Intraventricular meningiomas: a review of 16 cases with reference to the literature

Neoplasm

Intraventricular Meningiomas: A Review of 16 Cases with Reference to the Literature Makoto Nakamura, M.D.,* Florian Roser, M.D.,* Otto Bundschuh, M.D.,† Peter Vorkapic, M.D., Ph.D.,* and Madjid Samii, M.D., Ph.D.*,†,‡ *Department of Neurosurgery, Nordstadt Hospital, †International Neuroscience Institute, ‡Department of Neurosurgery, Hannover Medical School, Hanover, Germany

Nakamura M, Roser F, Bundschuh O, Vorkapic P, Samii M. Intraventricular meningiomas: a review of 16 cases with reference to the literature. Surg Neurol 2003;59:491–504. BACKGROUND

Primary intraventricular meningiomas are notably rare with an incidence of 0.5 to 3% among all intracranial meningiomas. We present a series of 16 patients with histologically verified intraventricular meningiomas, the clinical and neuroradiological findings, and surgical results.

CONCLUSION

Although intraventricular meningiomas are quite rare, they represent an important differential diagnosis of intraventricular neoplasms. They can reach a substantial size by the time of diagnosis, yet total removal can be achieved in most cases. © 2003 Elsevier Inc. All rights reserved. KEY WORDS

Meningioma, lateral ventricle, third ventricle, fourth ventricle, intraventricular tumor.

METHODS

The charts of the patients including surgical records, discharge letters, histologic records, follow up records and imaging studies were analyzed retrospectively from 1978 to 2001. RESULTS

Collectively, 110 primary intraventricular tumors were surgically resected in our neurosurgical department from 1983 through 2001. There were 16 patients with primary intraventricular meningiomas. Thirteen (81.3%) of these tumors were located in the lateral ventricles, one (6.2%) in the third and two (12.5%) in the forth ventricle. Mean age was 47.1 years and there was no difference in incidence between the sexes. The most common presenting symptoms and signs were headache, mental change, and hemianopia. Other symptoms included gait ataxia, vertigo, hemiparesis, double vision, aphasia, and alexia/ agraphia. On CT and MR studies most of the lateral ventricular meningiomas were located in the trigone (11 cases), two tumors originated at the level of foramen of Monro or in the frontal horn. The tumors were approached via a transcortical parieto-occipital (11 cases), transcallosal (3 cases), or median suboccipital (2 cases) route. Total removal was achieved in 15 out of 16 cases. There was no operative mortality. Clinical improvement was seen in symptoms like headaches, paresis, cerebellar signs and visual disturbances, whereas mental change showed less improvement.

Address reprint requests to: Dr. Makoto Nakamura, Department of Neurosurgery, Nordstadt Hospital, Haltenhoffstr. 41, 30167 Hannover, Germany. Received May 22, 2002; accepted November 14, 2002. © 2003 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 –1710

eningiomas account for approximately 15% of all intracranial neoplasms. They are known to occur in various locations within the brain, originating from the arachnoid cap cells. The primary occurrence of meningiomas in the ventricular system without dural attachment is extremely rare, with an incidence of 0.5 to 3% among all intracranial meningiomas. According to previous reports, their distribution is 77.8% in the lateral ventricular trigone, 15.6% in the third ventricle and 6.6% in the fourth ventricle [3,5,8 –17,19 –20,22,25–27,30,32–33,35,37,39,41, 43,45–47,49,52,54,56 –57,61– 66,68 –70,72–73,75–77,79, 81,83,85– 86]. In a series of approximately 1,800 meningiomas that underwent surgical resection at our institution from 1978 to 2001, the incidence of intraventricular meningiomas was 0.7%. This study will present our experience and results with this rare entity, demonstrating the clinical presentation, neuroradiological diagnosis and surgical results.

