Intraventricular Tumors: Surgical Considerations in Lateral and Third Ventricular Tumors.

Management of lateral and third ventricular tumors has been a challenge for neurosurgeons. Advances in imaging and pathology have helped in a better understanding of the treatment options. Technical refinement of microsurgical technique and addition of endoscopy has enabled more radical excision of tumors, when indicated, and added more safety.A proper understanding of the pathology at various ages and treatment options is continuously evolving. Many pediatric tumors are amenable to conservative surgical methods with effective complementary treatments. However, radical surgery is required in many adults as the main treatment and for many benign tumors. Various intraventricular lesions encountered and their surgical management is reviewed here for their efficacy, safety, and outcome, encompassing changes in our practice over the last 20 years.

The telovelar approach for fourth ventricular tumors in children: is removal of the posterior arch of C1 necessary?

PURPOSE: Various surgical nuances of the telovelar approach have been suggested. The necessity of removing the posterior arch of C1 to accomplish optimal tumor exposure is still debated. Therefore, we report on our experience and technical details of the fourth ventricular tumor resection in a modified prone position without systematic removal of the posterior arch of C1. METHODS: A retrospective analysis of all pediatric patients, who underwent a fourth ventricular tumor resection in the modified prone position between 2012 and 2021, was performed. RESULTS: We identified 40 patients with a median age of 6 years and a M:F ratio of 25:15. A telovelar approach was performed in all cases. In 39/40 patients, the posterior arch of C1 was not removed. In the remaining patient, the reason for removing C1 was tumor extension below the level of C2 with ventral extension. Gross or near total resection could be achieved in 34/39 patients, and subtotal resection in 5/39 patients. In none of the patients, a limited exposure, sight of view, or range of motion caused by the posterior arch of C1 was encountered, necessitating an unplanned removal of the posterior arch of C1. Importantly, in none of the cases, the surgeon had the impression of a limited sight of view to the most rostral parts of the fourth ventricle, which necessitated a vermian incision. CONCLUSION: A telovelar approach without the removal of the posterior arch of C1 allows for an optimal exposure of the fourth ventricle provided that critical nuances in patient positioning are considered.

Technical aspects of fourth ventricle ependymomas in adults: how I do it.

BACKGROUND: Ependymomas in the fourth ventricle in adults are rare entity. Surgical treatment of adult ependymomas is the only treatment modality since no other effective alternative is available. Radical resection often means cure but it is hindered by the nature and location of the lesion. METHODS: Technical aspects of the fourth ventricle ependymoma surgery in adults are discussed. Anatomy of the area is provided with the step-by-step surgical algorithm. CONCLUSION: Radical resection of low-grade ependymoma with a detailed understanding of the anatomy in this area is vital considering the high effectiveness of the treatment and its excellent prognosis.

How I do it? Resection of left ventricular central neurocytoma via trans-sulcal approach.

BACKGROUND: The management of lateral ventricle tumors requires a balance between maximizing safe resection and preserving neurological function. METHOD: The authors present a successful case of a left lateral ventricular central neurocytoma resection. The trans-superior frontal sulcus approach was employed, providing a safe corridor while minimizing damage to the surrounding neuroanatomy. The use of an endoscope further facilitated the procedure, enabling the confirmation of complete tumor removal and the preservation of deep venous drainage and periventricular structures. CONCLUSION: This case highlights the utility of the trans-sulcal approach and the benefits of endoscopic assistance in the management of lateral ventricle tumors.

Successful Surgical Treatment of a Giant Intraventricular Meningioma: A Case Report and Literature Review.

In our study, we document the case of a 48-year-old patient who presented at our clinic with various neurological disturbances. Magnetic Resonance Imaging revealed the presence of an intraventricular meningioma located in the body of the left lateral ventricle measuring 60 mm in diameter. This tumor was classified as a giant meningioma, accompanied by a significant amount of digitiform-type edema. A surgical procedure was conducted, resulting in a gross total resection of the tumor. Histopathological analysis identified the tumor as a fibrous meningioma. Postoperative assessments, as well as follow-ups conducted at 3 months and 1 year post-surgery, indicated considerable neurological improvement. The patient exhibited a remission of hemiparesis and gait disturbances along with a marginal improvement in the status of expressive aphasia. This case report underscores the significance of achieving total and safe resection of the tumor and includes an analysis of various cases from the literature, particularly focusing on those that describe minimally invasive surgical approaches and highlight the benefits of radiosurgery in the treatment of giant intraventricular meningiomas.

