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Meningioma of the anterior third ventricle presenting with parkinsonism
88
Surg Neurol 1984 ;21:88-92
Meningioma of the Anterior Third Ventricle Presenting with Parkinsonism Susuma Wakai, M.D., Kimiaki Nakamura, Takashi Nishizawa, M.D.,
Seiji Yokoyama,
M.D., Koji Niizaki, M.D., Masakatsu Nagai, M.D., M.D., and Soichi Katayama, M.D.
Departments of Neurosurgery and Neurology, Dokkyo University School of Medicine, Tochigi, Japan
Wakai S, Nakamura K, Niizaki K, Nagai M, Nishizawa T, Yokoyama S, Katayama S. Meningioma of the anterior third ventricle presenting with parkinsonism. Surg Neurol 1984;21:88-92.
The authors report an unusual case of a meningioma in the anterior third ventricle, w h i c h presented with parkinsonism w i t h o u t any sign of increased intracranial pressure. The mechanism whereby parkinsonism developed in this particular case is briefly discussed.
KEY WORDS" Meningioma; Third ventricle; Parkinsonism; Choroid plexus
Intraventricular meningiomas are very rare, constituting only 1 . 3 - 2 . 2 % of all cases with this tumor [3,9,16,18]. Reviewing 50 reported intraventricular meningiomas, Abbott and Courville [ 1] found only two cases that originated in the third ventricle. Markwalder et al [10] collected 33 such cases from the literature, including their own case in 1979. Only 11 occupied the anterior part of the third ventricle and originated from the choroid plexus. All showed symptoms of increased intracranial pressure. H e r e i n we report an unusual case of meningioma originating at this site, which presented with parkinsonian syndrome without any sign of increased intracranial pressure. The mechanism whereby parkinsonism developed in this particular case is briefly discussed.
Case Report
A 58-year-old woman was in good health until 6 years before admission, when she began to have a disturbance of gait with festination. On a morning 5 years before admission, she unexpectedly lost consciousness but reAddress reprint requests to: Susumu Wakai, M.D., Department of Neurosurgery, Dokkyo University School of Medicine, Mibu, Tochigi, 321-02, Japan.
© 1984 by Elsevier Science Publishing Co., Inc.
gained it in a few minutes. In May 1981, she experienced urinary incontinence and a high fever of 2 days' duration. After that episode, she became bradykinetic. On the morning of December 8, 1982, she found herself unable to stand; she was admitted to our neurological service on the same day. Neurological examination at admission revealed a mask face, positive Myerson's sign, and lead-pipe rigidity in all extremities. The patient was bradykinetic and unable to stand (astasia-abasia). Loss of sweating on the body and increased salivation were observed. Neither papilledema nor atrophy was found in the optic fundi. Results of neurological examination were otherwise normal. Two days after admission, the patient showed marked improvement of these symptoms despite no particular therapy. Muscular rigidity was noted only in the upper limbs. She became less bradykinetic and was able to walk. Roentgenograms of the skull were normal. Spinal puncture disclosed an initial pressure of 150 mm H e O with normal appearing cerebrospinal fluid. Computed tomography (CT) scanning on D e c e m b e r 15, 1982 demonstrated a round high-density mass with spotty calcification in the anterior part of the third ventricle, which occluded the foramen of Monro bilaterally. Both lateral ventricles were moderately dilated, with periventricular hypodensity around the frontal horns (Figure 1). The patient was transferred to the neurosurgical service on December 16, 1982. At that time, she showed mild muscular rigidity in the upper limbs, bradykinesia, and disturbance of gait with pulsion phenomenon. T h e r e was no dementia and no urinary incontinence. Computed tomography scanning after infusion of contrast medium disclosed homogeneous enhancement of the mass (Figure 1). Vertebral angiography demonstrated a slightly hypertrophied distal posterior medial choroidal artery and a tumor blush in the region of the foramen of Monro (Figure 2). A right frontal craniotomy was performed on December 24, 1982. The tumor was approached through 0090-3019/84/$3.00
Meningioma of the Third Ventricle
Figure 1. Computed tomography scanning. (A) Without contrast medium enhancement. A round high-density mass with spotted calcification is seen in the anterior part of the third ventricle occluding the foramen of Monro. Both lateral ventricles are dilated. Periventricular hypodensity around the frontal horn is also observed. (B and C) After infusion of contrast material, the mass is homogeneously enhanced. It seems to be indented into both medial thalami (C). (D) Coronal slice after contrast medium enhancement. Occlusion of the foramen of Monro seems complete on the right side but incomplete on the left (arrow). Arrowheads indicate anterior caudate vein.
