Tercerventriculostomía endoscópica del paciente adulto. Resultados tras la aplicación de nuestro protocolo / Endoscopic third ventriculostomy of the adult patient. Results from the application of our protocol

Introducción: La tercerventriculostomía endoscópica (TVE) es una técnica quirúrgica ampliamente reconocida para el tratamiento de la hidrocefalia obstructiva. Al igual que otras técnicas para el manejo de la hidrocefalia, la protocolización del manejo intra y peri-operatorio deviene en mejores resultados. Sin embargo, no existe en la literatura en castellano alguna publicación que exponga en detalle un protocolo de trabajo de TVE. El objetivo de este estudio es presentar los resultados tras la aplicación de nuestro protocolo. Materiales y Métodos: Se realizó una descripción del protocolo para TVE prequirúrgico, intraoperatorio y post-operatorio. Se realizó un análisis prospectivo de una serie de casos. Resultados: Un detallado protocolo fue presentado. Un total de 70 pacientes fueron incluidos para su análisis. La tasa de éxito del procedimiento fue del 82.43%. Hubo una mejoría en la escala de Karnofsky tras la TVE [media de 26.22 puntos (IC 95% 13,77 -36,92)]; siendo esta estadísticamente significativa (p=<0,001). Conclusión: La TVE demostró ser un procedimiento seguro y efectivo para el tratamiento de la hidrocefalia obstructiva. El protocolizar el procedimiento quirúrgico demostró una alta tasa de éxito en nuestra cohorte de pacientes, comparando con los resultados de la literatura internacional

Background. Endoscopic third ventriculostomy (ETV) is a worldwide accepted technique to treat obstructive hydrocephalus. As per many other techniques to treat hydrocephalus, protocols had improved the overall results and reduced the complications rate. However, there are no protocols written in Spanish literature, that illustrate in detailed a step by step on how to perform and follow up patients with ETV.The aim of this study is to present the results after the application of our protocol. Methods. A protocol with surgical technique, management and follow up for ETV in adults was written and a retrospective analysis of several cases was presented. Results. A detailed protocol was presented. Forty-three patients included in the protocol were analysed after ETV. The success rate of the procedure was 82.43%. There was a statistically significant improvement of a mean 26.22 points (IC 95% 13.77 -36.92) in the Karnofsky scale after the ETV (p=<0.001). Conclusion: ETV has shown to be a safe and effective procedure to treat obstructive hydrocephalus. The protocolization of the procedure proved a high success rate in our cohort of patients, comparable with the international literature results

Lymphoplasmacyte-Rich Meningioma of the Third Ventricle: Case Report

Introduction Meningiomas are the most common primary intracranial tumors, accounting for up to 35% of the neoplasms in this category. Approximately 10­20% of these neoplasms are histologically atypical, and the lymphoplasmacyte-rich meningioma (LPM) corresponds to a very rare subtype of meningioma that is characterized histopathologically by massive infiltrates of inflammatory cells. The case described in the present study is the sixth case of an intraventricular LPM found in the literature and the first case considering the location in the third ventricle. Case Description A 21-year-old male without previous comorbidities sought medical attention due to visual impairment (complaining of intermittent visual blur) for 2 months. A magnetic resonance imaging of the brain confirmed the presence of a well-delimited solid mass in the third ventricle of 3.0 2.3 cmwith a cystic component that extended itself inferiorly and distorted the visual pathway anatomy. Neurosurgeons decided to access the lesion using an interhemispheric transcallosal approach with a transforaminal access, and the lesion was resected completely. The patient has an ambulatorial endocrinological follow-up and is neurologically stable 6 months after the procedure. No new visual deficits were noted. Conclusion Lymphoplasmacyte-rich meningioma is a very rare intracranial tumor, and the involvement of the third ventricle make this case unique.