M

Patients and Methods A retrospective review of patients who had undergone surgical resection of primary intraventricular tumors at the Department of Neurosurgery at Nordstadt Hospital from 1978 to 2001 was con0090-3019/03/$–see front matter doi:10.1016/S0090-3019(03)00082-X

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First Symptom and Time to Diagnosis

IVTH

LATERAL FIRST SYMPTOM

VENTRICULAR MENINGIOMA (13 PATIENTS)

Headache Mental change Vertigo Gait disturbance Visual deficit Motor disturbance

5 (38.5%) 5 (38.5%) 3 (23.1%) 2 (15.4%) 2 (15.4%) 1 (7.7%)

DURATION TO DIAGNOSIS

Up to Up to Up to Up to Up to 7 mo

1 2 6 1 1

VENTRICULAR MENINGIOMA (2 PATIENTS)

yr yrs mo yr yr

ducted. Surgical records, discharge letters, histologic records, follow-up records and imaging studies were analyzed. There were 110 surgical resections of primary intraventricular tumors, 16 of which were primary intraventricular meningiomas. Eleven tumors were located in the lateral ventricles, two in the fourth and one in the third ventricle. One patient suffered from neurofibromatosis type II. The mean age was 47.1 years with equal distribution between the sexes. Surgical resection was performed using microsurgical technique under the operation microscope. Additionally, in 12 cases an ultrasonic aspirator was used for tumor reduction. Follow-up time ranged from 6 months to 11 years with a mean of 3 years.

Results CLINICAL FEATURES Cognitive and personality disturbance was seen in 13 patients such as memory disturbance, mental exhaustion and dullness. Disorientation was seen in seven patients and headache in six patients. Motor disturbance was noticed in five patients representing mostly a hemi- or monoparesis. The time period from the onset of the first symptom to the diagnosis ranged from 4 days to 2 years.

2

1 0 2 1 0 0

DURATION

IIIRD

DURATION

TO DIAGNOSIS

VENTRICULAR MENINGIOMA

DIAGNOSIS

2 mo Up to 2 mo 5 weeks

0 1 0 0 0 0

TO

4 weeks

A sudden onset of headaches, nausea, vomiting and blurred vision in one case led to the neuroradiological diagnosis only 4 days later. Many complaints were episodic or transient thus delaying the diagnosis in most patients. The two cases of fourth ventricular meningioma presented primarily with headaches, vertigo and gait ataxia. In both cases the diagnosis of an intraventricular tumor could be made in a relatively short period of 5 weeks and 2 months. Table 1 summarizes the first symptoms and the duration to diagnosis. Table 2 lists the symptoms at time of presentation. On neurologic examination the most common sign in patients with lateral ventricular meningiomas was homonymous hemianopia (six patients) followed by corticospinal signs (four patients) varying from spastic hemiparesis to mild hemi- or monoparesis. Papilledema was noted in three patients of whom two had headaches. Dysphasia was apparent in three patients, two of which were right handed with left trigonal tumors. One patient with fourth ventricular meningioma showed signs of cerebellar ataxia with dysmetria of the upper extremities and dysdiadochokinesis. Table 3 summarizes the neurologic signs at the time of admission.

Symptoms at Time of Presentation

LATERAL

IVTH

IIIRD

SYMPTOM

VENTRICULAR MENINGIOMA (13 PATIENTS)

VENTRICULAR MENINGIOMA (2 PATIENTS)

VENTRICULAR MENINGIOMA (1 PATIENT)

Mental change Headache Motor disturbance Gait disturbance Visual deficit Vertigo

7 (53.8%) 6 (46.2%) 5 (38.5%) 4 (30.8%) 4 (30.8%) 3 (23%)

0 2 0 1 0 2

1 0 1 1 1 0

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Neurological Signs at the Time of Admission

LATERAL

IVTH

IIIRD

SIGNS

VENTRICULAR MENINGIOMA (13 PATIENTS)

VENTRICULAR MENINGIOMA (2 PATIENTS)

VENTRICULAR MENINGIOMA (1 PATIENT)

Hemianopsia Corticospinal signs Papilledema Dysphasia Ataxia Alexia/agraphia Sensory deficit

6 (46.2%) 4 (30.8%) 3 (23%) 3 (23%) 2 (15.4%) 2 (15.4%) 1 (7.7%)