Surg Neurol 1984;21:88-92
89
the frontal horn of the right lateral ventricle. It occluded the foramen of Monro. The septum pellucidum and the fornix were markedly stretched upward. Anterior caudate and terminal veins were noticeably compressed and stretched by the t u m o r on both sides. After division of the right fornix, the t u m o r was dissected from the surrounding structures under the surgical microscope (Figure 3A). The mass was partially indented into both thalami, where the ependymal lining seemed to be destroyed. The tumor was attached to the stalk of the choroid plexus and was fed by the left posterior medial choroidal artery, which was divided after electrocoagulation. T h e excised
90
Surg Neurol 1984;21:88-92
Figure 2. Vertebral angiography (prolonged injection of 15 mL of 60% [Conray] meglumine iothalamate). A round homogeneous tumor stain is seen in the anterior part of the third ventricle. The posterior medial choroidal artery is slightly hypertrophied (arrowhead). Arrow indicates choroidal blush.
Wakai et al
mass measured 2.5 x 2.5 x 2.5 cm (Figure 3B). The pathologic report described it as a meningothelial meningioma with a n u m b e r of p s a m m o m a bodies (Figure 4). After operation, the patient developed a hemiparesis on the left side with some m e m o r y disturbance. H o w ever, muscular rigidity of the limbs and Myerson's sign disappeared. In the early morning of the second day after the operation, the patient was found to be unresponsive. A CT scan showed hemorrhage around the foramen o f M o n r o with marked dilatation of both lateral ventricles. Emergency ventricular drainage was instituted on D e c e m b e r 26, 1982. The patient regained consciousness but had a high degree o f disorientation and memory disturbance. Urinary incontinence ensued. Three weeks later a ventriculoperitoneal shunt was installed. The patient is now able to sit in a wheelchair. She has no muscular rigidity or Myerson's sign, but some m e m ory disturbance and bradykinesia persist. Sweating and salivation are both normal.
Figure 3. Photographs made during operation. (A) After exposure of the frontal horn of the right lateral ventricle. The septum pellucidum (large asterisk) and the septal vein (arrows) are markedly stretched upward. The foramen of Monro (arrowheads) is enlarged and completely occluded by the tumor (small asterisk). The choroid plexus is attached to the tumor. (B) Removed specimen.
~ii!i% ]i~
I
4 lilt!lilt B
ill/
Meningioma of the Third Ventricle
Figure 4. Photomicrographs of the tumor. (A) Typical picture of a meningothelial meningioma. A psammoma body is also seen. (H & E x 170.) (B) The part of the tumor attached to the choroidal stalk. A large artery (asterisk) and choroid plexus epithelium (arrow) are seen. (Azan, × 85.)
