Management strategies for pediatric patients with tectal gliomas: a systematic review.

Pediatric tectal gliomas generally have a benign clinical course with the majority of these observed radiologically. However, patients often need treatment for obstructive hydrocephalus and occasionally require cytotoxic therapy. Given the lack of level I data, there is a need to further characterize management strategies for these rare tumors. We have therefore performed the first systematic review comparing various management strategies. The literature was systematically searched from January 1, 2000, to July 30, 2020, to identify studies reporting treatment strategies for pediatric tectal gliomas. The systematic review included 355 patients from 14 studies. Abnormal ocular findings-including gaze palsies, papilledema, diplopia, and visual field changes-were a common presentation with between 13.6 and 88.9% of patients experiencing such findings. CSF diversion was the most performed procedure, occurring in 317 patients (89.3%). In individual studies, use of CSF diversion ranged from 73.1 to 100.0%. For management options, 232 patients were radiologically monitored (65.4%), 69 received resection (19.4%), 30 received radiotherapy (8.4%), and 19 received chemotherapy (5.4%). When examining frequencies within individual studies, chemotherapy ranged from 2.5 to 29.6% and radiotherapy ranged from 2.5 to 28.6%. Resection was the most variable treatment option between individual studies, ranging from 2.3 to 100.0%. Most tectal gliomas in the pediatric population can be observed through radiographic surveillance and CSF diversion. Other forms of management (i.e., chemotherapy and radiotherapy) are warranted for more aggressive tumors demonstrating radiological progression. Surgical resection should be reserved for large tumors and/or those that are refractory to other treatment modalities.

Recurrent Bell's palsy following ventriculoperitoneal shunt insertion: an unusual case to face.

We present the case of a 15 year old boy who developed transient lower motor neuron facial weakness on two separate occasions shortly after ventriculoperitoneal shunt insertion. Both episodes, each of which occurred on the ipsilateral side to shunt insertion, were transient, self-limiting and were managed medically with a course of oral steroids. We believe this is the first reported case of Bell's palsy after this type of surgery in a child. Potential pathophysiological mechanisms are discussed.

Bobble-head doll syndrome in an 80-year-old man, associated with a giant arachnoid cyst of the lamina quadrigemina, treated with endoscopic ventriculocystocisternotomy and cystoperitoneal shunt.

Bobble-head doll syndrome (BHDS) is a rare entity, characterized by antero-posterior head bobbing, which is of the type "yes-yes." Less frequently, having a head movement of the type "no-no" is described. We report an unusual case of an 80-year-old man with a cystic mass of the lamina quadrigemina, extending to the posterior fossa. We conclude that ventriculocystocisternotomy associated with a cystoperitoneal shunt is an effective treatment for a symptomatic giant arachnoid cyst in the lamina quadrigemina.

Pediatric tectal plate gliomas: a review of clinical outcomes, endocrinopathies, and neuropsychological sequelae.

Pediatric tectal plate gliomas are indolent slow-growing gliomas that often present with increased intracranial pressure or incidentally on routine brain imaging. We investigated clinical outcomes, endocrinopathies, and neuropsychological sequelae associated with tectal plate gliomas. Twenty-six patients with tectal plate glioma were identified in a 20-year retrospective review. Clinical outcomes, treatments, endocrine function, neuropsychological testing outcomes and radiographic imaging were reviewed for possible signs correlating with tumor progression. Among 26 patients, 19 presented with signs or symptoms of increased intracranial pressure (73 %) versus an incidental finding in 7 (27 %). Median follow-up was 46 months (range 8-143 months). Six of 26 (23 %) experienced progressive disease after diagnosis. Five of 26 (19 %) required more than one surgical procedure due to failure of initial endoscopic third ventriculostomy. Seven of 26 had history of endocrine dysfunction, of which, five presented with endocrine dysfunction (precocious puberty or short stature), 1 developed menstrual irregularities after surgical intervention and 1 had preexisting pan hypopituitarism. Of 12 patients with available neuropsychological testing, eleven had at least one indicator of executive functioning in the low-average to impaired range. While tectal plate gliomas have been considered indolent tumors that are rarely progressive, 23 % of patients in our cohort experienced disease progression and required further therapy. Neurocognitive deficits may occur, while endocrine deficiency is uncommon. Regular multidisciplinary oncology follow-up, routine monitoring with MRI and formal neurocognitive evaluation are imperative to provide early recognition of disease progression or recurrent hydrocephalus and to improve school functioning in this population.

