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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.

Intraventricular tumors often cause hydrocephalus because their location in the ventricles affect cerebrospinal fluid circulation. Even small tumors can lead to acute hydrocephalus when they block the cerebrospinal fluid flow. They may also be found as large tumors occurring in large spaces, such as in lateral ventricles. Since various histological tumors occur in ventricles, it is important to consider the treatment strategy according to the expected histological type before treating hydrocephalus in the early stage. In addition, it is beneficial to predict and evaluate the site and size of the tumor, the cause of hydrocephalus, and the effect of postoperative chemotherapy and radiation therapy. Some tumors are sensitive to chemotherapy and radiation therapy, so there is an advantage in performing a biopsy at the same time as hydrocephalus treatment. Ventricular drainage and ventricular peritoneal shunts for patients with high intracranial pressure are at risk of developing ascending hernias, so we should be careful with the procedure.

We report a case of a patient with large intraventricular tumor treated with craniotomy assisted by a neuroendoscope. A 25-year-old man, who had headache and nausea for several months, was transferred to our hospital with the diagnosis of an intraventricular tumor. Because of intracranial hypertension and hydrocephalus, we first performed a biopsy and bilateral intraventricular drainage using a neuroendoscope. Since the pathological finding indicated central neurocytoma, we secondarily attempted tumor removal. The main location of the tumor was the left lateral ventricle, protruding into the third ventricle and contralateral lateral ventricle. The operation was performed mainly under microscopic visualization through left-sided craniotomy, and the total excision was accomplished using a neuroendoscope through the right lateral ventricle. In order to accomplish the optimal removal of an intraventricular tumor, endoscope-assisted microsurgery should be considered a surgical strategy.

Subependymomas (SEs) are rare, benign, noninvasive, slow-growing tumors located anywhere along the ventricular walls. They arise most frequently in the fourth ventricle followed by the lateral ventricle, and less frequently in the septum pellucidum, third ventricle, and spinal cord. Most SEs are found incidentally at autopsy, but some may produce clinical symptoms. Tumor-related hemorrhage represents an extremely rare presentation sign. We describe a rare case of septum pellucidum SE as tumoral hemorrhage. The tumor was totally removed via an interhemispheric transcallosal approach. Histological examination found typical SE. Although the patient had transient memory impairment, he had a good postoperative course and was discharged on the twenty-first postoperative day.

In this report, the authors retrospectively review and discuss their results for neuroendoscopic surgery for intra- and para-ventricular tumors. This study included 28 patients who were admitted to our hospital for intra- or para-ventricular tumors between January 2005 and March 2013. There were 17 males and 11 females, and their age varied widely from 1 to 75 years. Using a neuroendoscopic technique, tumor biopsy was attempted in all 28 patients. Biopsy was possible in 25 patients(89.3%)but not in the other 3(10.7%)because of hypervascularity or tumor bleeding. Of these 25 patients, pathological diagnosis was possible in 23(92%), but not in other 2(8%)because of incomplete sampling. In 18 of 28 patients, various forms of hydrocephalus were observed. Neuroendoscopic procedures were quite useful to improve cerebrospinal fluid dynamics in 13 of these patients, including endoscopic third ventriculostomy(ETV)in 9(except for 1 patient with ETV failure), septostomy with ventriculoperitoneal shunting(VPS)in 3, and cystostomy in 1. Simple VPS was performed in the other 4 patients. These results suggest that neuroendoscopic surgery is valuable as a minimally invasive procedure for pathological diagnosis and hydrocephalus treatments in patients with intra- and para-ventricular tumors. Further development of neuroendoscopic equipment is warranted to accurately diagnose tumors with hypervascularity and subependymal tumors.