Discussion It has been established that parkinsonism is occasionally associated with brain tumor [2,5,7,12-15,17,22]. The present case had all of the symptoms except tremor, indicating parkinsonism before the operation, without any sign o f increased intracranial pressure. According to the review by Kaijima et al [7] of 58 cases of parkinsonism associated with intracranial space-occupying lesions, there were only 8 cases that directly involved the thalamus, the basal ganglia, or the midbrain. All were infiltrating intraaxial gliomas [2,5,12,15,17]. Recently, Garcial de Ydbenes et al [4] reported a case of longstanding parkinsonism secondary to a large craniopharyngioma that compressed the midbrain. They found atrophy of the substantia nigra as well as moderate loss of large cells with a decrease in levels o f norepinephrine
Surg Neurol 1984;21:88-92
91
and dopamine and its metabolites in both caudate and putamen nuclei. In our case, neither morphologic nor biochemical studies were performed. During the operation, however, the meningioma was found to have indented both medial thalami, and the anterior caudate as well as the terminal vein was compressed by the tumor. After removal of the tumor, muscular rigidity and Myerson's sign disappeared. Thus, it is reasonable to suppose that the mechanism whereby parkinsonism, at least the muscular rigidity and hyperactivity of the orbicularis oculi reflex that developed, may be ascribed to the effect of compression to the medial thalamus as well as to the deep veins draining the basal ganglia, resulting in dysfunction of the nigro-striate-pallidal system. The bradykinesia is still present, but its cause may be ascribed to the damage resulting from the postoperative hemorrhage. Parkinsonism caused by normal-pressure hydrocephalus is usually accompanied by dementia [6,11,19-21,23], which is one of a triad of symptoms in this condition. Our patient had no dementia before the operation. Fluc-
92
Surg N e u r o l 1984;21:88-92
tuation o f the symptoms may be related to the circulatory changes in the thalamus and the basal ganglia secondary to intermittent occlusion o f the foramen o f Munro by the tumor. Meningiomas originating from the stalk o f the charoid plexus o f the third ventricle are exceedingly rare [8,10]. The origin o f the tumor in the present case was verified to be in this structure at the operation as well as histologically (Figure 4B). Tumors arising in the anterior third ventricle near the foramen o f Monro that should be considered in the differential diagnosis o f lesions in this location are 1) choroid plexus papilloma; 2) ependymoma; 3) subependymal astrocytoma; 4) meningioma; and 5) colloid cyst, which is extremely rare in Japan [24]. Choroid plexus papilloma, e p e n d y m o m a , and subependymal astrocytoma tend to be lobulated and except for the latter, are much more c o m m o n in childhood. Colloid cyst does not contain calcium. Thus, w h e n a circumscribed round mass with calcification is seen at this particular site in the CT scan o f an adult, meningioma may be most likely, although its incidence is extremely rare.
References 1. Abbott KH, Courville CB. Intraventricular meningioma. Review of the literature and report of two cases. Bull Los Angeles Neurol Soc 1942;7:12-28. 2. Coers C, Kleyntjens F, Brihaye J. Syndrome parkinsonien d'origine tumorale. Acta Neurol Belg 1952;52:737-65. 3. Cushing H, Eisenhardt L. Meningiomas: Their classification, regional behaviour, life history, and surgical results. Springfield, Ill: Charles C Thomas, 1938. 4. Garcia de Ydbenes J, Gervas JJ, Iglesias J, Mena MA, Rio del RM, Somoza E. Biochemical findings in a case of parkinsonism secondary to brain tumor. Ann Neurol 1982;11:313-6. 5. Garcin R, Klein MR, Kipfer M, Le Bozec. Hemisyndrome parkinsonien gauche par tumeur fronto-calleuse droite disparaissant compl~tement apr~s ablation de celle-ci. Rev Neurol (Paris) 1943;3:8(/-3. 6. Jacobs L, Conti D, Kinkel WR, Manning EJ. "Normal-pressure" hydrocephalus. Relationship of clinical and radiographic findings to improve fi~llowing shunt surgery. JAMA 1976;235:510-2.
