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.

Trans-lamina terminalis approach to third ventricle using supraorbital craniotomy: technique description and literature review for outcome comparison with anterior, lateral and trans-sphenoidal corridors.

BACKGROUND: The trans-lamina terminalis approach has been described to remove third ventricular tumors. Various surgical corridors for this approach include anterior (via bifrontal craniotomy), anterolateral (via supra-orbital craniotomy), lateral (via pterional craniotomy) and trans-sphenoidal corridors. Supra-orbital craniotomy offers a minimally invasive access for resection of third ventricular tumors. MATERIAL AND METHODS: The trans-lamina terminalis technique through a supra-orbital craniotomy is described. Also, a literature review of clinical outcome data was performed for the comparison of different surgical corridors (anterior, antero-lateral, lateral, and trans-sphenoidal). RESULTS: The operative steps and anatomic landmarks for supra-orbital craniotomy are discussed, along with 3 representative cases and respective outcomes. Gross total resection was achieved in 2 patients, and one patient required reoperation for recurrence. Based on the current literature, the clinical outcomes after supra-orbital craniotomy for trans-lamina terminalis approach are comparable to other surgical corridors. CONCLUSIONS: The supra-orbital craniotomy for trans-lamina terminalis approach is a valid surgical choice for third ventricular tumors. The major strengths of this approach include minimal brain retraction and direct end-on view; however, the long working distance is a major limitation. The clinical outcomes are comparable to other surgical corridors. Sound understanding of major strengths, limitations, and strategies for complication avoidance is necessary for its safe and effective application.

Feasibility of neuroendoscopic biopsy of pediatric brain tumors.

PURPOSE: The purpose of this study was to investigate the potential value of neuroendoscopic biopsies in pediatric patients with peri- or intraventricular tumors. METHODS: From 2001 to 2008, 49 pediatric patients (mean age, 12.16 years) with tumors located in the intraventricular or paraventricular areas underwent neuroendoscopic biopsy, with or without simultaneous endoscopic third ventriculostomy. Neuroendoscopic biopsies were performed to verify the histological diagnosis of neoplasms and to establish pathological diagnoses necessary for planning appropriate treatment strategies. RESULTS: In 45 of 49 patients (91.8%) neuroendoscopic biopsy specimens were appropriate for diagnosis and revealed 27 germinomas, 11 astrocytomas, and one ependymoma, etc. The tumor location included the pineal gland (n = 28), thalamus (n = 7), intraventricle (n = 3), hypothalamus (n = 3), suprasellar area (n = 2), and diffuse multifocal area (n = 3). In two patients (4.1%) biopsy specimens were informative but not diagnostic. Tumor tissue specimens were undiagnostic in two patients (4.1%). There were eight transient morbidities, including four EOM limitations, two central DI, one EVD infection, and one CSF leakage. One patient experienced postoperative tumor bleeding requiring emergent operation. There was no case of operative mortality. CONCLUSION: Neuroendoscopic biopsy can be considered as the first choice for tissue sampling of periventricular and intraventricular tumors with acceptable risks.

Simultaneous choroid plexus carcinoma and pilocytic astrocytoma in a pediatric patient.

Simultaneous primary brain tumors in pediatric patients without prior chemotherapy or radiotherapy, phacomatosis, or known familial history are a rare occurrence. The authors report the case of a 4-year-old boy with simultaneous choroid plexus carcinoma and pilocytic astrocytoma with features of oligodendroglioma. Magnetic resonance imaging studies revealed diffuse heterogeneously enhancing left intraventricular and posterior fossa tumors initially believed most consistent with multicentric choroid plexus carcinomas. A multiple staged resection was carried out for each tumor and gross-total resection was achieved. Upon gross inspection intraoperatively as well as postoperative histological analysis, 2 distinct simultaneous tumors were identified: choroid plexus carcinoma and pilocytic astrocytoma. To the authors' knowledge this is the first case report published identifying 2 distinct tumor types with similar radiological appearances in a pediatric patient with no prior history of radiotherapy, chemotherapy, or phacomatosis.

Rare primary tumours of the hypothalamus in adults: clinical course and surgical treatment.

BACKGROUND AND PURPOSE: The paper presents the operative technique and the results of treatment of adult patients with primary tumours of the hypothalamus, including rare ones. The aim of the study was to show the possibility of safe surgical treatment of rare tumours of the hypothalamus through a bifrontal basal interhemispheric trans-lamina terminalis approach. MATERIAL AND METHODS: Five patients with tumours of the hypothalamus were operated on in the Neurosurgical Clinic in Sosnowiec between 1990 and 2008. There were 2 patients with craniopharyngiomas located exclusively in the third ventricle, and single patients with gemistocytic astrocytoma, Langerhans cell histiocytosis X and hamartoma of the hypothalamus each. The patients were treated surgically with a bi-frontal basal interhemispheric trans-lamina terminalis approach. In two cases, the neuronavigation system with the use of tractography (DTI) was used to determine the location of the lamina terminalis, the posterior surface of the optic chiasm and the optic tracts. RESULTS: All lesions were resected totally, except for partially resected hamartoma of the hypothalamus. The most common postoperative complication was diabetes insipidus, which was transient in two cases. A long-lasting follow-up of all the patients operated on did not reveal regrowth of the lesion. CONCLUSIONS: The bifrontal basal interhemispheric trans-lamina terminalis approach allows for radical resection of primary tumours of the hypothalamus while avoiding serious post-operative deficits. This approach enabled the preservation of the olfactory bulb and tract and prevented damage of the frontal lobes. The use of DTI helped to establish the location and borders of the lamina terminalis, to establish the posterior surface of the optic chiasm and the optic tracts, and to save the anterior and lateral wall of the hypothalamus.