0 0 0 0 1 0 0

1 1 1 0 1 0 0

The clinical features of our patient with third ventricular meningioma are described in the case illustration. DIAGNOSTIC INVESTIGATION In all patients a preoperative cranial computer tomography (CT) with and without contrast was performed. Nine tumors were located in the left lateral ventricle and four were in the right lateral ventricle. Most of them arose typically in the trigone but two tumors were found near the foramen of Monro with extension into the left and third ventricle. One of these two patients had neurofibromatosis (NF) type II. There was one third ventricle meningioma, and two tumors were located in the fourth ventricle. Tumor size ranged from 2-7 cm, with 3 tumors (18.8%) ⬍3 cm and 13 tumors (81.2%) ⱖ3 cm in diameter.

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All tumors showed an increased density and smooth margins were present in most cases (12 patients). Lobulation and an irregular margin were found in two cases each, and calcification was seen in six cases. Contrast enhancement was present in all tumors; enhancement was homogenous in 81.2% and inhomogeneous in 18.8%. In all trigonal ventricular meningiomas the tumor caused local dilatation of the posterior and temporal horn of the affected side. In the case of third ventricular meningioma, because of the enormous extension of the tumor, both lateral ventricles and the third ventricle were completely filled and dilated. In the two cases of fourth ventricular meningiomas, no hydrocephalus was present (Table 4). Magnetic resonance imaging (MRI) was performed in 13 patients. Most of the tumors were

CT Features of Intraventricular Meningiomas

AGE/ MAX. PTS SEX LOCALIZATION DIAMETER CALC.a DENSITY MARGINS 1 2 3

71/F Right trigone 68/M Right trigone 37/M Right frontal horn 27/M Right FM 28/F Left trigone 61/F Left trigone 59/F Left trigone 42/F Left trigone 57/F Left trigone 47/M Left trigone 62/F Left trigone 25/F Left trigone 77/M Left trigone 25/M III 40/M IV 28/M IV

4 5 6 7 8 9 10 11 12 13 14 15 16 a

7 cm 6 cm 5 cm 5 cm 2 cm 4.5 cm 2.8 cm 6 cm 3 cm 2.5 cm 3 cm 4.5 cm 5 cm 7 cm 3 cm 4.5 cm

⫹ ⫹ ⫹ ⫹

⫹ ⫹

CONTRAST ENHANCEMENT

PERITUMORAL HYDROCEPHALUS

EDEMA

Increased Smooth Increased Smooth Increased Smooth

Homogeneous Homogeneous Homogeneous

Local Local Local

⫹ ⫹ ⫹

Increased Increased Increased Increased Increased Increased Increased Increased Increased Increased Increased Increased Increased

Inhomogeneous Inhomogeneous Homogeneous Homogeneous Homogeneous Homogeneous Homogeneous Homogeneous Homogeneous Homogeneous Inhomogeneous Homogeneous Homogeneous

Bilateral Local Local Local Local Local Local Local Local Local Bilateral ⫺ ⫺

⫺ ⫺ ⫹ ⫹ ⫹ ⫹ ⫺ ⫹ ⫹ ⫹ ⫹ ⫺ ⫺

Lobulated Irregular Smooth Smooth Smooth Smooth Smooth Smooth Smooth Smooth Lobulated Smooth Irregular

CT, computed tomography; Calc., calcification. FM, near the foramen of Monro with extension of the tumor into the left and third ventricle in one case with associated neurofibromatosis type II.