Choroid plexus papillomas are rare; they comprise less than 1% of all intracranial tumors. In children, most of these neoplasms arise in the lateral ventricle while in adults they are primarily located in the fourth ventricle. We report 3 children with choroid plexus papilloma in the fourth ventricle; they were one 5-month-old girl and 2 boys aged 8-and 15-years. The baby girl presented with macrocephaly and signs of raised intracranial pressure, the 2 boys exhibited cerebellar signs. On magnetic resonance imaging (MRI) the tumors were well-enhanced with a cauliflower-like contour and hydrocephalus. In one case, diffusion weighted images (DWIs) showed an isointense tumor signal clearly different from the well-known hyperintensity of medulloblastomas, Via suboccipital craniotomy we succeeded in the total or subtotal surgical resection of these tumors and there were no sequela. None of the tumors have recurred in the intervening 2-9 years. In conclusion, choroid plexus papilloma should be included as a differential diagnosis in children presenting with tumors in the fourth ventricle. The contour of the tumor on MRI and its intensity on DWI may be clues for a correct preoperative diagnosis.

A 9-year-old boy was admitted to our hospital with daytime urinary incontinence for the past one year. MRI showed craniopharyngioma occupying the third ventricle. The tumor was excised by interhemispheric approach. Because hyponatremia and polyuria with high renal loss of sodium were observed on postoperative day 3, hydrocortisone and DDAVP were replaced. On postoperative day 24, successive general convulsions and hyponatremia recurred, and MRI FLAIR imaging showed marked brain edema in the bilateral parieto-occipital lobes. This finding disappeared late in the course of treatment, and the case was diagnosed as posterior reversible encephalopathy syndrome. The pathophysiology of cerebral salt wasting and posterior reversible encephalopathy syndrome in a craniopharyngioma patient are also discussed in the article.

A rare case of solitary fibrous tumor, located wholly within the fourth ventricle, is reported. A 57-year-old male presented with headache and nausea. The preoperative magnetic resonance images revealed a well circumscribed mass in the fourth ventricle that exhibited a low intensity on T1-weighted images and homogeneously enhanced with gadolinium. Vertebral angiogram revealed a tumor stain supplied from the choroidal branches of the posterior inferior cerebellar artery. The tumor was totally resected through a midline suboccipital approach. Histologically, the tumor was composed of spindle-shaped cells growing in fascicles within a collagenous matrix. Immunohistochemical staining demonstrated vimentin and the CD34 positivity of tumor cells. Solitary fibrous tumor is a newly described entity, which should be considered in the differential diagnosis for dural-based lesions.

The authors present a case of a subependymal giant cell astrocytoma (SGCA) not associated with tuberous sclerosis. On admission, a six-year-old boy had obstructive hydrocephalus caused by a huge intraventricular tumor. Preoperative T1-weighted MR images with gadolinium showed heterogeneous enhancement of the lesion. The tumor was totally removed through a right transcortical approach with frontal craniotomy. Immunohistochemical staining for glial fibrillary acidic protein (GFAP) showed a positive reaction in some of the large tumor cells and the labeling index of MIB-1 was < 1.0%. Histological examinations revealed SGCA. He has no other evidence of tuberous sclerosis at present, but the patient in this case is an infant, so there is a possibility of his being diagnosed as tuberous sclerosis in the future. Therefore, systemic regular follow-up is recommended, even when his condition is asymptomatic.

We reported a rare case of third ventricular chordoid glioma and reviewed the literature. A 25-year-old male presented with a two-year history of voracious appetite. Three months prior to admission, he developed progressive memory impairment. CT scan showed a well circumscribed, slightly hyperdense mass without calcification in the third ventricle. The 4.5-cm oval mass occupying the anterior part of the third ventricle was homogeniously enhanced on MR images after administration of contrast medium. Small cystic components were present in the periphery of the mass. CT-guided stereotactic biopsy was performed. Microscopically, epithelioid tumor cells were embedded in mucinous stroma containing a lympho-plasmacytic infiltration. The tumor cells were immunoreactive for GFAP and vimentin. The MIB-1-positive rate was 1.2%. The histological diagnosis was a chordoid glioma. One month after the biopsy, a right frontal craniotomy was performed to remove the tumor via the anterior transcallosal interfornitial approach. The tumor arising from the anterior part of the third ventricle wall was soft, mildly vascular and light-grayish. The tumor was completely resected. The histological findings were identical with those of the biopsy specimens. Postoperatively, the patient developed diabetes inspidus, hyperthermia, worsening memory impairment, and transient hyponatremia. The patient's symptoms gradually improved and follow-up MR images showed no evidence of recurrent tumor 17 months after the resection. Despite low-grade appearance, attachment of the tumor to the hypothalamus preclude complete resection, and this may result in tumor recurrence and less favorable prognosis in the current reports. Early detection and aggressive resection followed by stereotactic radiotherapy are important in the management of chordoid glioma.