[Disseminated ependymal dysembryoplastic neuroepithelial tumor: a case report and literature review]. / Disseminirovannaya vnutrizheludochkovaya dizembrioplasticheskaya neiroepitelial'naya opukhol': klinicheskii sluchai i obzor literatury.

Dysembryoplastic neuroepithelial tumor (DNET) is a benign mixed neuronal-glial neoplasm (WHO grade 1). DNET is most often localized in temporal lobes and found in children and young people with epilepsy. There a few cases of DNET in ventricular system with dissemination along the ependyma in the world literature. MATERIAL AND METHODS: We present a rare case of T1- and T2-negative ventricular system tumor. Only FIESTA imaging revealed dissemination with multiple focal lesions of the third ventricle, its bottom and lateral walls, anterior horns of lateral ventricles, cerebellar vermis, cervical and lumbar spinal cord. RESULTS: The patient underwent transcortical endoscopic biopsy of the third ventricle tumor with simultaneous ventriculoperitoneal shunting. DNET was diagnosed, and radiotherapy was subsequently performed. Literature data on this issue were analyzed. CONCLUSION: To date, disseminated forms of DNET are extremely rare. X-ray features and morphological results allow us to establish the correct diagnosis and determine further treatment strategy.

Granular cell tumor of the neurohypophysis presenting as a third ventricle mass.

Granular cell tumors of the neurohypophysis (GCT) are rare benign neoplasms belonging, along with pituicytoma and spindle cell oncocytoma, to the family of TTF1-positive low-grade neoplasms of the posterior pituitary gland. GCT usually present as a solid sellar mass, slowly growing and causing compressive symptoms over time, occasionally with suprasellar extension. They comprise polygonal monomorphous cells with abundant granular cytoplasm, which is ultrastructurally filled with lysosomes. Here we report the case of a GCT presenting as a third ventricle mass, radiologically mimicking chordoid glioma, with aberrant expression of GFAP and Annexin-A, which lends itself as an example of an integrated diagnostic approach to sellar/suprasellar and third ventricle masses.

Transcallosal and endoscopic hybrid approach to a rare entity of pediatric intraventricular tumors-cribriform neuroepithelial tumor: a case report and literature review.

PURPOSE: Cribriform neuroepithelial tumor (CRINET) is a provisional category of intraventricular tumors, sharing similarities with AT/RTs, and there is a lack of data about its pathology, prognosis, and surgical approaches in the literature. We have been challenged to describe the surgical approach to a rare case of CRINET and describe the intraoperative features since none has been described before. Surgical resection and chemotherapy hold a great importance of favorable prognosis. METHODS: Twenty-month-old male with intraventricular tumor underwent transcallosal intraventricular tumor resection and endoscopic intraventricular second look stages. The tumor was initially considered choroid plexus carcinoma and histopathological results pointed CRINET. The patient also received Ommaya reservoir for intrathecal chemotherapy employment. The patient's preoperative and postoperative MRI scans and tumor's pathological features are described with a brief history of the disease in the literature. RESULTS: Lack of SMARCB1 gene immunoreactivity and presence of cribriform non-rhabdoid trabecular neuroepithelial cells led to the CRINET diagnosis. The surgical technique helped us to approach directly into the third ventricle and perform total resection and intraventricular lavage. The patient recovered without any perioperative complications and is consulted pediatric oncology for further treatment planning. CONCLUSION: With our limited knowledge on the matter, our presentation may provide an inside to the course and progress of the CRINET as a very rare tumor and may help to set a basis for future investigations focused on its clinical and pathological features. Long courses of follow-up periods are required for establishing treatment modules and assessing the responses to surgical resection techniques and chemotherapy protocols.

