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Background: Removal of large hypervascular tumors in the lateral ventricle still poses a surgical challenge. These tumors are usually fed from choroidal arteries, and vascular control is typically performed late during the removal. We aimed to evaluate the clinical efficacy of our strategy for persistent preoperative obliteration of feeders from the choroidal arteries to manage large hypervascular tumors in the lateral ventricle., Methods: We retrospectively analyzed six patients with hypervascular tumors in the lateral ventricle. We first attempted to obstruct feeders using endovascular treatment, and, if unavailable, performed initial microsurgical occlusion through the temporal horn for the staged tumor removal., Results: In all patients, feeder obliteration was successfully performed; the anterior choroidal arteries were occluded by the endovascular treatment and microsurgical occlusion in one and five patients, respectively, while the lateral posterior choroidal arteries were occluded via endovascular treatment in four patients. No patients had permanent symptoms due to feeder obliteration, and tumor devascularization was achieved at the mean rate of 69.9%. During the tumor removal, the mean blood loss volume was 253 ml. No postoperative hemorrhage had occurred, and all patients scored ≤ 2 on the modified Rankin Scale at six months post-removal., Conclusions: Although further studies are warranted, persistent feeder obliteration of choroidal arteries could be an effective treatment strategy against large hypervascular tumors in the lateral ventricle.

Background: The rosette-forming glioneuronal tumour (RGNT) is a rarely encountered tumour that has been included as a new entity in the 2007 edition of the "World Health Organization (WHO) Classification of Tumours of the Central Nervous System". We describe a rather unusual case of multifocal cerebellar RGNT, located in the spinal cord and displaying leptomeningeal spread., Clinical Presentation: Twenty-four-year-old male with history of long-lasting headaches. A magnetic resonance scan revealed three heterogeneous lesions located within both cerebellar hemispheres and the left cerebellopontine angle, in addition to a spinal cord lesion at the level of the cervical region, and images of leptomeningeal spread. Interventions were performed in two stages; these involved resection of two cerebellar lesions, with a histopathological diagnosis of RGNT with atypical microvascular proliferation and focal necrosis. Although these tumours appear to be benign, our case debuted in an aggressive form, both from the radiological point of view and with respect to its histopathological characteristics. For this reason, the patient received adjuvant therapy with chemotherapy and radiotherapy., Conclusions: Experience of RGNT is limited. The prognostic significance of the histological findings of vascular proliferation and necrosis is still unknown. The clinical improvement in our patient endorses our decision to perform aggressive treatment.

Background: Narrow-band imaging (NBI) has been confirmed as a useful endoscopic technique to distinguish neoplasm from normal tissue, on the basis of the enhanced neovascularity of tumor tissue. NBI-guided tissue biopsy for laryngopharyngeal and digestive lesions is a novel methodology, but the feasibility for central nervous system tumors remains unclear. The aim of our study was to evaluate the feasibility of NBI-guided biopsy for intraventricular and paraventricular tumor., Methods: Fourteen patients with intraventricular or paraventricular tumors underwent neuroendoscopic biopsy using a videoscope with NBI. Ventricular walls and tumors were observed using conventional imaging, followed by NBI. Colors of ventricle walls and tumors visualized using NBI were compared to those visualized under conventional imaging. Extracted specimens were stained using CD31 antibody and numbers of microvessels in each specimen were counted for analyzing vascular density., Results: Normal ventricle walls were a similar color under conventional imaging and NBI. Tumor surfaces appeared to be cyan in color under NBI. Vessels on the tumor were more clearly visualized with NBI than with conventional imaging. NBI was able to identify tumor surfaces that were not perceptible on conventional imaging. All specimens in the lesion surfaces from cyan-colored areas under NBI contained tumor cells. Specimens extracted from regions that appeared cyan in color under NBI (51.0 vessels/mm(2)) had significantly greater vascular density than regions that appeared a normal color (17.4 vessels/mm(2); p = 0.039)., Conclusion: NBI-guided biopsy of intraventricular and paraventricular tumors is feasible for visualizing tumor surface-enhancing neovascularities. NBI would contribute to accurate histological diagnosis while minimizing injury to surrounding structures.