We report a case of subependymoma of the right lateral ventricle in a 59-year-old man. CT revealed a mass lesion in the right lateral ventricle. No calcification was seen in the tumor, and the right lateral ventricle was dilated dominantly by the tumor. The tumor showed intermediate intensity on T1-weighted MR images and high intensity on T2-weighted MR images. On contrast study, the tumor showed heterogeneous enhancement. We suspected this to be a case of central neurocytoma, and surgical resection was performed. The histological diagnosis was subependymoma, but we considered it difficult to differentiate from astrocytoma, central neurocytoma, and ependymoma.

We present a case of a symptomatic subependymoma (SE) in a young. The patient was a 20-year-old female who suffered from severe headache and vomiting. Precontrast CT scans revealed a large spotty-calcified isodensity mass lesion in the right anterior lateral ventricle, showing scarce contrast enhancement at the center of the mass and with marked hydrocephalus. MRI demonstrated the lesion as slightly hypo-intensity on T1-weighted image, hyper-intensity on T2-weighted image. On FLAIR imaging, the lesion indicated remarkable hyperintensity and was clearly distinguishable from surrounding brain parenchyma and the cerebrospinal fluid. After Gd-DTPA infusion central vein was revealed, but no tumor enhancement was seen. The tumor was totally extirpated through the transcortical approach. Histological diagnosis was SE, and high MIB-1 staining index (9.3%) was seen. FLAIR imaging is useful for the preoperative diagnosis and the postoperative assessment of SEs.

The treatment of craniopharyngioma becomes quite difficult when it extends into the third ventricle. In a 4-year-old boy, we encountered a large cystic craniopharyngioma which grew into the third ventricle. Initially, the tumor was successfully removed via a right transcallosal transchoroidal approach. A residual part seemed to have remained in the right perioptic region. Even though the patient had an episode of SIADH, his postoperative course was uneventful. He developed visual disturbance 4 months after the initial operation. CT and MRI revealed a large suprasellar mass. The tumor was totally resected via a right pterional approach. Careful follow-up disclosed again a small recurrent lesion in the anterior commisure. Gamma knife therapy was used to successfully reduce the volume of the tumor. The MIB-1 labeling index (LI) of the specimen taken at the time of the first operation was at 9.2% and that of the second operation at 21.2%. Recently, the importance of MIB-1 LI for assessing proliferative activity of this tumor was reported. In patients whose MIB-1 LI is higher, they have more significant rate of recurrence. Our results also indicate that in cases where MIB-1 LI indicates a high value, careful follow-up is necessary. Through fact of the necessity of two operations and additional gamma knife therapy, we would like to stress the importance of MIB-1 LI in indicating the proliferative activity of this tumor. These surgical procedures are presented here, and the role of MIB-1 LI in determining the proliferative activity of craniopharyngioma is also discussed.

Choroid plexus papillomas represent approximately 0.5% of all intracranial tumors, but they are found in the third ventricle only infrequently. We report a case of choroid plexus papilloma in the third ventricle which is difficult to differentiate from a pineal region tumor. A 4-month-old female presented with bulging fontanelle and sunset phenomenon. A CT scan and MRI showed marked hydrocephalus caused by a tumor extending from the posterior third ventricle to the peneal body. Preoperatively, we diagnosed the lesion as a pineoblastoma. The tumor was totally removed through the occipital transtentorial approach. Pathological examination of the tumor revealed a typical choroid plexus papilloma. The operation was uneventful, and she has grown normally without recurrence of the tumor for three years since the operation. A sagittal gadolinium-enhanced MRI was useful in our case to differentiate a choroid plexus papilloma from a pineal region tumor, because the former extended into the aqueduct forming the shape of the letter V while the latter compressed the aqueduct downward.

