveric study suggested that the choroidal fissure and the rostral portion of the superior medullary velum might be the origins of diverticula from the atrium and from the superior portion of the fourth ventricle, respectively. CONCLUSION: Ventricular diverticula should be distinguished from other cystic lesions in the quadrigeminal region. Detection of an ostium of a diverticulum or communication between the cyst and the ventricular system is important for diagnosis.     

Infratentorial supracerebellar approach to the colloid cysts of the third ventricle

OBJECTIVE: The transcallosal and the frontal transcortical approaches are the most widely used methods in surgery of third ventricle colloid cysts. However, these approaches require traction of the frontal lobe and dissection of the corpus callosum or corticotomy and involve some postoperative consequences. The rationale of the proposed method is to remove the colloid cyst by the infratentorial supracerebellar approach and the posterior wall of the third ventricle without dissection of any neural structures. METHODS: Five patients with a colloid cyst of the third ventricle were operated on by the proposed method. The first patient presented with several months' history of symptoms that included increased intracranial pressure and right-sided cerebellar signs, caused by a metastatic tumor of the right cerebellar hemisphere. The other four patients had symptoms including intracranial hypertension for an extended period of time without any other neurological deficits. In all patients, magnetic resonance imaging revealed a colloid cyst of the third ventricle without hydrocephalus. TECHNIQUE: With the infratentorial supracerebellar approach, the arachnoid of the quadrigeminal cistern is dissected. The pineal body is separated and displaced from the internal vein medially, and the posterior velum interpositum is opened. Perforation of the inferior layer of the tela choroidea just above the suprapineal recess allows opening of the third ventricle cavity. A foraminal region is exposed after a slight lateral displacement of medial surfaces of the thalamus along the third ventricle roof. CONCLUSION: The proposed approach through the infratentorial supracerebellar space and the posterior wall of the third ventricle may be used for removal of colloid cysts, especially in patients in whom the lateral ventricles are not enlarged.     

Arachnoid cyst of the quadrigeminal cistern

Arachnoid cyst located near the quadrigeminal cistern has been reported as paracollicular arachnoid cyst, arachnoid cyst of the quadrigeminal cistern, paramesencephalic arachnoid cyst, arachnoid cyst posterior to the third ventricle, cyst of the cisterna ambiens. The purpose of this paper is to present the clinical pictures, diagnostic studies and treatment of 5 cases of the arachnoid cyst of the quadrigeminal cistern. (1) The clinical symptoms and signs result from increased intracranial pressure without lateralizing signs (mid-line syndrome) due to hydrocephalus, precocious puberty and supra-collicular sign due to direct compression of the adjacent structures. (2) Endocrinological study of the pituitary gland shows no abnormal findings, but the patients with precocious puberty shows adult type response in LH and FSH. (3) Metrizamide CT cisternography could be considered as a safe and reliable neurological procedures in evaluating the communication between the cyst and the subarachnoid space as well as CSF dynamics, and subarachnoid space. (4) Patients were treated with ventriculoperitoneal shunt, followed by craniotomy and resection of the cyst wall with good results.     

Endoscopic treatment of quadrigeminal cistern arachnoid cysts.

Five patients with arachnoid cysts of the quadrigeminal cistern treated by endoscopic fenestration are reported and another eleven well-documented cases from the literature are reviewed. Among the five personal cases four were children and one was adult; the cyst fenestration was performed from the lateral ventricle in three cases and from the third ventricle in two. In four patients the endoscopic treatment resulted in clinical remission, whereas a two-month-old baby later required a shunt. The lateral ventricle-cystostomy and the third ventricle-cystostomy (according to the cyst extent) are the best endoscopic procedures, whereas the cyst fenestration through a suboccipital supracerebellar approach is no longer used. The rate of cured or improved patients after endoscopic surgery (14/16 or 87.5%) was rather similar to that of a group of twenty patients treated by traditional surgery (craniotomy and cyst excision and/or shunt) (85%). These data confirm that endoscopic fenestration of quadrigeminal cistern cysts must be performed as the first procedure because it is less invasive and avoids shunt dependency.     