Wakai et al
7. Kaijima M, Furui M. Shima F, Kitamura K, IkedaJ, Numaguchi Y, Komaki S. Epidermoid in the middle cranial fossa presenting with hemiparkinsonism. A case report. No Shinkei Geka 1978;6:1103-8. 8. Lee Y-Y, Lin S-R, Horner FA. Third ventricle meningioma mimicking a colloid cyst in a child. AmJ Roentgenol 1979;132:669-71. 9. MacCarty CS, Taylor WF. Intracranial meningiomas: Experiences at the Mayo Clinic. Neurol Med Chir (Tokyo) 1979;19:569-74. 10. Markwa|der TM, Seiler RW, Markwalder RV, Huber P, Markwalder HM. Meningioma of the anterior part of the third ventricle in a child. Surg Neurol 1979;12:29-32. 11. Mazza S, Laudisio A, Bergonzi P. Occult normal pressure hydrocephalus with parkinsonian symptomatology. Eur Neurol 1976;14:39-42. 12. Mettler FA, Davidoff LM, Crimes R. Static tremor with hemiplegia. Arch Neurol Psychiatry 1947;57:423-9. 13. Nicholson AN, Turner EA. Parkinsonism produced by parasagittal meningiomas. J Neurosurg 1964;21:104-13. 14. Oliver L. Parkinsonism due to midbrain compression. Lancet 1959;2:817-9. 15. Parker HL. Tumor of the brain simulating epidemic encephalitis and involving the third ventricle, the fourth ventricle, and the basal ganglia: Report of three cases. J Nerv Dis 1923;581-15. 16. Sano K, Wakai S, Ochiai C, Takakura K. Characteristics of intracranial meningiomas in child hood. Child's Brain 1981 ;8:98-106. 17. Sciarra D, Sprofkin BE. Symptoms and signs referable to the basal ganglia in brain tumor. Arch Neurol Psychiatry 1953;69:450-61. 18. Simpson D. The recurrence ofintracranial meningioma after surgical treatment. J Neurol Neurosurg Psychiatry 1957;20:22-39. 19. Spagna VA, Maeder MC, Johnson JC, Mazzaferri EL. Normal pressure hydrocephalus, parkinsonism, and primary empty sella-Coincidence of cause-effect? Neurology (Minneap) 1978;28:1191-3. 20. Sypert GW, Leffman H, Ojemann GA. Occult normal pressure hydrocephalus manifested by parkinsonism-dementia complex. Neurology (Mineap) 1973;23:234-8. 21. Tohgi H, Tomonaga M, Inoue K. Parkinsonism and dementia with acoustic neurinoma. Report of three cases. J Neurol 1978;217:271-9. 22. de Vera Reyes JA. Parkinsonian-like syndrome caused by posterior fossa tumor. Case report. J Neurosurg 1970;33:599-601. 23. Wakai S, Aoki N, Kubota M, Mizutani H. A case of lateral ventricular tumor (subependymal glomerate astrocytoma) with preceding parkinsonian symptoms due to normal pressure hydrocephalus. No Shinkei Geka 1976;4:1199-1203. 24. Wakai S, Kubota M, Aoki N, Nakahara A, Mizutani H, Ogawa H. A case of colloid cyst of the third ventricle. No Shinkei Geka 1978;6:499-503.
Surg Neurol 1984 ;21:88-92
Meningioma of the Anterior Third Ventricle Presenting with Parkinsonism Susuma Wakai, M.D., Kimiaki Nakamura, Takashi Nishizawa, M.D.,
Seiji Yokoyama,
M.D., Koji Niizaki, M.D., Masakatsu Nagai, M.D., M.D., and Soichi Katayama, M.D.
Departments of Neurosurgery and Neurology, Dokkyo University School of Medicine, Tochigi, Japan
Wakai S, Nakamura K, Niizaki K, Nagai M, Nishizawa T, Yokoyama S, Katayama S. Meningioma of the anterior third ventricle presenting with parkinsonism. Surg Neurol 1984;21:88-92.
The authors report an unusual case of a meningioma in the anterior third ventricle, w h i c h presented with parkinsonism w i t h o u t any sign of increased intracranial pressure. The mechanism whereby parkinsonism developed in this particular case is briefly discussed.
KEY WORDS" Meningioma; Third ventricle; Parkinsonism; Choroid plexus
Intraventricular meningiomas are very rare, constituting only 1 . 3 - 2 . 2 % of all cases with this tumor [3,9,16,18]. Reviewing 50 reported intraventricular meningiomas, Abbott and Courville [ 1] found only two cases that originated in the third ventricle. Markwalder et al [10] collected 33 such cases from the literature, including their own case in 1979. Only 11 occupied the anterior part of the third ventricle and originated from the choroid plexus. All showed symptoms of increased intracranial pressure. H e r e i n we report an unusual case of meningioma originating at this site, which presented with parkinsonian syndrome without any sign of increased intracranial pressure. The mechanism whereby parkinsonism developed in this particular case is briefly discussed.
Case Report
A 58-year-old woman was in good health until 6 years before admission, when she began to have a disturbance of gait with festination. On a morning 5 years before admission, she unexpectedly lost consciousness but reAddress reprint requests to: Susumu Wakai, M.D., Department of Neurosurgery, Dokkyo University School of Medicine, Mibu, Tochigi, 321-02, Japan.