Neonatal intracranial teratoma is rare and early attempts at surgical treatment are not usually successful. We describe an exceptionally rare case of neonatal intracranial tumor in the lateral ventricle composed of multiple cysts with little mass content which was highly suspected of teratoma and treated successfully by microsurgery. A 55-day-old male was admitted to our hospital with complaints of convulsive seizure. Examination found no obvious neurological deficit except mild enlargement and bulging of anterior fontanel. There were no abnormal laboratory findings. Computerized tomography with contrast medium revealed an 8 cm multicystic lesion with little mass content in the right lateral ventricle and hydrocephalus. Magnetic resonance imaging showed the cystic content as slightly higher in intensity than CSF on the T1-weighted image and of higher intensity than CSF on the T2-weighted image. The cyst wall was enhanced on T1-weighted image with gadolinium. The aqueduct was obstructed by compression due to the intraventricular cyst. A right occipitoparietal craniotomy was performed, which disclosed a hair in the cyst wall, two huge cysts, and independence of the intracystic lesion from the lateral ventricle. The tumor was removed except for a small part adjacent to the pineal region, from which the tumor had presumably originated. Mature teratoma was highly suspected on the basis of the hair in the cyst wall and histological examination of the specimen, which revealed hamartomatous tissues derived from two germ cell layers. After surgery, his hydrocephalus was improved and convulsive seizures were reduced remarkably. He was discharged ten days later and is being followed up. Reoperation will be performed if regrowth of the residual tumor occurs.

The transcallosal approach has been widely used for tumors located near the midline of the anterior part of the lateral ventricle, while the transcortical approach is known to provide a wide surgical field in cases of hydrocephalus. However, it is not always easy to choose the appropriate approach in individual cases. The size of the visualized field obtained via the surgical approach is one of the most important factors determining the accessibility of the lesion. In this study, we investigated the difference in the sizes of the fields afforded by these two approaches on the basis of our clinical experience and simulation studies. We surgically treated intraventricular pathology located at the anterior part of the lateral ventricle in five patients with tumors and one with a cyst. Tumors with lateral extension of less than 20 mm were approached via the transcallosal route, and those with more than 20 mm of lateral extension via the transcortical route. In the simulation study, the size of the surgical field was measured through a 3-cm incision of either the cerebral cortex or the corpus callosum under various conditions of ventricular enlargement. Two patients treated via the transcortical approach underwent subtotal removal; one of them had a large bilaterally extending tumor measuring 50 mm in its greatest diameter, and the other had tumor involvement of the fornix. The other three tumors and the cyst were totally resected. While postoperative subcortical hematoma developed in two patients, one each treated via the transcortical and the transcallosal approach, no deficits remained at discharge. Since enucleation procedure was insufficient in patients with hard tumors, a wider surgical field than that in patients with soft tumors was considered necessary. When combined approaches are considered indispensable for a patient with a massive tumor, the transcortical approach may be indicated for priority of order to prevent bilaterally residual tumors. The simulation study disclosed that, in either approach, wider surgical field was obtained as the size of ventricle increased. However, the transcallosal approach afforded a wider field than did the transcortical approach not only in ventricules of normal size but also in mild hydrocephalus with cortical thickness of between 30 and 40 mm. The transcortical approach, on the other hand, produced a much wider field in more advanced hydrocephalus with a thickness of less than 30 mm. A wider surgical field can be obtained by certain tactics such as upward retraction of the incised corpus callosum, moving the cortical window, or oblique or transverse cortical incision.

Enlargement of the foramen of Monro is an essential maneuver to obtain an appropriate surgical view when large, solid lesions in and around the third ventricle are to be removed via the anterior transcallosal approach (ATA). For this purpose, three methods, i.e., the subchoroidal, transchororidal, and transfornicial approaches have so far been reported. However, since the locations and the pathological natures of space occupying lesions in this region are widely variable, the indication as well as the feasibility of each approach has remained rather unclear. The present paper deals with our surgical experience with six patients (2 gliomas, 1 angioma, 1 AVM, 1 plexus papilloma, 1 basilar top aneurysm) operated on using the ATA in which variable methods of enlarging the foramen of Monro were employed. Aiming at complete removal or clipping of the lesion, the seemingly best among the above three approaches was determined preoperatively, considering the size, location, and pathological nature of the lesion. The shape of the choroid plexus of the roof of the IIIrd ventricle as revealed by MRI was also taken into account. The subchoroidal, transchoroidal, and the transfornicial approaches were employed in 3, 2, and 1 cases, respectively. Except for one glioma which ended up being removed extensively, all the tumors and AVM were totally removed and the aneurysm successfully clipped. From the above experience, the merits and demerits of each approach for different types of lesions are discussed in view of their suitability for achieving total removal.(ABSTRACT TRUNCATED AT 250 WORDS)