b

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isointense to cortex on T1 weighted images (nine tumors); four were hypointense. Homogenous gadolinium enhancement was present in 10 patients and heterogenous enhancement in three patients. On T2-weighted images most of the tumors were hyperintense (eight patients), or isointense (five patients) to cortex. Signal voids because of calcification were visible in five cases. Carotid and vertebral angiography was performed in five cases of lateral ventricular meningiomas and in the case of third ventricular meningioma. Among them all lateral ventricular meningiomas obtained their vascular supply from both anterior and posterior choroidal circulations. The tumor blush delineated the tumor more clearly on vertebral angiography in most of the cases. NEUROSURGICAL APPROACH The operative procedure was performed using microsurgical techniques in all 16 cases. Of the 13 lateral ventricular meningiomas, 10 were resected via a posterior parieto-occipital transcortical approach. Two tumors were resected via a transcallosal approach. Among them in one NF-II associated case the tumor was located at the level of foramen of Monro extending from the right ventricle into the left and third ventricle. In the second case the location of the tumor was in the trigone and body of the left ventricle. One tumor, located in the frontal horn and body of the lateral ventricle, was resected via a frontal approach. In both fourth ventricular meningiomas a median suboccipital craniotomy was performed with opening of the foramen magnum. The tumor was removed through the foramen of Magendie. In our single case of the unusually large third ventricular meningioma with filling of both lateral ventricles the tumor was subtotally removed via a transcallosal approach. In 15 patients total removal of the tumor was achieved. All lateral ventricular meningiomas showed an attachment to the choroid plexus. Because of the enormous size of the third ventricular tumor, the site of origin could no longer be identified intraoperatively. Partial calcification was intraoperatively detected in six tumors. An intraventricular drain was left in six patients after removal of lateral ventricular meningiomas for 5-7 days. No operative mortality was recorded. HISTOLOGIC EVALUATION Histologic examinations revealed five meningiomas to be of the fibromatous type, five of the meningotheliomatous type, two of mixed type and one each of angiomatous, transitional, psammomatous, and atypical type (Table 5). In two cases of fourth ven-

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Histological Meningiomas

Features

of

Intraventricular

TYPE

NO.

Fibromatous °1 Meningotheliomatous °1 Mixed type °1 Angiomatous °1 Transitional °1 Psammomatous °1 Atypical °2

5 5 2 1 1 1 1

tricular meningiomas, the histologic types were mixed and atypical. In one of these cases, a recurrent meningioma was discovered in the cerebellopontine angle later, which was resected several times and also revealed an atypical meningioma on histologic examination. In eight cases progesterone and estrogen receptors were immunohistochemically investigated, but all tumors were receptor negative. In six cases the Mib-1 LI was determined with a mean proliferation rate of 4.8% (ranging from 1 to 10%). OUTCOME/RESULTS The initial postoperative course was uneventful in most cases. There were no instances of aseptic meningitis or delayed hydrocephalus during hospital stay. In one case an intracerebral hemorrhage occurred a week after removal of a lateral ventricular meningioma via a parieto-occipital approach requiring surgical evacuation. She recovered quickly from second surgery. There was no perioperative mortality. Headache resolved in all eight patients mostly immediately after surgery. Cognitive improvement was seen in four of 13 cases of lateral ventricular meningioma but remained the same in three of 13 patients. Among seven of 13 patients with hemianopia, five patients showed improvement and two patients remained the same. In two cases new hemianopia occurred postoperatively and remained unchanged during the long-term follow-up. Motor and gait disturbance resolved in all six patients. Of the five patients presenting with vertigo, four had complete resolution after resection. Dysphasia also resolved in all three patients. Ataxia showed improvement in three of four patients. One patient had a seizure disorder 6 months after surgery of a lateral ventricular meningioma, which was controlled by proper anticonvulsive medication. Most of the patients did not have any postoperative complications related to disturbed CSF circulation except for the patient with the large third ventricular meningioma.

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(Figure 1). Subsequently, she was admitted for surgical resection of the tumor. On neurologic examination, a homonymous hemianopia of the contralateral side was additionally diagnosed. She did not have any other neurologic deficits. A carotid and vertebral angiography was performed showing a vascular supply of the tumor from both anterior and posterior choroidal arteries (Figure 2 and 3). A left parieto-occipital craniotomy was performed. Marked vascularization of the tumor was observed. After piecemeal resection of the tumor using microsurgical techniques and ultrasonic aspirator, the feeding vessels and the choroid plexus were coagulated. Total removal of the tumor was achieved without any difficulties. Postoperatively, the homonymous hemianopia showed some improvement with a residual right upper quadrantanopia. The postoperative MRI 1 year later showed no recurrent tumor (Figure 4). Imaging studies of a 42-year-old female with a left lateral ventricular meningioma presenting with headache and nausea. T1 weighted axial MR scan with gadolinium (Gd).