A case of neurocysticercosis with multiple intraparenchymal and intraventricular cysts]

Neurocysticercosis is a rare disease, and no association with intraventricular cysts has been reported in Japan. We report a case of neurocysticercosis that presented the unique symptom of a fourth ventricular cyst. A 55-year-old man with a 7 year history of neurocysticercosis and hydrocephalus developed a positional headache and vomiting 3 months after an L-P shunt, and was admitted to our hospital. MRI showed multiple intraparenchymal cysts, ventricular enlargement and an intraventricular cyst in the fourth ventricle. The cyst and the cysticercus in the fourth ventricle were totally removed via the suboccipital approach. Histological examination showed characteristics of cysticercus. Two weeks after this surgery, V-P shunt with neuroendoscopical observation of the ventricle was performed. A small cyst was detected in the right lateral ventricle. The symptoms disappeared after surgery. Following surgery, a therapeutic course of albendazole was administered at a daily dose of 600 mg for 30 days. MRI after administration of the anticysticercal drug revealed reduction in the size of the cysts.     

Middle fossa arachnoid cyst presenting an interesting clinical course: a case report

The mechanism of the disappearance of arachnoid cysts is not fully understood. We report a case of arachnoid cyst which disappeared after head injury. A 28-year-old male was found to have an arachnoid cyst in the left middle fossa following head injury. We followed him up, because he had no symptoms. Two weeks later, he suffered from severe headache. CT image showed a dilatation of the subdural space, and his symptom deteriorated. We performed subdural-perifocal shunt, but one month after, he developed a subdural hematoma. The subdural hematoma was irrigated through a burr hole. His symptom disappeared post operatively. Two months later, CT image showed the disappearance of subdural hematoma and the arachnoid cyst. This case suggested one of the mechanisms involved in the disappearance of arachnoid cyst after head injury.     

Endoscopic treatment of para- and intraventricular cerebrospinal fluid cysts.

This study has been made to define the role of endoscopy and the most appropriate approach and technique of endoscopic fenestration of paraventricular and intraventricular CSF cysts according to the cyst size and location. Twenty-two patients with intraventricular (13 cases) and paraventricular (9 cases) CSF cysts, operated upon by endoscopic technique in three Italian neurosurgical centers, are reviewed. Paraventricular hemispheric cysts have been treated by endoscopic fenestration from the cyst to the lateral ventricle. Midline intraventricular cysts (2 of the septum pellucidum and 4 of the velum interpositum) underwent fenestration from the right lateral ventricle to the cyst, with fenestration in both lateral ventricles in one case. Cysts of the choroid plexus have been fenestrated from the homolateral enlarged ventricle (4 cases) or from the contralateral compressed ventricle (2 cases). Twenty patients (more than 90%) were definitively cured by the endoscopic procedure, whereas only 2 patients required a shunt or a direct approach. We think that the endoscopic fenestration must be considered the treatment of choice of intraventricular and paraventricular CSF cysts.     

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.     

Suprasellar arachnoid cysts: Options in operative management

Summary Suprasellar arachnoid cysts are uncommon lesions the optimal management of which is still subject for debate. Various authors have presented differing treatment preferences which include: 1) Subfrontal fenestration of the cyst to the basal cisterns; 2) Transcallosal fenestration of the cyst into the lateral ventricles with optional shunting; 3) Cystoperitoneal shunt; 4) Percutaneous ventriculocystostomy. There is a significant incidence of re-operation whatever the initial approach.Based on recent experience with 5 operative cases of suprasellar arachnoid cyst and a selective review of 6 major operative series covering 42 cases, the available surgical options are critically analyzed. Percutaneous ventriculostomy may offer the best chance for a definitive treatment. However the technique is demanding and is not readily available. Cystoperitoneal shunting entails shunt dependency and has a significant incidence of failure, as does cyst marsupialization to the subarachnoid cisterns. The establishment of a single CSF space by surgically communicating the cyst with the ventricular system appears to offer the best chance of success in the treatment of suprasellar arachnoid cysts, though a concomittant shunt may still be required in the occasional hydrocephalic patient.     

Ruptured Distal Anterior Choroidal Artery Aneurysm Presenting with Casting Intraventricular Haemorrhage

Summary This report describes a rare case of a distal anterior choroidal artery aneurysm which developed intraventricular haemorrhage without subarachnoid haemorrhage as shown on computerized tomographic (CT) scan. A 69-year-old hypertensive man suddenly became unconscious. An emergency CT scan showed a severe intraventricular haemorrhage and a small round low-dense lesion within the haematoma at the right trigone. The haematoma with obstructive hydrocephalus made the lateral ventricles larger on the right than on the left. CT scan could not detect any subarachnoid haemorrhage. Right interal carotid angiography revealed a saccular aneurysm at the plexal point of the right anterior choroidal artery. We approached the aneurysm and the small round lesion through the trigone via a right temporo-occipital corticotomy. We could clip the aneurysmal neck and remove the intraventricular haematoma and the papillary cystic mass (corresponding to the small round lesion on CT scan) totally in one sitting. Histological examination revealed the aneurysm to be a true one and the papillary cystic mass to be a choroid plexus cyst.     