We report a case of intraventricular cystic meningioma in the left lateral ventricle. A-44-year-old male patient was admitted with headache on November 25, 1991. Neurological examination revealed acalculia and left homonymous hemianopsia. CT and MRI showed a solid tumor which originated in the body of the left lateral ventricle, and which was associated with a cystic component postero-laterally. Tumor strains fed by the left anterior choroidal artery and the medial and lateral posterior choroidal artery by angiography. The tumor was totally removed via the lateral temporal parietal approach. Histological examination revealed meningotheliomatous meningioma in the solid tumor and only gliosis in the wall of the cyst.

A patient is described who simultaneously suffered from hallucinations and one-and-a-half syndrome following surgical resection of a cavernous angioma located on the fourth ventricle floor. A 30-year-old male was admitted having a 10 year history of progressive weakness and hypesthesia of the right extremities. Neurological examination revealed right hemiparesis and hemihypesthesia. A computerized tomography (CT) scan showed a well circumscribed mixed-density area at the left portion of the pontine tegmentum. Magnetic resonance imaging (MRI) indicated a mixed intensity core surrounded by hypointense regions on T2-weighted images. A red mulberry-like tumor was found, during surgical procedures, on the mid-and left-portion of the fourth ventricle floor. The tumor was totally resected and the histological diagnosis was cavernous angioma. Visual hallucinations occurred several times following surgery, being subsequently described as images of moving worms, a dump truck next to the bed, and a bed falling from the ceiling. The patient soon understood these objects were not real. He simultaneously exhibited left lateral gaze palsy associated with left internuclear ophthalmoplegia i.e., one-and-a-half syndrome. Three months after surgery the visual hallucinations disappeared but the one-and-a-half syndrome was incompletely resolved. According to the neurological signs and the MRI results, the lesion site was considered to extend from the left lower pons to the midbrain. Previously reported operations of cavernous angioma of the fourth ventricle floor are also described.

Two cases of a programmable pressure valve trouble are reported. Case #1 was that of a 49-year-old male who had received a ventriculoperitoneal shunt (VPS) using a Sophy programmable pressure valve (Model S3) after the removal of the fourth ventricle ependymoma. After the VPS, the patient went through several episodes of complaining of headache due to the spontaneous movement of the rotor from the high pressure position to the medium or low pressure position. The symptom had disappeared after exchanging the valve for a new one and by setting the valve pressure at high. Examination of the removed valve revealed that the bending-degree of the spring tip was insufficient, and that the opening pressures at the medium and high pressure positions were both lower than the desired range. Case #2 was that of a 62-year-old female who had received a VPS for normal pressure hydrocephalus using a Sophy programmable pressure valve (Model S3) with the valve pressure set a high. However, her symptoms did not improve, so an attempt was made to change the valve pressure from the high pressure position to the medium pressure position with a ring magnet. But the rotor could not be moved. The valve was exchanged and the valve pressure was set at medium, and the symptoms of the patient improved postoperatively. Examination of the removed valve revealed that the movement of the rotor with a ring magnet was not able to be carried out smoothly.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrasonography using a 5-MHz sector-scanning probe was performed in 4 patients with intraventricular or periventricular lesions. All patients underwent craniotomy, and the lesions included an intraventricular cyst (Case 1, Fig. 1), a subependymoma (Case 2, Figs. 2 and 3), a hypothalamic glioma (Case 3, Fig. 4) and a periventricular cavernoma (Case 4, Fig. 5). The lesion was approached in the former 3 cases via the transcallosal route and in the last via the transcortical route. Preoperative MRI was performed in such a way that both the lesion and the anticipated operative route to it were shown on the image, so that the approach angle and surrounding structures could be assessed. During craniotomy, intraoperative ultrasonographic examination was performed while the dura was still closed. By frequently changing the probe direction, we were able to obtain an image similar to that shown on the preoperative MRI, and we then initiated intradural operative procedures at an angle parallel to the axis of the probe. Since MRI provides detailed anatomical information about the approach to the lesion and the tissue around it, it has become an indispensable tool in the planning of neurosurgical operations. Although ultrasonography generally provides poorer resolution than does MRI, especially for deep structures, it does provide convenient, real-time images of any slice. Because the interhemispheric fissure, lateral ventricle, and choroid plexus have distinctive shapes and echogenicity and, hence, can be readily recognized, we found that they can be good landmarks in the imaging of periventricular or intraventricular lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