[Neurootological symptoms in Bruns' syndrome]. / Objawy neurootologiczne w zespole Brunsa.

The aim of the study was to present clinical neurootological symptoms in the case of early stage of the fourth ventricle tumor diagnosed finally on the base of MRI. Visual-oculomotor, vestibular-oculomotor, vestibulo-spinal and other electrophysiological signs of the vestibular damage of the brainstem were: paresis of the sixth nerve unilaterally, prolonged latency of III-V waves on brain stem audiological responses (BERA), asymmetry of the fusion limit of optokinetic nystagmus, bilateral areflexia of the caloric and kinetic labyrinth reaction, abnormal Unterberger's test in craniocorpography, the presence of gaze nystagmus. The study stressed the value of the widen and careful neurootological examination in such cases.

Chordoid glioma of the third ventricle attached to the optic chiasm. Successful removal through a trans-lamina terminalis approach.

Chordoid glioma of the third ventricle constitutes a rare, very recently recognized histological entity. Most reports of this neoplasm, focused on its distinct histological features, have hypothesized about a probable origin of the lesion at the third ventricle floor and/or the lamina terminalis. We report on a new case, presenting neuroradiological and intraoperative pictorial evidences of the tumoral attachment, limited to the chiasm-lamina terminalis junction. A 53-year-old woman debuted with acute symptoms of obstructive hydrocephalus, visual disturbances and confusion. MRI investigation showed a large solid-cystic third ventricle mass bulging through the lamina terminalis and ventricular floor. After placing a ventriculoperitoneal shunt, the tumor was completely removed through a trans-lamina terminalis approach. A tight tumoral attachment to the junction of the posterior chiasm to the lamina terminalis was identified and dissected. No other adhesions to the third ventricle boundaries were found. A chordoid glioma was diagnosed on histological examination. One year after the surgical procedure the patient does not present new neurological deficits, and there are no signs of tumoral regrowth on the follow-up postoperative MRI. Chordoid glioma should be included in the differential diagnosis of third ventricle tumors. Preoperative neuroradiological suspicion of this lesion should alert the neurosurgeon about the presence of a tight tumoral adherence at the level of the chiasm-lamina terminalis junction. The trans-lamina terminalis approach provides a suitable route for an early control of this attachment under direct vision, allowing a safe dissection of the mass from the third ventricle.

[Case report of germinoma with synchronous lesions in the thalamus and para lateral ventricle].

A 25-year-old man presented with headache and consciousness disturbance. MRI revealed well enhanced mass lesions using gadolinium at bilateral thalamus and right para lateral ventricle with mild perifocal edema. Obstructive hydrocephalus was observed. On neuroendoscopic observation, the tumor was not appeared on the surface of the ventricle, therefore biopsy of the lesion was not sufficient to make a definitive pathological diagnosis. Third ventriculostomy was successful and the patient's consciousness improved. One week later, a stereotactic biopsy for right para lateral ventricle lesion made possible the histological diagnosis of typical germinoma. Post operative course was uneventful. Chemotherapy (CDDP and etoposide) following 30 Gy whole ventricle irradiation resulted in the complete response of the lesion. Four years later, he has no neurological deficit except for mild disturbance in his eye movement. Our experience suggests that a synchronous lesion at thalamus and para lateral ventricle seems to be due to subependymal infiltration other than CSF dissemination.

Suprasellar hemangioblastoma.

A 59-year-old woman presented with disturbance of consciousness and decreased visual acuity caused by a suprasellar mass identified on MRI. A bifrontal interhemispheric approach allowed removal of the top and lateral sides of the tumor from the wall of the third ventricle. The hypothalamus appeared to be the origin of the mass, which proved to be hemangioblastoma, a rare tumor in this location.

Auditory agnosia caused by a tectal germinoma.

The authors describe a patient with auditory agnosia caused by a tectal germinoma. Despite having normal audiometric tests, the patient failed to recognize words and musical characters. On head MRI, the inferior colliculi were infiltrated by tumor. Neuropsychological tests revealed severe impairment in recognition of environmental sounds and words, defective musical perception, and stop consonant-vowel discrimination. Inferior colliculus may play a role in the analysis of sound properties.

Primary hypothalamic-third ventricle lymphoma. Case report and review of the literature.

Primary central nervous system lymphomas (PCNSL) are infrequent tumors and their presentation as a solitary hypothalamic-third ventricle mass can be considered exceptional. We report the case of a 57-year-old woman with progressive visual deterioration, diabetes insipidus and mental confusion. She had a diffuse and homogeneous tumoral lesion involving the third ventricle and the adjacent hypothalamic area with marked enhancement after contrast administration on both, competed tomography scan and magnetic resonance images. It was approached and partially resected by the translamina terminalis route. Histological diagnosis proved to be a diffuse non-Hodgkin lymphoma and the patient subsequently was treated with adjuvant radiotherapy and chemotherapy. Followup examination showed visual acuity recover but persistent confessional state. Eight similar well described cases reported in the literature are reviewed with a description of the major diffenciating features of this neurological entity. Treatment of PCNSL remains a challenge, and the topographical location within the hypothalamic-third ventricle area is even more complex.