Background: Combining anti-angiogenesis agents with cytotoxic agents for the treatment of malignant gliomas may affect the cytotoxic drug distribution by normalizing the blood-brain barrier (BBB). This study examines the intratumoral concentration of temozolomide (TMZ) in the presence and absence of the pan-VEGF receptor tyrosine kinase inhibitor, cediranib., Methods: Seven nude rats bearing U87 intracerebral gliomas had a microdialysis probe centered within the tumor. Ten-days after tumor implantation, TMZ (50 mg/kg) was given orally. The extracellular fluid (ECF) concentrations of TMZ within the tumor were assessed via microdialysis for 6 h following TMZ administration. Cediranib (6 mg/kg) was then given orally, and 12 h later, TMZ was re-administered with subsequent microdialysis collection. A subset of animals also underwent functional MRI to assess angiogenesis in vivo at post-inoculation days 12 and 21, before and after the cediranib treatment., Results: After dosing of oral TMZ only, ECF-TMZ mean-C(max) and area under the concentration curve(AUC(0-∞)) within the tumor were 0.59 μg/mL and 1.82 μg h/mL, respectively. Post-cediranib, ECF-TMZ mean-C(max) and AUC(0-∞) were 0.83 μg/mL and 3.72 ± 0.61 μg h/mL within the tumor, respectively. This represented a 1.4-fold (p = 0.3) and 2.0-fold (p = 0.06) increase in the ECF-TMZ C(max) and AUC(0-∞), respectively, after cediranib administration. In vivo MRI measurements of the various vascular parameters were consistent with a BBB "normalization" profile following cediranib treatment., Conclusions: In the U87 intracerebral glioma model, within the first day of administration of cediranib, the intratumoral concentrations of TMZ in tumor ECF were slightly, but not statistically significantly, increased when compared to the treatment of TMZ alone with radiographic evidence of a normalized BBB.

Background: The progression of laser technology in neurosurgery has been limited by the poor maneuverability of traditional line-of-sight carbon dioxide (CO2) lasers and the propensity of other laser energies to cause collateral thermal injury to adjacent neural structures. The advent of a dielectric omnidirectional reflector and the subsequent development of phototonic bandgap fibers (PBF) have transformed the CO2 laser into a low-profile instrument with considerable dexterity and many potential new neurosurgical applications., Case Description: A 48-year-old woman presented with a large mass in the left lateral ventricle that was first diagnosed>20 years ago. The patient was asymptomatic until 1 month before presentation, when she began to experience progressive memory loss and neurocognitive decline., Results: The hand-held CO2 laser was used to debulk the tumor. The CO2 laser vaporized neoplastic cellular material and simultaneously cauterized microvascular structures., Conclusions: The CO2 laser was exceptionally useful in the resection of this long-standing and extremely calcified, yet vascular mass. A review of the evolution of laser technology applications in neurosurgery is presented, with a specific focus on the innovations that led to the development of the new PBF CO2 laser. This new technology may be advantageous in tumor surgery, particularly in the resection of long-standing calcified and vascular tumors that are not amendable to traditional surgical techniques., (Copyright © 2012 Elsevier Inc. All rights reserved.)

A 21-year-old man presented with a hemorrhagic central neurocytoma manifesting as acute onset of disturbance of consciousness and right hemiparesis. Computed tomography (CT) demonstrated a tumor in the left lateral ventricle during the course of evaluation for mental alteration 12 days before onset, but the tumor was left untreated because the patient refused to visit a neurosurgical institution. CT on admission revealed a large mass lesion located in the body of the lateral ventricle associated with massive intratumoral and intraventricular hemorrhage. He underwent emergent surgery for evacuation of the tumor with hematoma, and his neurological symptoms gradually recovered after surgery. The present case highlights the possibility of rapid deterioration of symptoms by massive hemorrhage from central neurocytoma. Surgical intervention should thoroughly be considered, if intratumoral hemorrhage is present, as hemorrhage from the central neurocytoma may lead to serious neurological complications.