Anomalies associées aux holoprosencéphalies à l'échographie anténatale: à propos d'une série de 11 cas à Ouagadougou (Burkina Faso)

Objectifs : décrire les anomalies associées aux holoprosencéphalies suspectées lors de l'échographie anténatale. Patients et méthodes. Il s'est agi d'une étude transversale descriptive. Nous avons inclus de façon consécutive, les cas suspects d'holoprosencéphalies diagnostiqués au cours d'échographies anténatales évolutives réalisées dans notre centre d'imagerie, entre janvier 2016 et décembre 2018, quel que soit l'âge gestationnel. Résultats : 11 cas suspects d'holoprosencéphalies ont été identifiés. Il s'agissait de formes alobaires dans huit cas et de forme semi lobaire dans trois cas. L'âge gestationnel médian lors du diagnostic était de 31 semaines d'aménorrhée [13 et 38 ans]. L'âge maternel médian était de 32 ans [23-41ans]. Il n'y avait pas de diabète maternel ou d'antécédent familial noté chez ces patientes. Les anomalies encéphaliques à type d'absence de la ligne médiane, de ventricules unique et de fusions des thalami étaient notées chez tous les foetus. Les anomalies nasales étaient présentes dans 8 cas /11, labiales dans 2 cas/11 et oculaires dans 5 cas/11. Les foetus étaient majoritairement de type féminin. On notait la présence d'autres anomalies dans 5 cas/11. Il s'agissait de néphropathie, d'anomalie fémorale et d'une communication interventriculaire. Conclusion : Malformation rare, l'holoprosencéphalie est diagnostiquée tardivement dans notre contexte. Il n'y avait pas de facteur étiopathogénique retrouvé. Les tests génétiques et l'étude du caryotype n'étaient pas disponibles dans notre contexte au cours de l'étude

Suprasellar chordoid glioma: a report of two cases

SUMMARY Chordoid glioma (CG) is considered a slow growing glial neoplasm. We report two new cases with endocrinological presentation, management and outcome. Case reports: 1) An 18 year-old female patient was admitted due to headaches, nausea and vomiting and visual abnormalities. She was in amenorrhea. A brain magnetic resonance imaging (MRI) demonstrated a 35 mm-diameter sellar and suprasellar mass. An emergency ventricular peritoneal valve was placed due to obstructive hydrocephalus. Transcraneal surgery was performed. The patient developed central hypothyroidism, adrenal insufficiency and transient diabetes insipidus; she never recovered spontaneous menstrual cycles. Histopathologic study showed cells in cords, inside a mucinous stroma, positive for glial fibrillary acidic protein (GFAP). Due to residual tumor gamma knife radiosurgery was performed. Three years after surgery, the patient is lucid, with hypopituitarism under replacement. 2) A 46 year-old woman complained about a three year-history of amenorrhea, galactorrhea and headache. An MRI showed a solid-cystic sellar mass 40 mm-diameter that extended to the suprasellar cistern. She had hypogonatropic hypogonadism and mild hyperprolactinemia. The tumor mass was removed via nasal endoscopic approach. Histopathological study reported cellular proliferation of glial lineage positive for GFAP. The patient evolved with central hypothyroidism and diabetes insipidus. She was re-operated for fistula and again under the diagnosis of extradural abscess. She evolved with cardiorespiratory descompensation and death, suspected to be due to a thromboembolism. In conclusion, the first case confirms that best treatment for CG is surgery considering radiotherapy as an adjuvant therapy. The other case, on the contrary, illustrates the potentially fatal evolution due to surgical complications.

Migration of Oxidized Cellulose to the Ventricle as a Complication of Endoscopic Third Ventriculostomy: A Case Report

Endoscopic third ventriculostomy (ETV) is an increasingly common neurosurgical procedure. Hemostatic agentes (porcine gelatin and oxidized cellulose) are normally placed to plug the cortical hole after ETV to avoid cerebral spinal fluid leakage, subdural hygroma, and hemorrhage. Here we report the case of a 6-year-old boy with hydrocephalus who underwent ETV and which oxidized cellulose was placed to plug the cortical hole.Magnetic resonance imaging of the head performed 3 months after the procedure showed the presence of oxidized cellulose in the ventricle. After an unsuccessful attempt to remove the cellulose, it was decided that the patient should be kept under observation. Twoyears later, the child is in good health and without any complaints. Hemostatic agents (especially oxidized cellulose) used on the cortical hole after ETV can migrate to the ventricle and compromise the procedure. Follow-up should be performedfor such patients, and the main focus should be on not causing further injury.