Staged Gamma Knife radiosurgery for a rosette-forming glioneuronal tumor of the fourth ventricle: a case report.

BACKGROUND: Rosette-forming glioneuronal tumor (RGNT) is a rare slow-growing neoplasm with mixed glial and neurocytic components. Surgical resection is the mainstay of treatment, whereas the role of adjuvant radiation therapies for residual or recurrent tumors has been poorly investigated. CASE PRESENTATION: We describe the case of a patient with a recurrent fourth ventricular RGNT who was treated with two-staged Gamma Knife radiosurgery (GKRS). GKRS was effective in controlling tumor growth and safe up to seven years from treatment. CONCLUSIONS: This case suggests that GKRS may be a safe and effective treatment for patients with recurrent or residual RGNT.

Endoscopic endonasal approach to remove pediatric intraventricular tumors of the third ventricle.

PURPOSE: Pediatric intraventricular tumors of the third ventricle are among the most difficult-to-treat brain tumors. Recently, endonasal endoscopic surgery for suprasellar, third ventricle, and median clivus lesions has become the common procedure, and its indications are expanding to pediatric cases. We describe our strategy for endonasal endoscopic surgery for pediatric third ventricle tumors. METHOD: We report on surgical anatomies and our surgical procedures in detail, including case presentations. RESULT: Endoscopic endonasal surgery has the advantage of providing a wider view of the tumor site, hypothalamus, optic chiasm, and other critical structures. Good indications for the endoscopic endonasal approach for intra-third ventricular tumors are those arising from the floor of the third ventricle. In particular, craniopharyngioma, a typical pediatric suprasellar tumor, sometimes extends into the third ventricle, causing great operative difficulty. However, aggressive removal for long-term control while preserving memory and visual function is important. We perform surgery with a strategy of radically removing tumors without causing damage to visual or brain function, and we adopt the "4-hands technique by two neurosurgeons" in full endoscopic surgery to remove tumors safely and aggressively. CONCLUSION: We describe our strategy for endonasal endoscopic surgery for pediatric third ventricle tumors, especially those extending from the suprasellar region into the third ventricle, and present a representative case.

Role of intra-operative squash cytology in rosette-forming glioneuronal tumor of the fourth ventricle: a case report.

Rosette-forming glioneuronal tumor (RGNT) of the 4th ventricle is a newly described WHO grade I brain tumor included in recent WHO classification of CNS tumors. It is a biphasic tumor thought to originate from pluripotent progenitor cells of subependymal plate. Intra-operative diagnosis plays an important role, as complete surgical excision is the treatment of choice. We are reporting a case of RGNT in a 19 years-old young male emphasizing the intra-operative pathological pointers and their role in accurate diagnosis for the suitable surgical intervention.

[Chordoid gliomas of the third ventricle]. / Opyt lecheniya khordoidnykh gliom III zheludochka.

BACKGROUND: Chordoid glioma is a rare slow-growing tumor of the central nervous system. Available world experience includes no more than 200 cases (lesion of the third ventricle in absolute majority of cases). Recognition and treatment of chordoid glioma are currently difficult problems due to small incidence of this disease. OBJECTIVE: To describe clinical manifestations and surgical treatment of chordoid glioma of the third ventricle considering literature data and own experience. MATERIAL AND METHODS: There were 12 patients (6 men and 6 women) with chordoid glioma between 2004 and 2023 (10 patients with lesion of the third ventricle, 1 - lateral ventricle, 1 - pineal region). Only patients with tumors of the third ventricle were analyzed. RESULTS: Total and subtotal resection was performed in 1 and 3 cases, respectively. Five patients underwent partial resection, 1 patient underwent biopsy. The follow-up data were available in 7 out of 10 patients (mean 25 months). Radiotherapy was performed in 4 patients (continued tumor growth in 2 cases). One patient died. CONCLUSION: Chordoid glioma is a benign tumor predominantly localized in the third ventricle. Preoperative MRI and CT in some cases make it possible to suspect chordoid glioma and differentiate this tumor from craniopharyngioma, meningioma and pituitary adenoma by such signs as isointense signal in T1WI, hyper- or isointense signal in T2WI, homogeneous contrast enhancement and edema of basal ganglia in T2 FLAIR images. The only effective treatment for chordoid glioma is surgery. Total resection is often impossible or extremely dangerous due to location of tumor, large size and invasion of the third ventricle. Postoperative mental disorders and diabetes insipidus, including severe hypernatremia, are common that requires mandatory monitoring of water and electrolyte balance.