Gamma Knife radiosurgery for low-grade tectal gliomas.

BACKGROUND: Tectal gliomas are present in a critical location that makes their surgical treatment difficult. Stereotactic radiosurgery presents an attractive noninvasive treatment option. However, tectal gliomas are also commonly associated with aqueductal obstruction and consequently hydrocephalus. This necessitates some form of CSF diversion procedure before radiosurgery. The aim of the study was to assess the efficacy and safety of Gamma Knife radiosurgery for tectal gliomas. PATIENTS AND METHODS: Between October 2002 and May 2011, 11 patients with tectal gliomas were treated with Gamma Knife radiosurgery. Five patients had pilocytic astrocytomas and six nonpilocytic astrocytomas. Ten patients presented with hydrocephalus and underwent a CSF diversion procedure [7 V-P shunt and 3 endoscopic third ventriculostomy (ETV)]. The tumor volume ranged between 1.2-14.7 cc (median 4.5 cc). The prescription dose was 11-14 Gy (median 12 Gy). RESULTS: Patients were followed for a median of 40 months (13-114 months). Tumor control after radiosurgery was seen in all cases. In 6/11 cases, the tumors eventually disappeared after treatment. Peritumoral edema developed in 5/11 cases at an onset of 3-6 months after treatment. Transient tumor swelling was observed in four cases. Four patients developed cysts after treatment. One of these cases required aspiration and eventually disappeared, one became smaller spontaneously, and two remained stable. CONCLUSION: Gamma Knife radiosurgery is an effective and safe technique for treatment of tectal gliomas. Tumor shrinkage or disappearance after Gamma Knife radiosurgery may preclude the need for a shunt later on.

Endoscopic third ventriculostomy for hydrocephalus due to tectal glioma.

BACKGROUND: Tectal gliomas commonly present with hydrocephalus from obstruction of the aqueduct of Sylvius. The creation of a ventriculostomy in the floor of the third ventricle (ETV) has been previously reported to by-pass aqueduct obstruction. The goal of this study was to determine the safety and efficacy of ETV in the presence of an obstructing tectal glioma. METHODS: We retrospectively reviewed the clinical presentation, management, and clinical outcome after ETV in patients diagnosed with tectal glioma and obstructive hydrocephalus in our institution over a period of 15 years. Shunt freedom at follow-up was the main outcome variable. Long-term clinical outcome was assessed at the most recent clinic visit. Clinical outcome was ranked as excellent, good, or poor according to resolution of symptoms and patient functional status. RESULTS: The median age at presentation was 16.5 years (range: 6.4 to 59 years) and the most common presenting symptom was headache. Eleven patients had ETV as a primary procedure and three patients underwent ETV as a substitute for shunt revision at the time of shunt failure. At follow-up (median 3.9 years, range: 2.2 to 7 years) 13 of 14 patients remain shunt independent with excellent (n=9) or good outcomes (n=5). CONCLUSIONS: In patients with tectal glioma causing obstructive hydrocephalus, ETV can be performed safely in the primary setting or as a substitute for shunt revision. A high rate of shunt freedom (78%-100%) at prolonged follow-up can be expected in this patient population.

Successful treatment of tremor by endoscopic third ventriculostomy in an adolescent with obstructive hydrocephalus due to tectal glioma: case report.

Hydrocephalus presenting with movement disorder is very rare, especially in children. We present the case of a 16-year-old boy who presented with bilateral intention tremor and slowed speech as a result of obstructive hydrocephalus secondary to a tectal glioma. Treatment with endoscopic third ventriculostomy improved his symptoms. We review the literature regarding this unusual presentation of an otherwise common condition.

Demonstration of Microsurgical Technique and Nuances for the Resection of a Midbrain Tectal Glioma via the Transcollicular Approach: 3-Dimensional Operative Video.