Objective: The optimal surgical approach for a trigone meningioma is still controversial. Here, we report two patients with trigone meningioma treated successfully via an occipital inter-hemispheric and trans-cortical approach in the lateral semi-prone position., Clinical Presentation: A 53-year-old woman was admitted to a local hospital with sudden transient dizziness and vomiting. The CT brain scan demonstrated a right intra-ventricular tumour. She was therefore transferred to our hospital for surgical treatment. The other patient was a 67-year-old woman who was admitted to a local hospital after a traffic accident and a CT brain scan revealed an incidental right intra-ventricular tumour. After referral to our hospital, periodic MRI examinations revealed gradual tumour enlargement within a one-year period. Neither of the patients had any neurological deficits, including in the visual fields., Intervention: The head of each patient was positioned so that the tumour-containing right ventricle was oriented downwards and laterally. An occipital inter-hemispheric approach was performed and using a navigation system, the tumour was identified about 1 cm in depth from the cortical surface. After the medial part of the tumour was debulked, the posterior and then the anterior choroidal blood supplies to the tumour were identified. Occlusion of these vessels achieved tumour haemostasis. The tumours were totally removed via a 1.5-cm cortical incision. Brain retraction was minimal because the right hemisphere was pulled down by gravity. Therefore, the para-splenial cisterns were easily accessed, resulting in early release of cerebrospinal fluid. Post-operative MRI showed complete removal of the tumour and the patients had no neurological deficits. Anti-epileptic medication was withdrawn one week after the operation., Conclusions: The occipital inter-hemispheric fissure lacks important bridging veins. The approach used and patient positioning minimized damage to the lateral aspect of the optic radiation and the corpus callosum. Except in patients with very large trigone meningiomas, this approach is useful for decreasing the risk of post-operative hemianopsia or epilepsy, and possibly speech disturbance, even in patients with a tumour in the dominant hemisphere.

Chordoid glioma, which generally occurs in adults, is a rare CNS tumor arising in the anterior part of the third ventricle. We report two cases of chordoid glioma of the third ventricle in a 42-year-old woman and a 51-year-old man, respectively. Both tumors showed essentially the same histological and immunohistochemical features; the tumors were composed of cords and nests of epithelioid, GFAP-immunoreactive cells in a mucinous stroma with lymphoplasmacytic infiltrates at the tumor periphery. Ultrastructural examination in one case revealed that the tumor cells were characterized by the presence of hemidesmosomes and associated focal basal lamina formation, intermediate junctions, microvilli and cilia, and intercellular microrosettes with microvilli. Of interest was that small blood vessels with fenestrated endothelial cells were present in the stroma. In the brain, the presence of fenestrated endothelial cells is a feature of the circumventricular organs (except the subcommissural organ), among which the organum vasculosum of the lamina terminalis is located in the anterior part of the third ventricular floor that is lined by specialized ependymal cells known as tanycytes. These findings further strengthen the hypothesis that chordoid glioma may represent a peculiar clinicopathological subtype of ependymoma (chordoid ependymoma) originating from the lamina terminalis area.

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.

Only a few cases of intraventricular meningioma have been reported and the association with intracranial haemorrhage is even rarer. More than ever, autopsy findings are scarce. Here, we report a case of primary intraventricular meningioma with intraventricular haemorrhage in a 57-year-old woman. A CT scan of the head initially suggested a malignant brain tumour as the lesion was quite inhomogeneous with hyper- and hypodense sections accompanied by fresh haemorrhage. At autopsy, the tumour was histologically diagnosed as a fibroblastic meningioma WHO-Grade I. The source of haemorrhage was most likely the tumour itself as it contained focally rather large angiomatous and additionally small cavernous vessels and acute haemorrhage in various sections. The assumptive adherence of the tumour to the choroid plexus was probably disrupted by the haematoma.