Grading Trigone Meningiomas Using Conventional Magnetic Resonance Imaging With Susceptibility-Weighted Imaging and Perfusion-Weighted Imaging.

OBJECTIVE: To compare conventional magnetic resonance imaging (MRI), susceptibility-weighted imaging (SWI), and perfusion-weighted imaging (PWI) characteristics in different grades of trigone meningiomas. METHODS: Thirty patients with trigone meningiomas were enrolled in this retrospective study. Conventional MRI was performed in all patients; SWI (17 cases), dynamic contrast-enhanced PWI (10 cases), and dynamic susceptibility contrast PWI (6 cases) were performed. Demographics, conventional MRI features, SWI- and PWI-derived parameters were compared between different grades of trigone meningiomas. RESULTS: On conventional MRI, the irregularity of tumor shape (ρ = 0.497, P = 0.005) and the extent of peritumoral edema (ρ = 0.187, P = 0.022) might help distinguish low-grade and high-grade trigone meningiomas. On multiparametric functional MRI, rTTPmax (1.17 ± 0.06 vs 1.30 ± 0.05, P = 0.048), Kep, Ve, and iAUC demonstrated their potentiality to predict World Health Organization grades I, II, and III trigone meningiomas. CONCLUSIONS: Conventional MRI combined with dynamic susceptibility contrast and dynamic contrast-enhanced can help predict the World Health Organization grade of trigone meningiomas.

High-Grade Supratentorial Intraventricular Tumours in Adults.

High-grade Intraventricular tumours are rarely encountered. Many of these tumours will have similar patterns on imaging of signal intensity and contrast enhancement. As IVT are regularly not targetable by radiation or systemic therapy, until now, surgical resection presents the treatment of choice.

Non-enhancing intraventricular tumours in adults.

Intraventricular tumours are relatively uncommon among all brain tumours, and non-enhancing lesions, mostly subependymoma, are even less frequently reported. Select cases of subependymoma can show variable contrast enhancement as well. Gross total surgical resection is recommended for treating these lesions, with no significant role of adjuvant chemotherapy or radiotherapy.

[Neuroendoscopic Surgery for Pediatric Intraventricular Tumors].

Various tumors are found in ventricles and tissues surrounding the ventricles in children, adolescents, and young-adult patients. They cause cerebrospinal fluid pathway obstruction, resulting in hydrocephalus and isolated ventricles. In this paper we describe a neoplasm arising from the lateral and third ventricle. Intraventricular tumors are good candidates for neuroendoscopic surgery. Firstly, minimally invasive and established procedures, neuroendoscopic biopsy with flexible endoscopy or rigid endoscopy, are performed. These endoscopic biopsies can be performed concurrently with other procedures, such as third ventriculostomy or septostomy, to improve cerebrospinal fluid circulation. Neuroendoscopic biopsy for intraventricular tumor is associated with high diagnostic yield and relatively low incidence of morbidity and mortality, compared with open surgery. Endoscopic diagnostic procedure also can be applied in patients without ventricular dilatation, assisted by neuronavigation or echo-guided equipment. Secondly, neuroendoscopic cylinder surgery also makes it possible to remove intraventricular tumors with less damage. The two hands technique with rigid endoscopy helps debulking and hemostasis during tumor removal. Further developments in endoscopic equipment and training systems aimed at enhancing cooperation between the operator and assistant should be expected in the future. Neuroendoscopic resection appears to be a safe and reliable treatment option for patients with intraventricular tumors.

A rare case of intraparenchymal subependymoma in a child.