The isolation and enlargement of the fourth ventricle after a ventriculoperitoneal (V-P) shunt was classified as "isolated fourth ventricle (IFV)". The term, "disproportionately large communicating fourth ventricle (DFV)" was first introduced by Scotti et al as being an enlarged fourth ventricle communicating with the third ventricle. The authors present a case of DFV after the resection of an astrocytoma. Upon recurrence of the tumor a second resection was carried out 5 years later. It was found that IFV had evolved because a cyst in the right temporal lobe was obstructing the aqueduct. After shunting of the tumor cyst, the aqueduct was again found to be patent and the fourth ventricle gradually decreased in size. A 34-year-old female presented headache, nausea, and a mild left hemiparesis. An initial CT scan demonstrated a fourth ventricle of approximately normal size and a right temporal mass. The first craniotomy revealed an astrocytoma. A CT scan after the surgical procedure showed enlargement of all ventricles, especially the fourth, resulting from the blockage of the foramina of Luschka and Magendie. The insertion of a V-P shunt was followed by a reduction in size of all ventricles. The diagnosis of DFV was thus confirmed because the fourth ventricle had a demonstrated communication with the third ventricle. After a second craniotomy for tumor recurrence five years later, a CT scan revealed the enlargement of the fourth ventricle and a cyst in the right temporal lobe. A metrizamide CT scan revealed that the cyst was isolated and an RI ventriculogram confirmed obstruction of the aqueduct.(ABSTRACT TRUNCATED AT 250 WORDS)

Twelve infants with choroid plexus tumors were reviewed retrospectively. Enlarging head circumference, bulging fontanelle, and vomiting were the major symptoms and signs appearing 2 to 5 weeks (mean = 3.7 weeks) before diagnosis. The average age at diagnosis was 7.7 months. Total removal was performed in 11 patients with choroid plexus papilloma, and partial removal was achieved in 1 patient with a choroid plexus carcinoma. A cerebrospinal fluid (CSF) diversionary shunt was placed temporarily in 6 infants and permanently in 4. Of the two patients not requiring CSF diversionary shunt, 1 needed a subdural-peritoneal shunt postoperatively. Histologically, 11 of 12 tumors were choroid plexus papillomas, and one was a choroid plexus carcinoma. All 12 patients were followed up for 4 months to 11 years (mean = 5.6 years). Eleven of 12 patients were alive at the time of their last check-up. All 11 survivors had normal psychomotor and neurological development. The treatment and outcome of choroid plexus tumors and management of associated hydrocephalus are discussed.

An adult case of malignant choroid plexus papilloma is very rare. This report is an adult case of malignant choroid plexus papilloma revealed in the lateral ventricle and in the cerebellopontine (CP) angle simultaneously. A 37-year-old man was admitted to the hospital complaining of headache, nausea, and a floating sensation on August 29, 1984. Neurological examination on admission revealed bilateral papilledema, left dysmetria and horizontal nystagmus. CT scan revealed a slightly high density round mass in the right lateral ventricle and a cystic mass with mural nodule in the left CP angle. The intraventricular mass and mural nodule were enhanced moderately and homogeneously. The initial surgery was for removal of the CP angle tumor, and 8 days later removal of the lateral ventricle tumor was carried out. The histology of these tumors was the same and revealed malignant choroid plexus papilloma. Postoperative radiation therapy was carried out 70Gy to the brain (whole brain; 50Gy, focal; 20Gy) and 30Gy to the whole spine. About 2 years later paraparesis, lower cranial nerve palsy, and disturbance of consciousness had progressed gradually. He died of the severe recurrence of the tumor in the brain stem, and multiple dissemination in the spinal cord on September 6, 1987. There was no recurrence of tumor in the right lateral ventricle. This is a very rare case of malignant choroid plexus papilloma which was revealed in both the supra- and infratentorial regions simultaneously. They may have developed independently or they may have arisen through subarachnoid seeding. Radical removal of the tumor is important to prevent recurrence of malignant choroid plexus papilloma.