1

Illustrative Cases PATIENT 1 A 42-year-old female patient presented with a 3-month history of intermittent headaches and nausea. She underwent magnetic resonance imaging, which showed a large tumor in the left trigonal region with maximal diameter of 6.1 ⫻ 4.9 ⫻ 4.5 cm

PATIENT 2 A 25-year-old male patient presented to our department with a long standing history of medical and surgical treatment for a third ventricular tumor, which was diagnosed at the age of 7 years, as he developed symptoms and signs of increased intracranial pressure because of obstructive hydrocephalus. A ventriculo-atrial shunt was inserted initially, but multiple shunt revisions and additional insertion of ventriculo-peritoneal shunts followed in outside hospitals because of recurrent hydrocephalus, and the tumor was considered to be inoperable. After the last operation with insertion of a

Carotid angiogram, lateral views. A, arterial phase and B, venous phase. The anterior choroidal artery (arrowheads) is very thin in the initial intraventricular segment, and becomes tortuous and convoluted around the tumor. In the venous phase, uniform tumor blush is clearly seen.

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Vertebral angiography, lateral views: A, arterial phase and B, venous phase. Typical inverted curvature of the lateral posterior choroidal artery, which surrounds the anterior aspect of the tumor with an anterior convexity. Uniform tumor blush is shown in the venous phase.

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ventriculo-peritoneal shunt to both occipital horns, the symptoms improved temporarily but progressive gait ataxia, motor disturbance and mental disturbance led to the initial consultation in our outpatient clinic. On neurologic examination the patient showed generalized slowing of movements

4

Postoperative T1 weighted axial MRI with no residual tumor.

and speech. He was adynamic. He had a bitemporal hemianopia and papilledema. A right sided hemiparesis and dysdiadochokinesis with gait ataxia was documented. MRI showed a large lobular midline tumor with inhomogeneous contrast enhancement but smooth margins with an extension of 7 ⫻ 7 ⫻ 6.5 cm from the level of the midbrain to the corpus callosum (Figure 5). On carotid angiography both anterior cerebral arteries were supplied by the left internal carotid artery and showed a marked shift to the right and antero-rostral direction (Figure 6). Via a transcallosal approach, the tumor was removed step by step using microsurgical technique and the ultrasonic aspirator. As it was anticipated by the neuroradiological studies, the tumor proved to be heterogenous with partially hard and soft consistency as well as partial calcification. Because of strong adhesion to the A2-segment of the anterior cerebral arteries, a residual tumor of 1 cm diameter had to be left to avoid any damage to the vessels. Postoperatively the patient recovered soon with improvement of hemiparesis and visual disturbance including papilledema. Cerebellar signs showed initial improvement except for symptoms of increased intracranial pressure that occurred intermittently during rehabilitation and resolved spontaneously. Periods of hypothermia and diabetes insipidus also occurred indicating hypothalamic and pituitary disturbance. The postoperative MRI (Figure 7) showed resection of most of the tumor with only a small residual part at the anterior cerebral arteries. Serial postoperative CT scans did not show any increase of the size of the ventricles, and

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Third ventricular meningioma in a 25-year-old male. A: Preoperative T1 weighted axial MRI scan with gadolinium (Gd). B: T1 weighted sagittal MRI scan.

therefore no additional shunting procedure was performed. The general medical condition of the patient worsened and he died because of pneumonia 1 year after surgery.

PATIENT 3 A 40-year-old male patient presented with a 2month history of intermittent headache and vertigo. On admission, the patient did not have any

Carotid angiography, arterial phase with anteroposterior (A) and lateral (B) views. Both anterior cerebral arteries are supplied by the left internal carotid artery and show a marked shift to the right and antero-rostral direction. There was no tumor blush seen in the venous phase.