© 1984 by Elsevier Science Publishing Co., Inc.
gained it in a few minutes. In May 1981, she experienced urinary incontinence and a high fever of 2 days' duration. After that episode, she became bradykinetic. On the morning of December 8, 1982, she found herself unable to stand; she was admitted to our neurological service on the same day. Neurological examination at admission revealed a mask face, positive Myerson's sign, and lead-pipe rigidity in all extremities. The patient was bradykinetic and unable to stand (astasia-abasia). Loss of sweating on the body and increased salivation were observed. Neither papilledema nor atrophy was found in the optic fundi. Results of neurological examination were otherwise normal. Two days after admission, the patient showed marked improvement of these symptoms despite no particular therapy. Muscular rigidity was noted only in the upper limbs. She became less bradykinetic and was able to walk. Roentgenograms of the skull were normal. Spinal puncture disclosed an initial pressure of 150 mm H e O with normal appearing cerebrospinal fluid. Computed tomography (CT) scanning on D e c e m b e r 15, 1982 demonstrated a round high-density mass with spotty calcification in the anterior part of the third ventricle, which occluded the foramen of Monro bilaterally. Both lateral ventricles were moderately dilated, with periventricular hypodensity around the frontal horns (Figure 1). The patient was transferred to the neurosurgical service on December 16, 1982. At that time, she showed mild muscular rigidity in the upper limbs, bradykinesia, and disturbance of gait with pulsion phenomenon. T h e r e was no dementia and no urinary incontinence. Computed tomography scanning after infusion of contrast medium disclosed homogeneous enhancement of the mass (Figure 1). Vertebral angiography demonstrated a slightly hypertrophied distal posterior medial choroidal artery and a tumor blush in the region of the foramen of Monro (Figure 2). A right frontal craniotomy was performed on December 24, 1982. The tumor was approached through 0090-3019/84/$3.00
Meningioma of the Third Ventricle
Figure 1. Computed tomography scanning. (A) Without contrast medium enhancement. A round high-density mass with spotted calcification is seen in the anterior part of the third ventricle occluding the foramen of Monro. Both lateral ventricles are dilated. Periventricular hypodensity around the frontal horn is also observed. (B and C) After infusion of contrast material, the mass is homogeneously enhanced. It seems to be indented into both medial thalami (C). (D) Coronal slice after contrast medium enhancement. Occlusion of the foramen of Monro seems complete on the right side but incomplete on the left (arrow). Arrowheads indicate anterior caudate vein.
Surg Neurol 1984;21:88-92
89
the frontal horn of the right lateral ventricle. It occluded the foramen of Monro. The septum pellucidum and the fornix were markedly stretched upward. Anterior caudate and terminal veins were noticeably compressed and stretched by the t u m o r on both sides. After division of the right fornix, the t u m o r was dissected from the surrounding structures under the surgical microscope (Figure 3A). The mass was partially indented into both thalami, where the ependymal lining seemed to be destroyed. The tumor was attached to the stalk of the choroid plexus and was fed by the left posterior medial choroidal artery, which was divided after electrocoagulation. T h e excised
90
Surg Neurol 1984;21:88-92
Figure 2. Vertebral angiography (prolonged injection of 15 mL of 60% [Conray] meglumine iothalamate). A round homogeneous tumor stain is seen in the anterior part of the third ventricle. The posterior medial choroidal artery is slightly hypertrophied (arrowhead). Arrow indicates choroidal blush.
Wakai et al
mass measured 2.5 x 2.5 x 2.5 cm (Figure 3B). The pathologic report described it as a meningothelial meningioma with a n u m b e r of p s a m m o m a bodies (Figure 4). After operation, the patient developed a hemiparesis on the left side with some m e m o r y disturbance. H o w ever, muscular rigidity of the limbs and Myerson's sign disappeared. In the early morning of the second day after the operation, the patient was found to be unresponsive. A CT scan showed hemorrhage around the foramen o f M o n r o with marked dilatation of both lateral ventricles. Emergency ventricular drainage was instituted on D e c e m b e r 26, 1982. The patient regained consciousness but had a high degree o f disorientation and memory disturbance. Urinary incontinence ensued. Three weeks later a ventriculoperitoneal shunt was installed. The patient is now able to sit in a wheelchair. She has no muscular rigidity or Myerson's sign, but some m e m ory disturbance and bradykinesia persist. Sweating and salivation are both normal.
