Unilateral Postoperative Deep Cerebral Venous Thrombosis with Complete Recovery: A Report of 2 Cases.

Postsurgical deep brain venous thrombosis has not been well described in children before. When approaching thalamic or intraventricular lesions, extra care should be taken to prevent injury to the internal cerebral veins (ICVs) and the vein of Galen. However, even when they are well preserved during surgery, postoperative hemodynamic changes, mainly in the first 24 h, or surgical manipulation can cause thrombosis of these veins. We report 2 children with unilateral postoperative ICV thrombosis; in 1 of the patients the vein of Galen was also thrombosed. Although both patients had altered sensorium initially, no anticoagulation therapy was given, and they both recovered well. When approaching thalamic or intraventricular lesions, extra care should be taken to prevent injury to the ICV and the vein of Galen. The surgeon should respect the deep brain venous system when approaching midline structures. Both the neurosurgeon and the neuroradiologist should be aware of this possible complication in order to make a prompt diagnosis and to offer proper treatment if needed.

Resection of tumors of the third ventricle involving the hypothalamus: effects on body mass index using a dedicated surgical approach.

Resection of large lesions growing into the third ventricle is considered nowadays still a demanding surgery, due to the high risk of severe endocrine and neurological complications. Some neurosurgical approaches were considered in the past the procedures of choice to access the third ventricle, however they were burden by endocrine and neurological consequences, like memory loss and epilepsy. We report here the endocrine and functional results in a series of patients operated with a recently developed approach specifically tailored for the resection of large lesions growing into the third ventricle. Authors conducted a retrospective analysis on 10 patients, operated between 2011 and 2012, for the resection of large tumors growing into the third ventricle. Total resection was achieved in all patients. No perioperative deaths were recorded and all patients were alive after the follow-up. One year after surgery 8/10 patients had an excellent outcome with a Karnofsky Performance Status of 100 and a Glasgow Outcome score of 5, with 8 patients experiencing an improvement of the Body Mass Index. Modern neurosurgery allows a safe and effective treatment of large lesions growing into the third ventricle with a postoperative good functional status.

Neurogenic fever in a patient with a chordoid glioma.

Chordoid gliomas are rare tumours. Despite being considered low-grade neoplasms, recent reviews have reported generally poor prognosis due to complications involving severe hypothalamic symptoms. We report a patient aged 30 years with chordoid glioma. What makes this case report interesting is the presence of neurogenic fever, which was already present before the final diagnosis of the brain tumour and also several months after the surgical removal. Since the patient underwent a subtotal resection of the tumour, it remains unclear whether the fever was due to hypothalamic dysfunction or remnants of the tumour. We also performed temperature logging with a continuous-monitoring recording device.

Comparative Anatomical Study on Operability in Surgical Approaches to the Anterior Part of the Third Ventricle.

BACKGROUND: Surgery of the third ventricle still represents a challenge in modern neurosurgery. To optimize the surgical planning, some aspects, related to ventricular anatomy, have to be taken into consideration. An operability score could represent a preoperative tool to evaluate these variables to choose a tailored surgical approach. METHODS: We compared the transcallosal transforaminal approach and the combined interhemispheric subcommissural translamina terminalis approach (CISTA) to the anterior part of the third ventricle, applying the operability score. RESULTS: Compared with the transcallosal transforaminal approach, the CISTA provides a statistically significant improvement in terms of depth of surgical field, surgical angle of attack, and maneuverability arc considering as 4 approach-related critical structures: the optic chiasm (P value: <0.0001, <0.0001, <0.0001, respectively), the anterior commissure (P value: <0.0001, <0.0001, <0.0001 respectively), the tuber cinereum (P value: <0.0001, 0.0224, 0.0173), and the interthalamic adhesion (P value: 0.2917, <0.0001, <0.0001 respectively). CONCLUSIONS: Tumors originating from the anterosuperior part of the third ventricle can be easily approached through a transcallosal transforaminal route, whereas lesions arising from the anteroinferior portion of the third ventricle might be safely and effectively approached through the CISTA.

Using the trans-lamina terminalis route via a pterional approach to resect a retrochiasmatic craniopharyngioma involving the third ventricle.

Retrochiasmatic craniopharyngiomas involving the anterior third ventricle are challenging to access. Although the pterional approach is a common route for suprasellar lesions, when the craniopharyngioma extends behind the chiasma into the third ventricle, access is even more difficult, and the lamina terminalis may offer a good working window. The translamina terminalis approach provides direct access to the retrochiasmatic portion of the tumor with minimal brain retraction and no manipulation of the visual nerves. In this video, we emphasize the utility of using the lamina terminalis corridor to resect the retrochiasmatic intraventricular portion of a craniopharyngioma. The video can be found here: https://youtu.be/hrLNC0hDKe4 .

Thalamic rosette-forming a glioneuronal tumor in an elderly patient: Case report and literature review.

The rosette-forming glioneuronal tumor (RGNT) is a novel type of brain tumor recently listed in the WHO 2007 classification of central nervous system (CNS) tumors. We report the case of a 75-year-old woman harboring a thalamic RGNT with third ventricle dissemination. Age and location make the present case exceptional and which has never previously been reported. A review of the clinical, pathological and radiological features is presented along with the relevant literature.

Intraventricular craniopharyngiomas: surgical management and outcome analyses in 24 cases.