Tectal gliomas are a rare subset of intrinsic brainstem lesions. The microsurgical resection of these lesions remains a major challenge.1,2 Transcollicular approaches on one side, via the superior or inferior colliculi or both, are neurologically well tolerated without obvious or major auditory or oculomotor consequences. However, any postoperative acute visually triggered saccadic abnormalities caused by iatrogenic superior colliculus damage generally resolve during the postoperative period, as other oculomotor structures compensate for these functions in unilateral lesions. In this surgical video, we present a 37-yr-old man with long-standing seizures, new onset headaches, progressive ataxic gait, and imbalance. Magnetic resonance imaging (MRI) showed a circumscribed nonenhancing dorsal midbrain cystic mass with compression on the aqueduct causing hydrocephalus. The lesion had a low signal intensity on T1-weighted images and a high signal intensity on T2-weighted images. The patient first underwent an endoscopic third ventriculostomy. Although his headaches greatly improved after the third ventriculostomy, he remained quite symptomatic in terms of gait imbalance and ataxia. The patient underwent a supracerebellar, infratentorial, transcollicular approach for resection of the tectal tumor. Simultaneously, motor and somatosensory evoked potentials were monitored. Both the surgery and the postoperative course were uneventful, with postoperative MRI showing gross total resection of the mass, and histopathology indicating a WHO (World Health Organization) grade I pilocytic astrocytoma. The patient continued to do well without recurrence at 2-yr follow-up. In this video, we demonstrate step-by-step microsurgical techniques for resecting these challenging tectal gliomas via the infratentorial-supracerebellar-transcollicular approach. The patient consented to the procedure and publication of his images.

Fully Endoscopic Transforaminal-Transchoroidal Approach for Tectal Area Tumor Removal.

BACKGROUND: The surgical approaches to lesions located in the tectal area have remained controversial. The essential functions in the surrounding areas and the difficulties in obtaining a good surgical view during tumor removal have made these procedures risky and challenging. Endoscopic transforaminal approaches have been previously described for biopsy and intraventricular tumor removal. However, the endoscopic transforaminal-transchoroidal gross resection technique for such cases has barely been described. METHODS: The endoscopic entry points and trajectories were planned using preoperative magnetic resonance imaging. Once the endoscope was inside the ventricular system, the angles of work and tumor exposure of the upper posterior part of the third ventricle were carefully evaluated. If the angle of work was insufficient for tumor removal, the choroidal fissure was opened using endoscopic bipolar electrode and dissectors. Tumor removal was performed using an endoscopic ultrasonic aspirator. We have presented a 3-case series of patients affected by tectal tumors that were treated using a fully endoscopic transforaminal-transchoroidal approach. RESULTS: Total gross resection of the tumors was achieved in 2 patients. Subtotal resection was achieved in the third patient. No major complications had developed in relationship to the procedure. No new cognitive impairment was reported secondary to this technique. CONCLUSIONS: In our experience, a fully endoscopic transforaminal-transchoroidal approach was a suitable treatment for this complex pathological entity. Opening of the choroidal fissure added an extra angle of work and improved the exposure of the upper posterior part of the third ventricle.

Brain catecholamines: relation to defense reaction evoked by acute brainstem transection in cat.

The concentration of noradrenaline, but not serotonin, in the brainstem of cats is reduced 3 hours after the production of a defense reaction by supracollicular decerebration, even when movements and changes in blood pressure are abolished by transection of the spinal cord. After midcollicular decerebration, which does not elicit a defense reaction, noradrenaline concentrations do not change. The decrease in its concentration accompanying the defense reaction produtced by brain lesions probably reflects activity, in this behavior, of neturons containinig noradrenaline.

Quadrigeminal cyst management by cystoperitoneal shunt in a 4-year-old Persian cat.