Figure 3. Photographs made during operation. (A) After exposure of the frontal horn of the right lateral ventricle. The septum pellucidum (large asterisk) and the septal vein (arrows) are markedly stretched upward. The foramen of Monro (arrowheads) is enlarged and completely occluded by the tumor (small asterisk). The choroid plexus is attached to the tumor. (B) Removed specimen.
~ii!i% ]i~
I
4 lilt!lilt B
ill/
Meningioma of the Third Ventricle
Figure 4. Photomicrographs of the tumor. (A) Typical picture of a meningothelial meningioma. A psammoma body is also seen. (H & E x 170.) (B) The part of the tumor attached to the choroidal stalk. A large artery (asterisk) and choroid plexus epithelium (arrow) are seen. (Azan, × 85.)
Discussion It has been established that parkinsonism is occasionally associated with brain tumor [2,5,7,12-15,17,22]. The present case had all of the symptoms except tremor, indicating parkinsonism before the operation, without any sign o f increased intracranial pressure. According to the review by Kaijima et al [7] of 58 cases of parkinsonism associated with intracranial space-occupying lesions, there were only 8 cases that directly involved the thalamus, the basal ganglia, or the midbrain. All were infiltrating intraaxial gliomas [2,5,12,15,17]. Recently, Garcial de Ydbenes et al [4] reported a case of longstanding parkinsonism secondary to a large craniopharyngioma that compressed the midbrain. They found atrophy of the substantia nigra as well as moderate loss of large cells with a decrease in levels o f norepinephrine
Surg Neurol 1984;21:88-92
91
and dopamine and its metabolites in both caudate and putamen nuclei. In our case, neither morphologic nor biochemical studies were performed. During the operation, however, the meningioma was found to have indented both medial thalami, and the anterior caudate as well as the terminal vein was compressed by the tumor. After removal of the tumor, muscular rigidity and Myerson's sign disappeared. Thus, it is reasonable to suppose that the mechanism whereby parkinsonism, at least the muscular rigidity and hyperactivity of the orbicularis oculi reflex that developed, may be ascribed to the effect of compression to the medial thalamus as well as to the deep veins draining the basal ganglia, resulting in dysfunction of the nigro-striate-pallidal system. The bradykinesia is still present, but its cause may be ascribed to the damage resulting from the postoperative hemorrhage. Parkinsonism caused by normal-pressure hydrocephalus is usually accompanied by dementia [6,11,19-21,23], which is one of a triad of symptoms in this condition. Our patient had no dementia before the operation. Fluc-
92
Surg N e u r o l 1984;21:88-92
tuation o f the symptoms may be related to the circulatory changes in the thalamus and the basal ganglia secondary to intermittent occlusion o f the foramen o f Munro by the tumor. Meningiomas originating from the stalk o f the charoid plexus o f the third ventricle are exceedingly rare [8,10]. The origin o f the tumor in the present case was verified to be in this structure at the operation as well as histologically (Figure 4B). Tumors arising in the anterior third ventricle near the foramen o f Monro that should be considered in the differential diagnosis o f lesions in this location are 1) choroid plexus papilloma; 2) ependymoma; 3) subependymal astrocytoma; 4) meningioma; and 5) colloid cyst, which is extremely rare in Japan [24]. Choroid plexus papilloma, e p e n d y m o m a , and subependymal astrocytoma tend to be lobulated and except for the latter, are much more c o m m o n in childhood. Colloid cyst does not contain calcium. Thus, w h e n a circumscribed round mass with calcification is seen at this particular site in the CT scan o f an adult, meningioma may be most likely, although its incidence is extremely rare.
