Intraventricular Craniopharyngiomas—Overcoming Their Relative Inaccessibility: Institutional Experience With a Review of Literature

Introduction: Craniopharyngiomas constitute 2–4% of intracranial neoplasms. Intraventricular craniopharyngiomas (IVCrs) are the rarely encountered varieties of these lesions.Objective: The objective of the study was to study the special features in clinical presentation, imaging, management, and surgical outcome of IVCrs.Materials and Methods: This retrospective analysis included the combined experience from two tertiary care institutions. Medical records of histopathologically proven cases of IVCrs from January 1994 to June 2021 were assessed, and images were analyzed based on the criteria by Migliore et al. for inclusion of solely intraventricular lesion with the third ventricular ependyma demarcating it from the suprasellar cistern.Results: Among the 25 patients included (mean age: 35.4 years), the most common presentation included headache (n = 21, 84%), vomiting and other features of raised ICP (n = 18, 72%), visual complaints (n = 12, 48%), and endocrinopathies (n = 11, 44%). Fifteen had predominantly cystic tumors, two were purely solid, and eight were of mixed consistency. Primary open microsurgical procedures were performed in 18 (72%) patients, of which four (16%) were endoscope-assisted. Seven (28%) underwent a purely endoscopic procedure. One underwent a staged surgery with endoscopic cyst fenestration and intracystic interferon (IFN)-alpha therapy, followed by microsurgical excision. Complete excision was achieved in 10 patients, near-total in nine, and partial excision in six. Four patients underwent a ventriculoperitoneal shunt (one before the definitive procedure). At a median follow-up of 36 months (range:11–147 months), five patients developed a recurrence, and one had a stable small residue. This patient and two others with small cystic recurrences were observed. One patient was managed with radiotherapy alone. Another underwent re-surgery after a trial of radiotherapy, and the last patient developed a local recurrence, which was managed with radiotherapy; he then later developed an intraparenchymal recurrence, which was operated.Conclusion: Purely IVCrs present with raised intracranial pressure, and visual disturbances are less common. Their deep-seated location and limited surgical field-of-view makes minimally invasive endoscopic-assisted surgery most suitable for their excision. The thin-walled cystic lesions may be occasionally adherent to the ependymal wall in close vicinity to the thalamus–hypothalamus complex, making complete excision difficult. Their responsiveness to radiotherapy, often leads to a gratifying long-term outcome.

Diffusion analysis of fluid dynamics with incremental strength of motion proving gradient (DANDYISM) to evaluate cerebrospinal fluid dynamics

Purpose To visualize and analyze the dynamics of cerebrospinal fluid (CSF) motion in the cranium, we evaluated the distribution of motion-related signal dephasing by CSF on Diffusion ANalysis of fluid DYnamics with Incremental Strength of Motion proving gradient (DANDYISM) method, a composite imaging method using various low b values. Materials and methods This study examined ten subjects aged 25–58. We acquired DWIs on a 3T clinical scanner with b values 0, 50, 100, 200, 300, 500, 700, and 1000 s/mm2 in total imaging time of 4 min. We constructed DANDYISM images and evaluated the CSF area distribution with decreased motion-dephasing signal using a scoring method. Results The DANDYISM images showed statistically significant higher CSF scores in the ventral posterior fossa, suprasellar cistern, and Sylvian vallecula compared to the lateral ventricle and frontal and parietal CSF spaces, indicating greater CSF movement in the former areas. Conclusion The results indicated prominent CSF motions in the ventral portion of the posterior fossa, suprasellar cistern, and Sylvian fissure but smaller motions in the lateral ventricles and parietal subarachnoid space. This method may provide information of CSF dynamics in the clinical settings within short imaging time.

Atypical presentation of a high-grade astrocytoma in a pediatric rheumatology Practice

Introduction. Hip pain is common in childhood. The main dilemma is to differentiate between benign conditions and those causing significant morbidity and mortality. Material and methods. A clinical case report of a toddler presenting with Musculoskeletal (MSK) mask due to a brain tumor. Results. A 2-year-old boy presented to the ER complaining of hip pain, muscle weakness, and limping. The neurologic exam showed no abnormalities. At the 3rd day of admission, patient condition worsened, and papillary edema was revealed. MRI revealed a tumor in the suprasellar cistern/prepons region. Conclusions. In case of atypical MSK symptoms, a careful evaluation of children should be carried out to prevent any delay in diagnosis.

Oculomotor schwannoma causing a progressive complete third-nerve palsy

A 69-year-old woman presented with an 8-month history of diplopia and examination findings consistent with a right third-nerve palsy. Head MRI identified the presence of a 5.8 mm, nodular, isointense lesion in the suprasellar cistern, which demonstrated enhancement with gadolinium contrast. The lesion did not show any evidence of growth over a 3-month follow-up period. These MRI findings, alongside the clinical features, suggest oculomotor nerve schwannoma. Oculomotor schwannomas are a rare cause of third-nerve palsy. The presenting features and management options for oculomotor schwannomas are discussed to provide a framework for the diagnosis and management of these patients.

Intrasellar Cavernous Hemangioma: A Case Report and Literature Review

Intrasellar cavernous hemangioma is rare. There are no specific symptoms and the mass effect often mimics pituitary macroadenoma. We present one case of intrasellar cavernous hemangioma that was misdiagnosed. Progressively decreasing vision was the main symptom in this case. The prolactin level was mildly increased but other biochemistry examinations were normal. Magnetic resonance imaging showed an enlarged pituitary fossa and an irregular solid tumor (33 mm × 22 mm × 22 mm) in the sella turcica and parasellar region. Subtotal removal in the case was performed through a transsphenoidal approach. Postoperatively, the patient's visual acuity improved. Through a literature review of 8 intrasellar cavernous hemangiomas, we found most lesions are likely to extend into the suprasellar cistern and cavernous sinus, and total resection is difficult. Transsphenoidal approach surgery should be applied for decompression of the optic nerve and biopsy, and stereotactic radiosurgery is preferable.

Lateral Ventricle to Sylvian Fissure Shunt for Obstructive Hydrocephalus: First Report

Cerebrospinal fluid (CSF) pathway studies have revealed that the CSF secreted from the choroid plexus of the ventricles after egressing from the fourth ventricle reaches the basal suprasellar cistern and ultimately the sylvian cisterns. From the sylvian cistern, the CSF travels over the cerebral convexity subarachnoid space to reach the superior sagittal sinus and enters the bloodstream. Diverting CSF from the lateral ventricle with a shunt catheter to the sylvian cistern can be an option to treat obstructive hydrocephalus. An adult patient with posttraumatic hydrocephalus with contraindications to ventriculoperitoneal and ventriculoatrial shunt placement underwent this procedure of diverting CSF from the lateral ventricle to the sylvian cistern successfully, and he had immediate relief of symptoms of raised intracranial pressure. Although preliminary results seem logical and promising, more cases and longer follow-up is required to consider this shunt operation an option in the treatment of obstructive hydrocephalus.