In this report, we separately performed dynamic computed tomographic perfusion and dynamic susceptibility contrast-T2 magnetic resonance perfusion imaging on 2 cases of brain tumors (one was a glioblastoma, and the other was a central neurocytoma). Between the 2 methods, we saw the discrepancy in values of cerebral blood volume and cerebral blood flow, differences in location of the maximal cerebral blood volume, and regions with abnormal increased cerebral blood flow besides the solid part of the tumors. Both differences and similarities of the 2 techniques with their advantages and pitfalls were analyzed in detail. The developing trends in the near future were also discussed.

We report five cases of tumors occurring in three children and in two adults. The tumors had unusual histomorphology and a mixture of ependymal and piloid-like astrocytic features and a myxoid stroma similar to myxopapillary ependymomas. MR imaging in three of the cases showed aggressive, intensely enhancing partially cystic hypothalamic-suprasellar masses near midline and near the floor of the third ventricle. In the three pediatric cases, the tumor encased the circle of Willis. This newly characterized tumor, the tanycytoma, has neoplastic cells with histomorphologic and ultrastructural characteristics similar to those of the tanycyte.

Chordoid glioma is a homogeneous tumour involving the third ventricular region of middle-aged women, containing a small central cyst or necrosis. Histologically the tumour has a chordoid appearance. We report a new case with a haemodynamic imaging approach which indicates tumour angiogenesis at the capillary level.

The proliferative potential of central neurocytomas was determined in a biopsy series of 36 cases and compared with clinical outcome. The mean size of the growth fraction, as determined by MIB-1 labeling index (MIB-1 LI) at first biopsy, was 2.8 +/- 2.5 with a range of 0.1 to 8.6%. Neurocytomas with an MIB-1 LI > 2% comprised 39% of cases and showed a close correlation with the presence of vascular proliferation (p = 0.0006). The Kaplan-Meier analysis showed a highly significant difference in disease-free survival between the 2 groups (p = 0.0068). Over an observation time of 150 months, there was a 22% relapse among patients with an MIB-1 LI less than 2% and a 63% chance of relapse among those with an MIB-1 LI greater than 2%. We propose the term "atypical central neurocytoma" for the latter subset, corresponding to WHO grade II.

A case of central neurocytoma that was confirmed with ultrastructural and immunohistochemical studies has been reported. Ultrastructurally, thin cytoplasmic processes of tumor cells showed differentiation into neuronal cells containing parallel bundles of microtubules and abortive synapses with dense-core vesicles and/or clear vesicles. It was frequently found that the clusters of tumor cell processes were close to or around the microvessels. Microvessels were composed of endothelial cells without fenestrations and had tight junctions in the endothelial clefts. Neurosecretory granules in thin cell processes appeared close to microvessels and may have been secreted around microvessels.

Background: New World Health Organization classifications have categorized central neurocytomas as neuronal tumors. The differential diagnosis between central neurocytomas and other tumors is important for selection of the optimal therapy modality for the management of intraventricular tumors. To characterize the pathophysiology and proliferating activity of central neurocytoma accurately, cerebral blood flow and metabolism in five patients with central neurocytoma were studied using positron emission tomography (PET)., Methods: Tracers used for the present study included C15O2, C15O, 15O2, and 18F-fluorodeoxyglucose (FDG). Regional cerebral blood flow (rCBF), cerebral blood volume (rCBV), oxygen extraction fraction (rOEF), cerebral metabolic rate of oxygen (rCMRO2), and cerebral metabolic rate of glucose (rCMRGl) were quantitatively analyzed in tumor lesions and the contralateral gray matter. Four patients with central neurocytoma underwent a complete PET study, including all circulatory and metabolic parameters; one patient was studied with 11C-methyl-L-methionine and FDG tracers., Results: Tumor rCBF and rCBV were higher than comparable values in the contralateral gray matter in three of four patients. This high level of perfusion corresponds to angiographic findings that show intense tumor staining in tumors fed by perforated arteries. Tumor rOEF and rCMRO2 were significantly lower than corresponding values in the gray matter (rOEF, P < 0.01; rCMRO2, P < 0.05 by Student's t test). Tumor rCMRGl ranged from 2.68 to 6.26 mg/100 ml/minutes and did not exceed contralateral gray matter values in any of the five patients. Tumor rCMRGl was significantly lower (P < 0.02) than the gray matter rCMRGl. One tumor exhibited a relatively high value of rCMRGl (comparable to gray matter rCMRGl), and increased in size 4 months after partial resection. No other tumors appeared during postoperative follow-up periods that ranged from 4 to 135 months., Conclusions: Circulation and metabolism parameters measured by PET offer insight into the biologic characteristics of central neurocytoma. Tumor rCMRGl may be an indicator of the proliferating activity in central neurocytoma.