Quadrigeminal cysts represent intracranial cystic accumulations of cerebrospinal fluid within the arachnoid mater at the level of the quadrigeminal cistern. Quadrigeminal cysts are rare in cats, with only one previous report in the veterinary literature. A 4-year-old, male-neutered Persian cat was presented with a 1-year duration of initially episodic, but later progressive, obtundation and collapse. Magnetic resonance imaging of the brain revealed a quadrigeminal cyst with marked compression of the adjacent neural structures, cerebellar herniation and obstructive hydrocephalus. Cystoperitoneal shunt placement was performed after the cat became refractory to medical therapy and this resulted in return of normal neurological status. The improvement in the neurological deficits following placement of a cystoperitoneal shunt in this case appeared to be correlated with resolution of the secondary effects (in particular the obstructive hydrocephalus) rather than resolution of the quadrigeminal cyst. Cystoperitoneal shunt placement was an effective long-term treatment option for the management of the quadrigeminal cyst in this cat.

Tectal glioblastoma.

Brain stem gliomas are a heterogeneous group of neoplasms arising mostly in paediatric patients. Tectal plate gliomas represent a particular type of brain stem tumours usually with a benign, indolent clinical course, presenting with signs of raised intracranial hypertension due to supra-tentorialhydrocephalous caused by aqueductal stenosis. Seldom high-grade lesions arise in this location with tremendous therapeutic implications. When a malignant tumour is clinically and radiographically suspected a biopsy should be performed to obtain histological confirmation. Treatment is then planned in a case-by-case basis. We present the case of a glioblastoma of the tectal plate in a 22 years-old woman operated upon by a supracerebellar-infratentorial approach.

Two-stage treatment of a tectal ganglioglioma: endoscopic third ventriculostomy followed by surgical resection.

Tumours of the quadrigeminal plate in adults are usually benign. Nevertheless, obstructive hydrocephalus due to compression of the Sylvian aqueduct is an almost invariable early finding. Whether or not direct excision is undertaken, temporary or permanent treatment of the hydrocephalus is warranted. Endoscopic third ventriculostomy is an alternative to insertion of a shunt and provides both acute and long-term relief of hydrocephalus-related symptoms. We chose a two-stage approach for treating a tectal ganglioglioma in an adult: endoscopic third ventriculostomy followed by surgical excision. The advantages and disadvantages of each therapeutic strategy are discussed.

Incidental pediatric intraparenchymal xanthogranuloma: case report and review of the literature.

Juvenile xanthogranuloma (JXG) is a specialized form of non-Langerhans cell histiocyte proliferation that occurs in children. The majority of cases present as a solitary cutaneous lesion with a predilection for the head and neck region; however, isolated lesions occasionally have been identified in the central nervous system. The cutaneous forms of JXG usually follow a benign course. Other physicians have reported surgery as the first line of treatment in symptomatic patients with accessible lesions. Adjuvant therapies may be indicated for multicentric or surgically inaccessible lesions. The authors describe an unusual case of isolated intraparenchymal JXG in an asymptomatic child with no cutaneous manifestations and provide a review of the literature.

[Quadrigeminal cistern and calcarine fissure lipoma: case report and review of the literature]. / Lipoma de la cisterna cuadrigémina y cisura calcarina: caso clínico y revisión de la literatura.

We report the case of a multiple intracranial lipoma in a 47 year-old patient presenting with headache dizziness and quadrantanopsia. MR imaging revealed the presence of 2 lipomas, one located within the quadrigeminal cistern and the other in the calcarine fissure. To our knowledge, this combination of this rare lesion has not been yet described. We review the current literature.

[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.

The use of fluorescein sodium in the biopsy and gross-total resection of a tectal plate glioma.

Intravenous administration of fluorescein sodium fluoresces glioma burden tissue and can be visualized using the surgical microscope with a specialized filter. Intraoperative guidance afforded through the use of fluorescein may enhance the fidelity of tissue sampling, and increase the ability to accomplish complete resection of tectal lesions. In this report the authors present the case of a 19-year-old man with a tectal anaplastic pilocytic astrocytoma in which the use of fluorescein sodium and a Zeiss Pentero surgical microscope equipped with a yellow 560 filter enabled safe complete resection. In conjunction with neurosurgical navigation, added intraoperative guidance provided by fluorescein may be beneficial in the resection of brainstem gliomas.