Arachnoid cyst in the region of the fourth ventricle mimicking clinical picture of normal pressure hydrocephalus

Arachnoid cysts in the region of the fourth ventricle are rarely reported. Two cases with intraventricular arachnoid cysts (one in the fourth and one in the right lateral) manifesting normal pressure hydrocephalus have been described in the previous literature. Here we report a clinically similar case in which the cyst was wedged in cerebellar vermis and compressed the fourth ventricle. Slow enlargement of the cyst could explain the clinical picture. The removal of the cyst resulted in a marked improvement of the symptoms despite the lack of significant changes in ventricular size.     

Supracallosal interhemispheric arachnoid cyst: resolution after intracystic hemorrhage and infection

A case of a large, symptomatic, supracallosal interhemispheric arachnoid cyst is presented. Positive contrast-enhanced computed tomographic (CT) cystography after stereotactic puncture and aspiration demonstrated lack of communication between the cyst and the subarachnoid space or ventricular system. A cystoperitoneal shunt was successful in relieving the patient's symptoms for 5 years. A delayed shunt infection after gynecologic surgery necessitated removal of the shunt, and was complicated by asymptomatic intracystic hemorrhage. Thereafter, serial CT and magnetic resonance imaging scans showed eventual disappearance of the cyst.     

Disproportionately large communicating fourth ventricle associated with syringomyelia and intradural arachnoid cyst in the spinal cord successfully treated with additional shunting. Case report

A 44-year-old woman presented with a rare case of disproportionately large communicating fourth ventricle (DLCFV) associated with syringomyelia and intradural arachnoid cyst in the spinal cord. Ventriculoperitoneal shunt operation was performed for hydrocephalus after subarachnoid hemorrhage. She developed DLCFV, which was then associated with syringomyelia and spinal intradural arachnoid cyst. Shunting of the fourth ventricle improved DLCFV, and then the syringomyelia and arachnoid cyst. Although the aqueduct was patent, independent pressure control of the fourth ventricle and the other ventricles was necessary to improve the symptoms. Shunting of the fourth ventricle should be considered for patients with DLCFV when the symptoms persist despite adequate pressure control of the other ventricles.     

A case of quadrigeminal cistern arachnoid cyst associated with hydrocephalus

A case of quadrigeminal cistern arachnoid cyst associated with hydrocephalus is reported. A 1-year-old girl was admitted to our service on July 31, 1984, because of mental retardation and an enlarged head. She was born of a full-term pregnancy and normal vaginal delivery without prenatal complications. Progressive increase in her head circumference was noticed at the age of 6 months by her family physician. On admission she was found to be a well-nourished infant with a head circumference of 56 cm, bulging anterior fontanelle and mental retardation. Marked dilatation of the lateral ventricles and a large cyst in the quadrigeminal cistern were demonstrated on plain CT. There were no findings of communication between the ventricular system and the cyst on metrizamide CT ventriculography. The extension of the cyst from the quadrigeminal cistern to the right cerebello-pontine angle was demonstrated on reconstructed coronal CT. Reconstructed sagittal section revealed huge hydrocephalus caused by aqueductal stenosis. A vertebral angiography demonstrated opening of the para-mesencephalic segments of the bilateral posterior cerebral arteries and downward displacement of the right superior cerebellar artery. Accordingly, a large quadrigeminal cistern arachnoid cyst with hydrocephalus caused by aqueductal stenosis was suspected. Following V-P shunt operation for hydrocephalus, right temporo-parietal craniotomy was performed. The inner wall of the lateral ventricle was thin and an expanding cyst was observed through it. A partial resection of the cyst wall with the ventricular wall was performed to obtain communication between the cyst and lateral ventricle. The content of the cyst was watery clear fluid like CSF.(ABSTRACT TRUNCATED AT 250 WORDS)     

Multiple intradural arachnoid diverticuli: the need for complete myelography

A 12-year-old boy presented with enuresis, leg weakness, and lower extremity spasticity. An initial lumbar water-soluble contrast myelogram disclosed an arachnoid diverticulum. After the insertion of a cystopleural shunt, the patient improved and was dry. However, 2 months later the patient became enuretic and developed weakness. Repeat myelography showed a second arachnoid diverticulum located in the midthoracic region. This second diverticulum was treated by marsupialization of the cyst wall to the subfascial space. The authors stress the need for complete myelography in patients with intradural spinal arachnoid diverticuli and present a brief review of the literature.