Involvement of the choroid plexus by malignant lymphoma is rare. This case showed mass lesions at the choroid plexus in the first stage of systemic non-Hodgkin's malignant lymphoma. A 53-year-old female was admitted with headache, diplopia, and gait disturbance. The patient was alert but had left supraclavicular and axially lymph node swelling. Computed tomography scan revealed enhanced masses at the lateral and fourth ventricles. The lymph node biopsy disclosed non-Hodgkin's malignant lymphoma, diffuse large cell type. The immunological marker was the B-cell type. At surgery, there was highly vascular white tumor at the choroid plexus of the right lateral ventricle. The tumor also involved adjacent brain tissue. Pathological examination revealed infiltration of lymphoma cells to the choroid plexus. The subependymal and perivascular spaces of the choroid plexus were filled with lymphoma cells. Virchow-Robin space and white matter of adjacent brain tissue were also involved by lymphoma. After surgery, whole brain irradiation of 35 Gy and chemotherapy were performed. However, 14 months after initial diagnosis, the patient expired because of systemic involvement by the lymphoma.

A 61-year-old female was referred because of headache and gait disturbance. A computed tomography (CT) scan revealed a midline isodense mass lesion. The limit of the tumor was equivocal even after administration of contrast medium. Magnetic resonance imaging (MRI) study, however, clearly showed the relationship between the tumor and the surrounding structures, such as the corpus callosum, the ventricular cavities. The tumor had originated from the region of the septum pellucidum and positioned just beneath the corpus callosum from the genu to the splenium with the roof of the third ventricle pushed downward. The tumor was totally extirpated via the interhemispheric paratranscallosal route. The tumor was typical subependymoma. The post-operative course was uneventful. Transient psychiatric disturbance and inability to retain recent memory were observed and the former subsided in several weeks. CT and MRI characteristics of subependymoma are summarized and the usefulness of MRI to locate tumors and to plan proper surgical approaches are emphasized.

This is the first report of extraneural metastasis of malignant glioma through V-P shunt tube and growth in peritoneal cavity as ascitic form. The patient was a 43-year-old man who was admitted to our hospital with occipital headache. CT scan showed enhanced cystic tumor mass at left temporal lobe. Craniotomy and partial excision of the tumor was done and the histology of tumor tissue showed a malignant astrocytoma. Following this treatment, the patient received the adjuvant therapies of radiation, chemotherapy and immunotherapy with interferon, and also recraniotomy three times. In the mean time, a ventriculo-peritoneal shunt was set up for internal hydrocephalus. One month later, abdominal bulging appeared and yellowish ascites could be obtained with peritoneal tap. In the ascite, tumor cells with glial fibrillary acidic protein were observed at the concentration of 5-10 x 10(4) cells/ml. The patient died three months after extraneural metastasis to the abdominal cavity as ascitic form. At autopsy, solid metastatic mass lesion was not found in extraneural region include abdomen.