Strictly Intraventricular Craniopharyngioma: Case Report and Literature Review

Strictly intraventricular craniopharyngiomas are a rare topographical variety of craniopharyngiomas. The correct diagnosis is important in order to define the surgical planning, as the surgical access is different for suprasellar tumors with secondary invasion of the third ventricle. An image diagnosis may be difficult, though suggestive patterns exist. The aim of the present case report and literature review is to add to the scarce literature on strictly intraventricular craniopharyngiomas, as well as to remind the neurosurgeon of this rare diagnosis so that the proper treatment is provided.

Craniofaringiomas puramente intraventriculares constituem uma rara variedade topográfica dos craniofaringiomas. O diagnóstico correto é fundamental para a definição do plano cirúrgico, posto que o acesso a este tipo de tumor difere dos tumores suprasselares com invasão secundária do terceiro ventrículo. A confirmação por neuroimagem pode ser difícil, embora existam características sugestivas. A presente descrição de caso, bem como a revisão de literatura, visa contribuir com a escassa literatura a respeito de craniofaringiomas puramente intraventriculares, além de remeter o neurocirurgião a este diagnóstico raro para a adoção da conduta correta de tratamento.

O papel da membrana de Liliequist na terceiro ventriculostomia endoscópica / The role of the Liliequist membrane in endoscopic third ventriculostomy

A Terceiro Ventriculostomia Endoscópica (TVE) é operação intracerebral que trata a hidrocefalia. Para sua realização é necessário conhecimento da anatomia cirúrgica da membrana aracnoidea de Liliequist, que deve ser aberta durante o procedimento. Porém, a anatomia do ponto de vista neuroendoscópico é pouco conhecida, já que os ângulos de abordagem são diferentes da anatomia descritiva clássica e mesmo da anatomia cirúrgica microscópica. Há discrepância na literatura quanto a eficácia da TVE, sobretudo em crianças, em que pode ocorrer a não abertura completa da membrana de Liliequist (ML). Para compreensão do comportamento da ML, a sua associação com o Tuber Cinereo (TC) e o assoalho do III Ventrículo (IIIVT) e outras peculiaridades, foi realizada, prospectivamente, a observação sistemática destas características durante 57 operações. Os dados foram registrados após o procedimento e posteriormente estudados. Os objetivos eram sistematizar as características anatômicas destas estruturas do ponto de vista neuroendoscópico, avaliar se as alterações seguiam algum padrão e se interferiam no procedimento técnico, correlacionando com a evolução. Pela análise dos dados percebeu-se que as características da ML são variáveis e dificultam, em uma percentagem considerável de vezes, a sua interpretação e seu manejo pelo neurocirurgião. Também, que o TC alterado e separado da ML são fatores associados à maior dificuldade de realização da TVE. Que as TVE realizadas nas hidrocefalias por malformações congênitas, processos inflamatórios e pós sangramento (prevalentes na infância) estão associadas a maior dificuldade de manejar a ML e podem explicar o índice de insucesso maior observado na literatura em crianças abaixo de 2 anos.

Endoscopic Third Endoscopic (ETV) is a neurosurgical procedure to treat hydrocephalus. To be fully performed it is necessary opening an arachnoid structure, the Liliequist Membrane (LM). However the LM surgical anatomy from the neuroendoscopic point of view is not yet completely studied, since approach angles are different from classics descriptive and microsurgical anatomies. There is a literature discrepancy regarding the ETV efficacy, especially in children over 2 years old, which may be due to LM incomplete opening. In order to understand the LM anatomical behavior, the relationship with tuber cinereo (TC), the floor of the III Ventricle and other peculiarities, a systematic prospective observation of these characteristics was performed during the 57 surgeries. Data were recorded after the procedure and studied. Objectives were to systematize LM anatomical characteristics from neuroendoscopic perspective, understand if anatomical changes follows a pattern interfering on the procedure, and if there is correlation with patients evolution. The data analysis shows that LM characteristics are variable, making difficult the neurosurgeon management. Whenever TC anatomy modifies, or when TC and ML are separated, difficulty to perform ETV increases. When hydrocephalies are due to congenital malformations, inflammatory processes and post bleeding (prevalent in childhood), LM management is much harder, witch may explain the higher failure rate in children under 2 years of age observed in literature.