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amination revealed a meningioma of a mixed type. The patient did not have any neurologic deficits at the time of discharge and on long-term follow up. The postoperative MRI scan confirmed total removal of the tumor (Figure 9).

Discussion

7

Postoperative axial MRI scan with gadolinium (Gd) with nearly total removal of the tumor.

neurologic deficits particularly symptoms and signs of increased intracranial pressure or of a cerebellar origin. MR imaging showed a tumor in the fourth ventricle with homogenous contrast enhancement and smooth margins measuring a diameter of 3 cm (Figure 8). A median suboccipital craniectomy with resection of the tumor in toto via the foramen of Magendie was performed using microsurgical techniques and an ultrasonic aspirator. Histologic ex-

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GENERAL CLINICOPATHOLOGICAL CONSIDERATIONS The first description of an intraventricular meningioma was given by Shaw in 1854 who described an encapsulated fibrous tumor occurring in the right trigone [74]. MacDowell performed a documented left trigonal tumor operation in 1881 [58]. Cushing and Eisenhardt reported a case of a third ventricular meningioma and commented on a case from Earnest Sachs who reported a “plexus type” meningioma of the fourth ventricle [21]. In 1965 Delandsheer summarized the literature concerning lateral ventricular meningiomas and found 175 cases in total [24]. Until 1986 only 400 cases of intraventricular meningiomas could be identified in the world literature [19]. A total of 532 intraventricular meningiomas have been reported so far, including 132 additional cases since 1986 [3,5,6 –17,19 –20,22,25–27,30,32– 33,35–39,41,43– 47,49,52–54,56 –57,60 – 66,68 –70,72– 73,75–77,79,81– 83,85– 86]. Among them 414 occurred in the lateral ventricles (77.8%), 83 in the

Fourth ventricular tumor in a 40-year-old patient presenting with headache and vertigo. A: T1 weighted axial MRI with gadolinium (Gd). B: T1 weighted sagittal MRI with Gd.

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Postoperative axial (A) and sagittal (B) MRI scan with Gd. There is no residual tumor.

third ventricle (15.6%), and 35 in the fourth ventricle (6.6%). Concerning the age and gender of patients with meningiomas in general, female preponderance is well documented. In intraventricular meningiomas the representation by females varies from 41% to as high as 82% [19]. In our small series no sex preference was observed with eight females and eight males. The mean age reported for lateral ventricular meningiomas varied from 20 to 50 years. Mean ages concerning third and fourth ventricular tumors are 28.7 years and 35.7 years, respectively. In our series the mean age of lateral ventricular meningiomas was 50.8 years. Our single patient with third ventricular meningioma was 25 years old at the time of surgery. The mean age of the patient with fourth ventricular meningioma was 34 years. Most of the clinical symptoms, which are produced by intraventricular meningiomas regardless of their location, are related to increased intracranial pressure, but symptoms can also be caused by direct pressure on the surrounding brain structures. The tumors often grow slowly to a substantial size before they become symptomatic, unless the lesion is located in a region where it interferes with CSF circulation early on. As mentioned previously by Delandsheer in his review of 175 cases from the literature [24], one can

summarize that patients with lateral ventricular meningiomas often present with a clinical syndrome suggesting both a posterior cranial fossa lesion and a cerebral hemisphere lesion with intermittent and paroxysmal nature of some symptoms. NEURORADIOLOGICAL ASPECTS The neuroradiological diagnosis of intraventricular meningiomas was based on air and iodized contrast ventriculography and pneumoencephalography up to 1950. Carotid angiography and vertebral angiography then became the investigations of choice in the diagnosis of this type of tumor. Characteristic carotid angiographic findings have been repeatedly mentioned in the literature [1,40,82]. Vertebral angiography was particularly useful when the carotid angiographic images were similar to those seen in any deep parietal mass, especially when there was no blood supply to the tumor through the anterior choroidal artery [38,44,53]. Unenhanced and enhanced CT and MRI now permit the safest and certainly the most accurate modality for diagnosing these tumors. Conforming to the literature, all meningiomas showed increased density on CT scan; most of them showed a smooth margin and the tumors were well circumscribed. Contrast enhancement was present in all tumors with homogenous enhancement in 87.5%. Hydrocephalus produced by lateral intraventricular me-