Subependymoma is a slow-growing, exophytic, intraventricular glial neoplasm that commonly arises in the ventricular system. However, a report found that the frequency of intracerebral subependymoma was 0.4% in 1000 routine autopsies. To the best of our knowledge, only seven cases of intracerebral subependymoma have been reported. We report a rare case of intracerebral subependymoma in a child. An 11-year-old girl with generalized tonic-clonic seizures visited the emergency room and had an intraparenchymal tumor on the left frontal lobe on magnetic resonance imaging (MRI). Craniotomy with gross total removal was performed without any perioperative morbidities. The tumor was finally histopathologically diagnosed as a subependymoma.

Primary intracranial intraventricular leiomyoma: a literature review.

Leiomyomas, benign tumors of well-differentiated smooth muscle and vascular collagenous tissue, usually occur in the uterus but can develop wherever smooth muscle is present. Primary intracranial leiomyomas are rare tumors. We present the case of a 40-year-old woman with a primary intraventricular leiomyoma. She consulted us for headache, dizziness, and black spots in her vision. Magnetic resonance images (MRI) disclosed a mass rooted in the posterior septum pellucidum. The tumor was totally excised by the senior author with no residual seen on intraoperative MRI. Pathological examination showed it to be a benign spindle-cell neoplasm. On the 6th month control MRI, there was no recurrence. We also reviewed articles relevant to primary intracranial leiomyomas.

Microsurgical endoportal MRI/US-navigated approach for the resection of large intraventricular tumours: a 20-consecutive patients case series.

OBJECTIVES: Deep lesions located in lateral and third ventricles can be accessed thorough interhemispheric transcallosal or transcortical trans-ventricular approaches. Traditional brain retractors are made by 'non-cerebral engineered' spatulas, which do not equally distribute pressure on surrounding structures damaging brain. In this paper, we present a series of 20 intraventricular tumours resected through a MRI/US-navigated microscopic transcortical endoportal approach. PATIENTS AND METHODS: Between January 2014 and December 2017, 20 patients underwent US-MRI neuronavigated (Esaote®, Genova, Italy) transcortical endoportal (Vycor® Viewsite Brain Access System TC Model, Vycor® Medical Inc., Boca Raton, FL) surgery for intraventricular deep-seated lesions with the intent to reach maximal safe resection. RESULTS: Gross total removal was achieved in 14 patients (70%). The only prognostic factor that resulted in statistical significance related to surgical radicality from multivariate analysis was white matter infiltration (p = 0.043), regardless of other tumour (dimensions, origin and location inside ventricular system, histopathology) and patient (age, gender, clinical presentation) characteristics. The mean duration of surgery was 225.9 min (± 59). Neither critical events, nor major bleedings, nor intraoperative deaths occurred during surgery. One case of postoperative CSF infection (5%) was registered. Six patients (30%) required permanent CSF drainage system (Ommaya reservoir, VP shunt) in the postoperative period. The mean Functional Independence Measure (FIM) score at last follow-up was 105 (range: 65-124). CONCLUSIONS: Transcortical transventricular endoportal surgery seems to be a valuable alternative to transcallosal surgery, although further prospective multicentre studies with larger number of patients, evaluation of pre- and post-operative neuropsychological outcomes and achievement of postoperative DTI and f-MRI are needed to confirm our results.

Chordoid Glioma: A Neoplasm Found in the Anterior Part of the Third Ventricle.

ABSTRACT: Chordoid glioma is a rare low-grade tumor that originates almost exclusively in the anterior part of the third ventricle. The diagnosis and treatment of the tumor remain controversial. In this article, the authors present a novel case of chordoid glioma of the third ventricle. The patient was treated with less invasive microsurgery followed by low-dose gamma knife radiosurgery. Magnetic resonance imaging revealed a decrease in tumor size and necrosis in the central region of the tumor, without significant complications at follow-up 14 months later. Based on these findings, the authors suggest that less invasive microsurgical resection followed by low-dose gamma knife radiosurgery is safe and effective for the treatment of chordoid glioma of the third ventricle.