Craniopharyngioma with Intratumoral Hemorrhage and Superficial Siderosis

Superficial siderosis of the central nervous system (CNS) is a progressive and debilitating neurological disease manifesting sensorineural hearing loss, cerebellar ataxia, and pyramidal tract signs. Chronic extravasation of blood into the subarachnoid space results in the accumulation of hemoglobin derivate in the subpial layer of the CNS, which is toxic to the neural tissues. Craniopharyngioma is a benign third ventricle tumor, which rarely presents with tumor bleeding. We report a rare case of superficial siderosis associated with craniopharyngioma with intratumoral hemorrhage in a patient with no history of prior trauma or CNS surgery.

Transphenoidal Surgery : The Optimal Approach to Chordoid Gliomas of the Third Ventricle?

No abstract available.

Transphenoidal Surgery : The Optimal Approach to Chordoid Gliomas of the Third Ventricle?

No abstract available.

Hypomania in Bobble-Head Doll Syndrome: A Case Report of Surgically Treated Stereotypy and Hypomania

A 22-year-old man was admitted with gradually aggravating stereotypic head movement with hypomania. Brain magnetic resonance imaging showed a large suprasellar arachnoid cyst extending into the third ventricle, with obstructive hydrocephalus, characteristic of bobble-head doll syndrome. Endoscopic fenestration of the suprasellar arachnoid cyst was performed. Stereotypic head movement stopped immediately after surgery and hypomanic symptoms gradually improved within a month. During 4 years of follow-up observation without medication, neuropsychiatric symptoms did not relapse. We report our experience of surgically treating stereotypy and hypomania in a case of bobble-head doll syndrome and discuss the possible neuropsychiatric mechanisms of this rare disease.

Tratamiento endoscópico de quistes coloideos del tercer ventrículo / Third ventricle colloid cysts endoscopic approach

Introducción: los quistes coloideos (QC) son tumores benignos de crecimiento lento, que comprenden menos del 1% de los tumores intracraneales. Se presentan en adultos jóvenes y se ubican más frecuentemente en el techo del tercer ventrículo. El objetivo de este trabajo es presentar una serie de pacientes con QC del tercer ventrículo operados por vía endoscópica, analizar la técnica quirúrgica, ventajas y desventajas. Desarrollo: se realizó una búsqueda retrospectiva de pacientes operados por vía endoscópica, en el Servicio de Neurocirugía del Hospital Italiano de Buenos Aires, de tumores del tercer ventrículo en un período de 2 años (2013-2015), con diagnóstico de QC confirmado por anatomía patológica . Se identificaron cinco pacientes, tres mujeres y dos hombres, cuyo promedio de edad fue de 50 años. No hubo complicaciones perioperatorias y ninguno mostró recidiva en el lapso de observación. Conclusión: la vía endoscópica es una vía técnicamente simple y con muy baja morbilidad. Si bien no siempre puede realizarse una exéresis completa, los trabajos prospectivos permitirán definir si esto resulta suficiente para el control de la enfermedad. (AU)

Colloid cysts are benign, slow-growing tumors, comprising less than 1% of intracranial tumors. They occur in young adults and are more frequently located on the roof of the third ventricle. The objective of this study is to present a series of patients with Colloid cysts operated endoscopically and analyze advantages and disadvantages of this surgical technique. We performed a retrospective review of Colloid Cysts operated on endoscopically, at the Neurosurgical Department of Hospital Italiano de Buenos Aires in a period of 2 years (2013-2015). Five patients were identified, three women and two men whose average age was 50 years. No perioperative complications were observed, with no recurrences during the follow up period. Conclusion: the endoscopic approach is technically simple and has very low morbidity. Although a complete excision can not always be performed, prospective studies will allow us to define whether if is sufficient to control the disease. (AU)

Chordoid Glioma of the Third Ventricle, a Rare Tumor with an Unexpected Outcome

Chordoid glioma is a rare tumor of the third ventricle whose imaging features are difficult to distinguish from other more common lesions in this location. There are only 83 cases described so far in the literature. Although gross total resection (GTR) is the treatment of choice, immediate postoperative mortality with this approach can be as high as 29%, and morbidity among survivors can reach 67%. We report a case of a male patient of advanced age, with a third ventricle mass lesion, who presented with a progressive right temporal hemianopia. Imaging was compatible with craniopharyngioma, meningioma or even metastasis. Chordoid glioma was not considered in the differential diagnosis. The patient underwent surgery and GTR was achieved. There were no postoperative complications, and the patient was discharged from the hospital three weeks later. Unexpectedly, two days afterwards, he suffered a major brainstem hemorrhagic stroke and, unfortunately, died.