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ningiomas is usually localized to the ipsilateral trigone and temporal horn [51]. In all lateral trigonal ventricular meningiomas in our series, the tumor caused local dilatation of the posterior and temporal horn of the affected side. On MRI, meningiomas usually are hypo- to isointense on T1-weighted images and iso- to hyperintense on T2-weighted images relative to cortex [59,71]. It has also been reported that the T2 signal intensity of meningioma may correlate with its histologic subtype. In a study of 40 biopsy-proven meningiomas a 75% correlation between MR appearance and tumor subtype was demonstrated [29]. The MR characteristics of our series conform with the above mentioned signal characteristic with 69% of the tumors being isointense to cortex on T1 weighted images and 31% hypointense. On T2 images 62% of the tumors were hyperintense and 38% isointense to cortex. NEUROSURGICAL APPROACHES In rare cases meningiomas develop in the frontal horn or close to the foramen of Monro. These tumors can be removed via a transfrontal approach. Various surgical approaches to lateral ventricular meningiomas in their much more common trigonal location have been advocated in the past. Cushing proposed a temporoparietal approach [21]. A transfrontal approach was preferred by Busch [4]. Olivecrona suggested a posterior middle temporal gyrus approach [67], recommended previously by De La Torre [23] and also favored by Criscuolo and Symon in 1986 [19]. In 1960 Cramer mentioned the merits of a posterior parieto-occipital incision [18], and Fornari et al systematically used this technique in their 1981 series [31]. An approach through the posterior corpus callosum and splenium was suggested by Kempe and Blaylock [50]. Others recommended a modification of the transcallosal approach [34,48,80]. A parieto-occipital interhemispheric parasplenial approach with incision in the precuneal area was performed by Yasargil [84] and others [2,42] for surgical removal of splenial and para-atrial tumors or arterio-venous malformations. The posterior middle frontal and posterior middle temporal approaches were suggested by several authors because of the advantage for an initial access to the anterior choroidal artery [19,23,24]. Nevertheless, the size of the tumor often obscures early identification of the anterior choroidal artery. Early access can only be reached if the artery is not displaced medially by the tumor, as it was angiographically proven in half of the cases in one series [31]. It is stated that postoperative visual field def-

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icits are minimized as the incision parallels the visual projection fibers [19]. But permanent motor and language deficits remain a problem with tumors in the dominant hemisphere. A posterior inferior temporal gyrus incision offers adequate vascular control and tumor access but is likely to damage Meyer’s loop resulting at least in a quadrantanopia. The posterior transcallosal approach was suggested by Kempe and Blaylock to remove tumors in the ventricular trigone of the dominant hemisphere [50]. They reported three cases of meningiomas operated on by this route without any postoperative complications. Others also favored this approach with slight modifications [34,48,80]. This approach is useful to attack tumors occupying the middle body of both lateral ventricles and tumors with bilateral ventricular extension. However, Levin and Rose reported a disconnection syndrome in their case operated on by this approach. An occipital corticotomy or lobectomy offer good trigonal exposure but poor vascular access and a definite homonymous hemianopia [4,67]. In our series a parietooccipital approach in 10 of 11 trigonal meningiomas was applied with no technical difficulties. This approach has been criticized by others [24] because it does not allow prior access to the supplying vessels and because of the risk of damaging the optic radiation, although preliminary occlusion of all the feeding vessels of such tumors cannot be achieved in other approaches either. With temporal approaches it is only possible to reach the intraventricular segment of the anterior choroidal artery, provided that the artery is not obscured by the tumor. With the posterior transcallosal approach, it is possible to have initial control to the posterior choroidal arteries only. In our experience, via the parieto-occipital route, the choroidal vessels can be controlled after debulking the tumor by piecemeal removal, usually lying underneath. Regarding the risk of damage to the optic radiation, the parieto-occipital approach does not itself cause visual damage. The optic radiation runs inferolaterally to the ventricles as shown by anatomic studies [28], and the ventricular trigone can be reached through a parietooccipital route without interrupting the optic radiation. In our series among seven patients presenting with hemianopia, five showed improvement, and in two cases the hemianopia remained unchanged. In two cases new hemianopia occurred postoperatively and remained the same in the longterm follow-up. In one case this was probably because of a postoperative cortical hemorrhage, which required a second surgery.