OBJECTIVE: Pure intraventricular craniopharyngioma is a rare subtype of craniopharyngioma that attaches frequently to the hypothalamus. The main challenge in tumor removal is protection of hypothalamic structure. The aim of our study was to set up a feasible risk-evaluation approach to help the surgeons make an individual treatment plan. METHODS: We reviewed retrospectively 24 patients with pure intraventricular craniopharyngioma who underwent surgical therapy. Third ventricular deformation and thalamic attachment of the tumor were assessed by preoperative magnetic resonance imaging and intraoperative inspection. Correlations between the outcome, extent of removal, and different attachment grades were analyzed. RESULTS: Preoperative magnetic resonance imaging grade had a significant correlation with functional outcome. Attachment grade was significantly correlated with endocrine, functional, and radiologic outcome. In the gross total removal (GTR) group, significantly more newly developed endocrinologic deficits were observed compared with patients who underwent subtotal removal (STR). All 6 GTR cases with the greatest attachment grade (grade 2) acquired newly developed endocrine insufficiency. CONCLUSIONS: Attachment and deformation grade evaluated based on our criteria are significantly correlated with postoperative outcome. GTR of tightly attached tumor is associated with worse endocrinologic, functional, and radiologic outcomes compared with STR. Hence, we suggest that individual surgical plans should be made according to the grade of tumor attachment and hypothalamic deformation. STR should used in tumors with a high grade to achieve a good long-term outcome and avoid severe postoperative sequelae.

The transventricular preforniceal approach for exophytic chiasmatic/hypothalamic astrocytomas extending into the anterior third ventricle.

BACKGROUND: Surgical treatment of large exophytic chiasmatic/hypothalamic astrocytomas extending into the anterior third ventricle remains a challenging task for neurosurgeons. In particular, when the tumor extends from the chiasmatic region upward to the foramen of Monro, damage to the fornix and other neurovascular structures is a major concern. OBJECTIVE: To describe the technique used in the transventricular preforniceal surgical approach to remove the superior and superoposterior part of the tumor in the third ventricle for treatment of exophytic chiasmatic/hypothalamic astrocytoma. METHODS: The transventricular preforniceal approach was used in two cases of exophytic chiasmatic/hypothalamic astrocytoma. The approach is summarized in 4 procedures: 1) exposure of the anterior horn of the lateral ventricle by the transcallosal approach, 2) identification of the foramen of Monro and the fornix, 3) incision of the septum pellucidum or the wall of the lateral ventricle, in front of the columns of the fornix, and 4) removal of the tumor through the space between the anterior commissure and the columns of the fornix. RESULTS: Because the tumor compressed the foramen of Monro posteriorly and stretched the space between the anterior commissure and the columns of the fornix, the posterosuperior part of the tumor in the third ventricle was successfully removed through the surgical corridor in front of the columns of the fornix. In both cases, tumors were successfully removed using this approach without damaging the fornix and the anterior commissure. Residual tumor was removed using an anterior interhemispheric translamina terminalis approach in a two-stage surgery. CONCLUSIONS: The transventricular preforniceal approach can be applied for removing the superior part of exophytic chiasmatic/hypothalamic astrocytomas, because the space between the anterior commissure and the fornix is stretched by the tumor, providing an appropriate surgical corridor.

Infundibulo-tuberal or not strictly intraventricular craniopharyngioma: evidence for a major topographical category.

PURPOSE: This study investigates retrospectively the clinical, neuroradiological, pathological and surgical evidence verifying the infundibulo-tuberal topography for craniopharyngiomas (CPs). Infundibulo-tuberal CPs represent a surgical challenge due to their close anatomical relationships with the hypothalamus. An accurate definition of this topographical category is essential in order to prevent any undue injury to vital diencephalic centres. METHODS: A systematic review of all scientific reports involving pathological, neuroradiological or surgical descriptions of either well-described individual cases or large series of CPs published in official journals and text books from 1892 to 2011 was carried out. A total of 1,232 documents providing pathological, surgical and/or neuroradiological evidence for the infundibulo-tuberal or hypothalamic location of CPs were finally analysed in this study. FINDINGS: For a total of 3,571 CPs included in 67 pathological, surgical or neuroradiological series, 1,494 CPs (42%) were classified as infundibulo-tuberal lesions. This topography was proved in the autopsy of 122 non-operated cases. The crucial morphological finding characterizing the tubero-infundibular topography was the replacement of the third ventricle floor by a lesion with a predominant intraventricular growth. This type of CP usually presents a circumferential band of tight adherence to the third ventricle floor remnants, formed by a functionless layer of rective gliosis of a variable thickness. After complete surgical removal of an infundibulo-tuberal CP, a wide defect or breach at the floor of the third ventricle is regularly observed both in the surgical field and on postoperative magnetic resonance imaging studies. CONCLUSIONS: Infundibulo-tuberal CPs represent a major topographical category of lesions with a primary subpial development at the floor of the third ventricle. These lesions expand within the hypothalamus itself and subsequently occupy the third ventricle; consequently, they can be classified as not strictly intraventricular CPs. A tight attachment to the hypothalamus and remnants of the third ventricle floor is the pathological landmark of infundibulo-tuberal CPs.

Interhemispheric endoscopic resection of large intraventricular and thalamic tumors.

A transfrontal route is the traditional endoscopic approach to intraventricular tumors. Small lesions can be biopsied using the parallel port channel of the endoscope. For larger tumors a ventriculoport can be used for resection. This technique nevertheless requires traversing the brain tissue, is difficult in the setting of small ventricles, and allows only limited mobility. The authors describe the endoscopic resection of large intraventricular tumors via an interhemispheric route using rigid suction with a mounted endoscope, and thus circumventing some of the problems with the traditional approach.