References 1. Abbott KH, Courville CB. Intraventricular meningioma. Review of the literature and report of two cases. Bull Los Angeles Neurol Soc 1942;7:12-28. 2. Coers C, Kleyntjens F, Brihaye J. Syndrome parkinsonien d'origine tumorale. Acta Neurol Belg 1952;52:737-65. 3. Cushing H, Eisenhardt L. Meningiomas: Their classification, regional behaviour, life history, and surgical results. Springfield, Ill: Charles C Thomas, 1938. 4. Garcia de Ydbenes J, Gervas JJ, Iglesias J, Mena MA, Rio del RM, Somoza E. Biochemical findings in a case of parkinsonism secondary to brain tumor. Ann Neurol 1982;11:313-6. 5. Garcin R, Klein MR, Kipfer M, Le Bozec. Hemisyndrome parkinsonien gauche par tumeur fronto-calleuse droite disparaissant compl~tement apr~s ablation de celle-ci. Rev Neurol (Paris) 1943;3:8(/-3. 6. Jacobs L, Conti D, Kinkel WR, Manning EJ. "Normal-pressure" hydrocephalus. Relationship of clinical and radiographic findings to improve fi~llowing shunt surgery. JAMA 1976;235:510-2.
Wakai et al
7. Kaijima M, Furui M. Shima F, Kitamura K, IkedaJ, Numaguchi Y, Komaki S. Epidermoid in the middle cranial fossa presenting with hemiparkinsonism. A case report. No Shinkei Geka 1978;6:1103-8. 8. Lee Y-Y, Lin S-R, Horner FA. Third ventricle meningioma mimicking a colloid cyst in a child. AmJ Roentgenol 1979;132:669-71. 9. MacCarty CS, Taylor WF. Intracranial meningiomas: Experiences at the Mayo Clinic. Neurol Med Chir (Tokyo) 1979;19:569-74. 10. Markwa|der TM, Seiler RW, Markwalder RV, Huber P, Markwalder HM. Meningioma of the anterior part of the third ventricle in a child. Surg Neurol 1979;12:29-32. 11. Mazza S, Laudisio A, Bergonzi P. Occult normal pressure hydrocephalus with parkinsonian symptomatology. Eur Neurol 1976;14:39-42. 12. Mettler FA, Davidoff LM, Crimes R. Static tremor with hemiplegia. Arch Neurol Psychiatry 1947;57:423-9. 13. Nicholson AN, Turner EA. Parkinsonism produced by parasagittal meningiomas. J Neurosurg 1964;21:104-13. 14. Oliver L. Parkinsonism due to midbrain compression. Lancet 1959;2:817-9. 15. Parker HL. Tumor of the brain simulating epidemic encephalitis and involving the third ventricle, the fourth ventricle, and the basal ganglia: Report of three cases. J Nerv Dis 1923;581-15. 16. Sano K, Wakai S, Ochiai C, Takakura K. Characteristics of intracranial meningiomas in child hood. Child's Brain 1981 ;8:98-106. 17. Sciarra D, Sprofkin BE. Symptoms and signs referable to the basal ganglia in brain tumor. Arch Neurol Psychiatry 1953;69:450-61. 18. Simpson D. The recurrence ofintracranial meningioma after surgical treatment. J Neurol Neurosurg Psychiatry 1957;20:22-39. 19. Spagna VA, Maeder MC, Johnson JC, Mazzaferri EL. Normal pressure hydrocephalus, parkinsonism, and primary empty sella-Coincidence of cause-effect? Neurology (Minneap) 1978;28:1191-3. 20. Sypert GW, Leffman H, Ojemann GA. Occult normal pressure hydrocephalus manifested by parkinsonism-dementia complex. Neurology (Mineap) 1973;23:234-8. 21. Tohgi H, Tomonaga M, Inoue K. Parkinsonism and dementia with acoustic neurinoma. Report of three cases. J Neurol 1978;217:271-9. 22. de Vera Reyes JA. Parkinsonian-like syndrome caused by posterior fossa tumor. Case report. J Neurosurg 1970;33:599-601. 23. Wakai S, Aoki N, Kubota M, Mizutani H. A case of lateral ventricular tumor (subependymal glomerate astrocytoma) with preceding parkinsonian symptoms due to normal pressure hydrocephalus. No Shinkei Geka 1976;4:1199-1203. 24. Wakai S, Kubota M, Aoki N, Nakahara A, Mizutani H, Ogawa H. A case of colloid cyst of the third ventricle. No Shinkei Geka 1978;6:499-503.