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The operative mortality reported in the majority of the series ranged from 0 to 42% [31]. In one series it was shown that in four patients en bloc tumor removal led to a mortality of 75% whereas none of the patients died after piecemeal removal. In our series operative mortality was 0%. Postoperative epileptic seizures were reported in 29% of patients operated on via a parieto-occipital route in one series [31]. In our series one patient developed postoperative seizure that was controlled by appropriate antiepileptic medication.

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6.

7.

8.

9. 10.

Conclusion Although intraventricular meningiomas are quite rare, they represent an important differential diagnosis of intraventricular neoplasms. CT or MRI imagings enable a correct diagnosis of meningiomas with intraventricular location in most of the cases. The tumors often grow slowly to a substantial size before they become symptomatic. Because of the intermittent and vague symptoms, the neuroradiological diagnosis can be delayed even in the modern era, as witnessed in our series. Compared to previous series, where the interval between the first symptom and diagnosis ranged up to 20 years [31], the advent of modern imaging studies allow for an earlier and more precise diagnosis. The operating microscope, microsurgical technique and the use of the ultrasonic aspirator allow a piecemeal and almost total removal of such tumors. Especially for lateral intraventricular meningiomas with trigonal location, several surgical approaches have been proposed in the past. The parieto-occipital route for resection of these tumors is a safe surgical approach, which is not necessarily associated with postoperative visual deficits. Piecemeal reduction of the tumor volume with ultrasonic aspirator can be safely and easily performed. Furthermore, it is not necessary to have initial access to the feeding vessels.

11. 12.

13. 14.

15. 16.

17.

18. 19.

20.

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COMMENTARY

Dr Nakamura et al report 16 cases with primary intraventricular meningiomas. Primary intraventricular meningiomas account for 2% of all intracranial meningiomas and usually arise in the trigonal region of a lateral ventricle than in the body of the ventricle. Meningiomas arising within the third and fourth ventricle are extremely rare; only a few cases have been reported. In Dr Nakamura’s series, there were 13 cases (81.3%) with the tumors located in the lateral ventricles. Primary intraventricular meningiomas are quite rare. Other tumors in the ventricle include choroid plexus papilloma, epidermoids, subependymomas, and exophytic components of gliomas. With the modern neuroradiologic technique, the differential diagnosis of intraventricular neoplasms is not difficult. The CT and MRI appearance is similar to the MRI appearance of maningiomas found elsewhere, i.e., on CT scans and T1-weighted MRI the tumors are usually isointense with brain and exhibit bright homogeneous enhancement after gadoliniuam administration. Dr Nakamura et al have conscientiously reviewed the primary intraventricular meningiomas including clinical features, diagnostic investigation, surgical approaches, and the results. This paper gives a summarized look on intraventricular meningiomas. Chung-cheng Wang, M.D. Beijing Neurosurgery Institute Beijing, P.R. China The authors described well and precisely the clinical and pathological data and the therapeutic outcome of their own 16 intraventricular meningiomas. Meningiomas in the ventricular system are not so common, but 164 cases (1.7%) were reported in total 10,089 cases of meningiomas by Japanese Brain Tumor Registry in 2000 [1]. There were 148 cases in the lateral ventricles, nine cases in the third, and seven cases in the fourth ventricle. It seems to me that tumors reported in this article were very large. In 10 out of 16 tumors, the diameter of the tumor was more than 4.5 cm. When the size of the tumor is not so large (i.e., less than 3 cm), the