Internal drainage of cerebrospinal fluid utilizing a mechanical tube has been an increasingly common and effective procedure for the relief of non-communicating hydrocephalus with intracranial tumor. However, several cases have recently been reported in which extraneural metastases of the tumor were initiated through the shunt tube implanted. The purpose of this paper is to present two cases with malignant brain tumor metastasizing extraneurally through ventriculoperitoneal shunt, and to review the reported cases in the literature. Case 1 The patient, a 9-year-old boy, had been suffering from headache and vomiting for 3 months prior to admission to the Neurosurgical Clinic, Gumma University Hospital. On admission, he had choked discs and cerebellar dysfunction with a staggering gait. The clinical diagnosis was a 4th ventricle tumor. On November 29, 1971, a suboccipital craniectomy was performed. A medullary tumor in the 4th ventricle was partially removed, and ventriculoperitoneal shunt was also performed. Subsequently postoperative irradiation was given, and the symptoms were abated. Histological diagnosis was ependymoblastoma. Thirteen months later, he was again admitted because of visual disturbance, psychic change and pituitary hypofunction. Bilateral frontal craniotomy revealed a large mass over the midline of the anterior skull base, accompanied by numerous meningeal neoplastic deposits. The tumor was partially removed and histologically proven to be meningeal metastases of ependymoblastoma. Irradiation was again given and the symptoms improved. But the 4th ventricle tumor recurred 5 months after the 2nd operation, and then a massive intraperitoneal effusion appeared. Cytological examination revealed clusters of tumor cells in the ascites. The patient died on September 8, 1974, namely 22 months after the ventriculoperitoneal shunt was implanted. Postmortem examination showed a solid tumor in the 4th ventricle which was accompanied by diffuse meningeal dissemination, and metastases were present throughout the peritoneal surface...

Two cases with epidermoid and one case with dermoid in the 4th ventricle were treated in our clinic during the last one year. The clinical findings in these three cases were described, and dermoid and epidermoid tumors in the 4th ventricle were discussed dealing with the incidence and the characteristic features of the findings in CT scanning. The correct diagnosis of both epidermoid and dermoid in the 4th ventricle was done by CT-scanning which showed an irregular low density area of EMI No. -4 approximately 12 in the posterior fossa without any contrast media enhancement. The low density lesion could be differentiated by both angiogram and ventriculogram from arachnoid cyst, ependymoma, cystic astrocytoma and cystic hemangioblastoma in the 4th ventricle. Total removal of the tumor was performed on 2 cases, and a part of the tumor capsule attached to the medulla oblongata was left in the other case. All patients returned to their own job after operation.

A rare case of craniopharyngioma wholly located within the third ventricle is reported. A 55-year-old female was admitted to our hospital with the complaints of headache and fever of unknown origin. Neurological findings were normal. Computed tomography (CT) scan showed homogeneously enhanced mass lesion within the third ventricle. Axial and coronal CT scans disclosed an intact suprasellar cistern. The tumor was completely removed using an interhemispheric trans-lamina terminalis approach. Histological diagnosis was squamous cell type of craniopharyngioma. Post-operative diabetes insipidus was well controlled, and irradiation of 50 Gy was performed. Craniopharyngioma located entirely in the third ventricle was reviewed, and etiology, clinical feature and treatment were discussed.

Our experience with the transcallosal approach to para-ventricular tumors is reviewed and our operative technique is described. A group of 7 patients with a variety of tumors affecting the lateral ventricle, 3rd ventricle and basal ganglia have been treated using an anterior transcallosal approach. Using a posterior transcallosal approach, we operated upon 2 patients with thalamic tumors. The anterior part of the body of the corpus callosum is divided in the anterior transcallosal approach and the posterior part of the body of the corpus callosum is divided with preservation of the splenium in the posterior transcallosal approach. The division amounting to approximately 2-3 cm is sufficient exposure. With the exception of tumors affecting the basal ganglia, thalamus and anterior 3rd ventricle, complete excision of each lesion was effected. There were no operative deaths. The complications in this group of patients were primarily related to the nature and location of the primary tumor, but four complications were directly related to the transcallosal approach. Venous infarctions occurred in 2 patients and subdural fluid collections occurred in 2 patients. Therefore, planning of the flap placement and the extent of brain retraction must be based on preoperative angiographic assessment of parasagittal venous tributaries. We performed some detailed studies of the interhemispheric transfer of somesthetic and perceptual motor tasks, as well as psychometric testing post-operatively in 2 patients. No significant clinical deficit subsequent to dividing the anterior part of the body of the corpus callosum could be demonstrated. The results and clinical material indicate that transcallosal approach is a safe, feasible alternative in the management of the tumors in these regions.