O glioma cordoide é um tumor raro do terceiro ventrículo, e as suas características imagiológicas são difíceis de distinguir de outras lesões mais comuns nesta localização. Até a data presente, existem apenas 83 casos de gliomas cordoides descritos na literatura. A remoção macroscópica total destes tumores deve ser o tratamento de escolha; no entanto, a mortalidade pós-operatória imediata pode chegar aos 29%, e a morbilidade pode atingir os 67% entre os sobreviventes. Nós descrevemos o caso de um homem idoso com uma lesão tumoral no terceiro ventrículo, que se manifestou com uma hemianopsia temporal direita progressiva. Os exames de imagem eram compatíveis com craniofaringioma, meningioma ou até metástase. O glioma cordoide não foi considerado como uma das hipóteses no diagnóstico diferencial inicial. O paciente foi submetido a cirurgia, tendo-se obtido a remoção macroscópica total. Não houve qualquer complicação no período pós-operatório, e o paciente teve alta hospitalar após três semanas. Inesperadamente, dois dias após a alta clínica, o paciente sofreu um AVC hemorrágico do tronco cerebral, e acabou por falecer.

Malignant Transformation of Craniopharyngioma without Radiation Therapy: Case Report and Review of the Literature

Craniopharyngiomas exhibiting histologic malignancy are extremely rare. Herein, we report the case of a 26-year-old male patient who underwent suprasellar mass excision via an interhemispheric transcallosal approach. Histopathological examination indicated that the craniopharyngioma was of the adamantinomatous subtype. The patient received postoperative medical treatment for endocrine dysfunction and diabetes mellitus without radiation treatment. Two years after the operation, he presented with progressive visual disturbance and altered mentality. Magnetic resonance imaging revealed a huge mass in the suprasellar cistern and third ventricle. He underwent a second operation via the same approach. The histopathological examination showed an adamantinomatous craniopharyngioma with sheets of solid proliferation in a spindled pattern, indicating malignant transformation. Malignant transformation of craniopharyngioma in the absence of radiation therapy has been reported in only five cases, including this one. We present a case of malignant transformation of craniopharyngioma with a brief review of relevant literature.

Meningiomas intraventriculares: reporte de 7 casos y revisión bibliográfica / Intraventricular meningiomas: report of 7 cases and bibliographic review

Introducción: Los meningiomas intraventriculares tienen una baja prevalencia. Dado su origen en plexos coroideos o tela coroidea presentan predilección por los ventrículos laterales. Suelen ser de gran tamaño al momento diagnóstico y de histología preponderantemente benigna. Materiales y Métodos: Realizamos revisión retrospectiva de historias clínicas de pacientes operados de estos tumores durante el período 1999-2014, en nuestra institución junto a una revisión bibliográfica. Resultados: Se operaron siete pacientes con meningiomas intraventriculares de los cuales seis tuvieron localización atrial, cinco fueron derechos y uno izquierdo; el caso restante corresponde a una lesión del IV ventrículo. Todos fueron de sexo femenino con edad promedio de 49 años. La presentación clínica prevalente fue cefalea, trastorno cognitivo leve y hemianopsia homónima en los tumores supratentoriales. Disfunción trigeminal y facial periférica izquierda, disfagia y ataxia troncal se observaron en la lesión del IV ventrículo. Se realizaron dos abordajes parietales, uno precuneal, tres temporales y un abordaje telovelar. En el postoperatorio, 2 pacientes presentaron hemianopsia homónima secuelar. Dos pacientes presentaron signos de atipia por lo cual recibieron radioterapia postoperatoria. Conclusión: Dada su escasa prevalencia el objetivo quirúrgico en meningiomas intraventriculares es la remoción completa con la menor morbilidad postoperatoria posible. En los casos atípicos sugerimos realizar radioterapia postoperatoria para reducir el riesgo de recidivas.