A 63-year-old man was admitted to our hospital because of loss of memory, disorientation, nausea, and urinary incontinence. Cerebral computed tomographic and magnetic resonance imaging scans revealed a tumor with intratumoral hemorrhage affecting the corpus callosum and the septum pellucidum. A partial resection of the tumor was performed, but the patient died the next day from an episode of bleeding. Postmortem examination revealed a highly vascularized subependymoma with acute bleeding in the tumor and in the surrounding brain parenchyma. The importance of considering a highly vascularized subependymoma is noted when a tumor related to the ventricular system is diagnosed.

With the introduction of additional diagnostic methods, computerized axial tomography, interventricular tumors are discovered at a time when these lesions are still small and may have presented very insignificant or no clinical symptoms. If the lesion is a benign tumor as a meningioma and within the lateral ventricle of the dominant hemisphere a very difficult problem persents itself to the patient and surgeon. Shall they wait until the tumor reaches such a size to make more permanent symptoms to justify entering the ventricle by the conventional approach through the middle temporal gyrus and leaving the patient at least with a visual field defect? Or should surgery be postponed until the ventricle especially the temporal horne is enlarged due to blockage by the tumor, making the operative procedure technically easier? The authors present a method used in three atrial trigonal meningiomas of the dominant hemisphere which did not result in any neurological deficit which was not present before surgery and which abolished paroxysmal attacks of hemianopsia and severe headaches in one patient. The latter patient was believed to have suffered from migraine for 2 1/2 years.

Computed tomograms, angiograms, and operative findings in 18 intra-atrial and 6 para-atrial lateral ventricle tumors were reviewed. Intra-atrial tumors were characteristically homogeneous, with an intraluminal mass effect. The benign types engulfed the choroid glomus; on angiography, the choroidal arteries were enlarged, with a definite tumor blush. Intra-atrial tumors without choroid involvement were usually gliomas. Para-atrial tumors had a low-density center on CT scans (in adults) with an extraluminal mass effect, displaced the glomus, and were avascular on angiography. They were low-grade gliomas in adults and ependymoblastomas in children. Forty non-atrial paraventricular and intraventricular masses were also reviewed. In general, an intraventricular, homogeneous mass which engulfs the choroid glomus on CT and has a significant choroidal artery supply on angiography is of choroidal origin and likely to be benign.

Loss of upper and lower homonymous sectors in the visual field, and wasting of corresponding sectors in the retinal nerve fibre layer, followed ligation of the distal part of the anterior choroidal artery in a patient with a meningioma of the velum interpositum. Clinical and radiological evidence indicated that the visual pathway was damaged within that part of the lateral geniculate body that is served by the anterior choroidal artery.

A positive diagnosis of tumors located within the fourth ventricle should be based on specific signs therby excluding other space occupying lesions in the posterior fossa. These are a typical omega form of the hemispheric cerebellar branches on the lateral projection, and an also typical inverted 3 form of the PICA in the semiaxial projection. Alteration of the veins of the lateral recess of the fourth ventricle and of the precentral cerebellar vein are important venous signs. Indirect signs are found in the absence of tonsillar herniation with arterial and venous signs of AP stretching of the cerebellar tonsils.

A case of intraventricular cavernous hemangioma is reported, with a review of the literature, especially that dealing with angiography of intracerebral lesions. Dense venous poolings and a localized area of venous stain were observed in this case.