Introduction: Intraventricular meningioma’s have a low prevalence. Given its origin in choroid plexus or tela choroidea presents predilection by the lateral ventricles. They tend to be large at the time of diagnosis and predominantly benign histology. Methods: We performed retrospective review records of patients operated of intraventricular meningioma’s during the period 1999-2014 in our institution with a review of the literature. Development: We operated seven patients with these tumors, six with atrial location, five were right and one left; the remaining case corresponds to a lesion in the fourth ventricle. All were female with an average age of 49 years. The prevalent clinical presentation was headache, mild cognitive disorder and homonymous hemianopsia in supratentorial tumors. Trigeminal and peripheral left facial dysfunction, dysphagia and central ataxia were observed in the lesion of the fourth ventricle. Parieto-occipital two approaches, one interhemispheric precuneal approach, three temporal and a telovelar approach were carried out. Postoperatively, two patients had homonymous hemianopsia. Two patients presented signs of atypia which received postoperative radiation therapy.Conclusion: Given its low prevalence the surgical goal in intraventricular meningiomas is complete removal with less possible postoperative morbidity. In atypical cases we suggest to perform postoperative radiotherapy to reduce risk of recurrence.

Choroid plexus coagulation for pediatric hydrocephalus: review of historical aspects and rebirth

This study aims to review historical aspects and rebirth of the endoscopic choroid plexus coagulation (CPC) for pediatric hydrocephalus. The first CPC procedure goes back to early 1930s. After the development of other treatment methods and the understanding of CSF dynamics, the application of CPC dramatically decreased by 1970s. In 2000s, there was a rebirth of CPC in combination with endoscopic third ventriculostomy (ETV), and remains one of the options for the treatment of pediatric hydrocephalus in selected cases. CPC might provide a temporary reduction in CSF production to allow the further development of CSF absorption in infant, and adding to ETV for infants with communicating hydrocephalus may increase the shunt independent rate thus avoiding the consequence of late complication related to the shunt device. This is important for patients who are difficult to be followed up, due to geographical and/or socioeconomic difficulties. And also adding CPC to ETV for obstructive hydrocephalus in infants younger than 1 year of age may also increase the successful rate. Furthermore, CPC may be an option for cases with high chance of shunt complication such as multiloculated hydrocephalus, extreme hydrocephalus and hydranencephaly. In comparison with the traditional treatment of CSF shunting, the role of CPC needs to be further evaluated in particular concerning the neurocognitive development.

Avaliação anatômica comparativa dos acessos transcorioideo e transforniceal transcorioideo ao terceiro ventrículo / Comparative anatomical assessment of transchoroidal approach and transforniceal transchoroidal approach to the third ventricle

O acesso ao terceiro ventrículo constitui verdadeiro desafio ao neurocirurgião. Nesse contexto, estudos anatômicos e morfométricos são úteis para estabelecer as limitações e as vantagens de determinado acesso cirúrgico. O acesso transcorioideo é versátil e promove exposição adequada da região média e posterior do terceiro ventrículo. Entretanto, a coluna do fórnice limita a exposição da região anterior do terceiro ventrículo. Há evidências de que a secção ipsilateral da coluna do fórnice tenha pouca repercussão na função cognitiva. Esta tese compara a exposição anatômica proporcionada pelo acesso transforniceal transcorioideo com o do acesso transcorioideo e realiza avaliação morfométrica de estruturas relevantes e comuns aos dois acessos. Material e métodos: A exposição anatômica proporcionada pelos acessos transcaloso transcorioideo e transcaloso transforniceal transcorioideo foram comparadas em oito cadáveres não submetidos à conservação, utilizando o sistema de neuronavegação (Artis, Brasília, Brasil), para aferir a área de trabalho, a área de exposição microcirúrgica, a exposição angular no plano longitudinal e transversal de dois alvos anatômicos (túber cinéreo e aqueduto cerebral). Adicionalmente, foram quantificados a espessura do parênquima do lobo frontal direito, a espessura do tronco do corpo caloso, o diâmetro longitudinal do forame interventricular, a distância de trabalho da superfície cortical ao túber cinéreo e a distância de trabalho da superfície cortical até o aqueduto cerebral. Os valores obtidos foram submetidos a análise de estatística utilizando o teste de Wilcoxon. Resultados: Na avaliação quantitativa, o acesso transforniceal transcorioideo proporcionou maior área de trabalho (transforniceal transcorioideo = 150,299 +/- 11,147 mm2; transcorioideo = 121,421 +/- 7,698 mm2; p < 0,05), maior área de exposição microcirúrgica (transforniceal transcorioideo = 100,920 +/- 8,764 mm2; transcorioideo = 79,944 +/- 4,954 mm2; p <...

Approaches to the third ventricle constitute a formidable challenge to the neurosurgeon and, in this context, anatomical and morphometric studies are useful to establish the limitations and advantages of certain surgical approaches. The transchoroidal approach is a versatile one that promotes adequate exposure of the middle and posterior regions of the third ventricle. However, the column of fornix limits the exposure of the anterior third ventricle region. There is evidence that the ipsilateral section of the column of fornix has little effect on the cognitive function. This thesis compares the anatomical exposure using the transchoroidal transforniceal technique with the transchoroidal approach, and performs morphometric assessment of relevant structures common to both approaches. Material and methods: The anatomical exposure achieved through the transchoroidal transcallosal approach and transchoroidal transforniceal transcallosal were compared in 8 fresh cadavers using the neuronavigation system (Artis, Brasilia, Brazil), to assess the working area, microsurgical exposure area, to quantify the angular exposure in the longitudinal and cross-sectional planes to two anatomical targets (tuber cinereum and cerebral aqueduct), to measure the thickness of the right frontal lobe parenchyma, corpus callosum body thickness, longitudinal diameter of the interventricular foramen, working distance from the cortical surface to the tuber cinereum and working distance from the cortical surface to the cerebral aqueduct. The values obtained were submitted to statistical analysis using Wilcoxon's test. Results: In the quantitative assessment, the transchoroidal transforniceal approach provided: larger working area (transchoroidal transforniceal = 150.299 +/- 11.147 mm2; transchoroidal = 121.421 +/- 7.698 mm2; p < 0.05), larger area of microsurgical exposure (transforniceal transchoroidal = 100.920 +/- 8.764 mm2; transchoroidal...

Rapid Visual Deterioration Caused by Posterior Fossa Arachnoid Cyst

Posterior fossa is a site next to the middle fossa where arachnoid cyst frequently occurs. Generally, most arachnoid cysts are asymptomatic and are found incidentally in most cases. Although arachnoid cysts are benign and asymptomatic lesions, patients with posterior fossa arachnoid cysts often complain of headaches, gait disturbance, and ataxia due to the local mass effects on the cerebellum. We observed a patient with a posterior fossa arachnoid cyst who had visual symptoms and a headache, but did not have gait disturbance and ataxia. We recommended an emergency operation for decompression, but the patient refused for personal reasons. After 7 days, the patient revisited our hospital in a state of near-blindness. We suspected that the arachnoid cyst induced the hydrocephalus and thereby the enlarged third ventricle directly compressed optic nerves. Compressed optic nerves were rapidly aggravated during the critical seven days; consequently, the patient's vision was damaged despite the operation. Considering the results of our case, it is important to keep in mind that the aggravation of symptoms cannot be predicted; therefore, symptomatic arachnoid cysts should be treated without undue delay.

Expanded Endoscopic Transnasal Approach to the Chordoid Glioma of the Third Ventricle : The First Case Ever Reported

Chordoid glioma of the third ventricle is a rare and challenging tumor to surgery because of its unique anatomical location and its close juxtaposition to the neurovascular structures and hypothalamus. The authors report a case of chordoid glioma of the third ventricle in a 43-year-old woman, who presented with headache and somnolence. The tumor was approached by endoscopic transnasal technique with a favorable result. Histopathologic examination disclosed a neoplastic tissue composed of eosinophilic epithelioid cells, mucinous, periodic acid Schiff-diastase positive, extracellular matrix, and scattered lymphoplasmacytic infiltrates. The best treatment option remains controversial. Customarily, the surgical route to remove chordoid glioma is transcranial; however, the undersurface of the optic chiasm and optic nerves preclude an adequate surgical visualization. In contrast, an expanded endoscopic transnasal approach provides a direct midline corridor to this region without any brain retraction.

Chordoid Glioma with Intraventricular Dissemination: A Case Report with Perfusion MR Imaging Features

Chordoid glioma is a rare low grade tumor typically located in the third ventricle. Although a chordoid glioma can arise from ventricle with tumor cells having features of ependymal differentiation, intraventricular dissemination has not been reported. Here we report a case of a patient with third ventricular chordoid glioma and intraventricular dissemination in the lateral and fourth ventricles. We described the perfusion MR imaging features of our case different from a previous report.