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Neuropsychological findings in patients with intraventricular tumors
Surgical Neurology 64 (2005) 500 – 503 www.surgicalneurology-online.com
Neoplasm
Neuropsychological findings in patients with intraventricular tumors Ralf Buhla,T, Hongguang Huangb, Birgit Gottwalda, Zoran Mihajlovica, H. Maximilian Mehdorna a b
Department of Neurosurgery, University of Kiel, 24105 Kiel, Germany Department of Neurosurgery, University of Zhejiang, Hangzhou, China Received 4 October 2004; accepted 25 April 2005
Abstract
Background: Intraventricular tumors are quite rare and become symptomatic with hydrocephalusrelated signs such as headache, double vision, and seizures. Also, most of the patients show neuropsychological deficits, especially memory problems and lack of attention. Methods: We reviewed the charts and computed tomographic/magnetic resonance images of 15 patients with tumors of the lateral and third ventricle, who were also examined by a neuropsychologist pre- and postoperatively. Neuropsychological testing included tests of attention, memory, executive functions, and concentration. Results: Between 1995 and 2003, 7 patients with colloid cysts of the third ventricle (3 men, 4 women; mean age, 38 years), 5 patients with meningiomas of the lateral ventricle (2 men, 3 women; mean age, 51 years), and 3 patients with astrocytomas and ependymoma (2 men, 1 woman; mean age, 38 years) were treated. All patients with colloid cysts and meningiomas showed mental changes, especially attention and memory deficits. Symptoms improved markedly after surgical intervention. The 3 patients with astrocytoma and ependymoma showed normal results pre- and postoperatively. Conclusion: Neuropsychological testing is very useful in patients with intraventricular lesions and important for follow-up examinations. It should be included in every workup examination in this small patient group. D 2005 Elsevier Inc. All rights reserved.
Keywords:
Intraventricular tumors; Neuropsychological examination
1. Introduction Intraventricular tumors are quite rare and usually become symptomatic with hydrocephalus-related signs such as headache, double vision, and seizures. Also, most of the patients show neuropsychological deficits, especially memory problems and lack of attention. Neuropsychological examinations in patients with subarachnoid hemorrhage are performed regularly, and some papers have been published [5]. Few publications have dealt with patients with intraventricular tumors and most of them dealt with the surgical approach such as the transcallosal
Abbreviations: HAWIE-R, Hamburg-Wechsler Intelligence Test; WMS-R, Wechsler Ged7chtnistest; TMT, Trail-Making Test. T Corresponding author. Tel.: +49 0431 5974801. E-mail address: [email protected] (R. Buhl). 0090-3019/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2005.04.040
approach. But there is also some uncertainty whether neurobehavioral outcome relates more to initial tumor size and location or surgical factors [1]. Moreover, it is controversial whether associated ventricular dilatation or raised intracranial pressure contributes to longer-lasting cognitive changes independent of operative consequences [8]. 2. Methods We reviewed the charts and computed tomographic/ magnetic resonance images of 15 patients with tumors of the lateral and third ventricle, who were also examined by a neuropsychologist pre- and postoperatively. Neuropsychological testing included tests of attention, memory, executive functions, and concentration, namely, MehrfachWortwahl Test, HAWIE-R, WMS-R, Rey Osterrieth Figur
501
R. Buhl et al. / Surgical Neurology 64 (2005) 500 – 503
(preoperative)/Taylor Figur (postoperative), TMT, Testbatterie zur Aufmeksamkeitsprqfung, and Test zur Wortflqssigkeit. 3. Results Between 1995 and 2003, 7 patients with colloid cysts of the third ventricle (3 men, 4 women; mean age, 38 years), 5 patients with meningiomas of the lateral ventricle (2 men, 3 women; mean age, 51 years), and 3 patients with astrocytomas and ependymoma (2 men, 1 woman; mean age, 38 years) were treated. All patients with colloid cysts and meningiomas showed mental changes, especially attention and memory deficits. This was independent of tumor size or associated hydrocephalus. Symptoms improved markedly after surgical intervention. The 3 patients with astrocytoma and ependymoma showed normal results pre- and postoperatively. Two patients were operated on because of an astrocytoma (World Health Organization grade I) located in the left frontal horn of the lateral ventricle (Fig. 1). Both tumors were 1 cm in diameter and there was no associated hydrocephalus. They became symptomatic with headache. The patients were 43 and 56 years old. With navigation-guided endoscopy, both tumors could be removed completely. There were no neuropsychological deficits pre- and postoperatively. A 15-year-old girl complained of headache, dizziness, and visual deterioration for 1 month. The tumor in the right frontal horn of the lateral ventricle was 4 cm in diameter and there was only little hydrocephalus. The tumor was removed completely via a transcortical approach with neuronavigation. There were no neuropsychological deficits pre- and postoperatively.
Fig. 2.
3.1. Colloid cysts Seven patients with colloid cysts were operated via a right frontal transcortical transventricular approach with neuronavigation-guided endoscopy. Mean age was 38 years (range, 29-58 years). There were 3 male and 4 female patients. Symptoms were headache in 5 patients, double vision in 4 patients, and dizziness in 2 patients. Hydrocephalus was also associated in every patient. Memory and concentration deficits were found in all patients. These patients also showed deficits in attention and in their visualspatial performance. Postoperatively, in 5 patients, these deficits improved, whereas in 2 patients, these symptoms persisted and were better 3 months after surgery. 3.2. Meningioma Five patients were operated on because of a meningioma. There were 3 female and 2 male patients. Mean age was 51 years (range, 38-69 years). Three were located in the left trigonum, one in the right trigonum, and one in the right ventricle, near the cella media (Fig. 2). This patient also had hyperparathyroidism and he presented with loss of weight, hypercalcaemia, and a lack of performance. The tumor size was between 1.5 and 7 cm (mean, 4.2 cm). Symptoms were headache in 3 patients, dizziness and double vision in 2 patients, and hemiparesis and gait disturbances in
Fig. 1.
Fig. 3.
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R. Buhl et al. / Surgical Neurology 64 (2005) 500 – 503
Table 1 Neuropsychological findings pre- and postoperatively of representative tests HAWIE (digit span), WMS (logical memory), and TMT
Colloid cysts AS SG GR GP CG JP IK Meningioma RM RL PM SS ES
HAWIE
WMS
TMT (s)
Clinical Outcome
10/12 10/14 4/6 6/7 11/11 7/8 10/12
62/70 54/64 34/30 40/38 68/74 54/70 64/72
45/26 52/35 60/53 70/68 30/18 60/52 50/36
Better Better Worse Worse Better Better Better
10/12 11/11 3/3 11/11 11/11
68/73 52/61 23/20 50/57 68/75
64/59 67/49 68/81 58/50 69/33
Better Better Worse Better Better
Standardized data.
2 patients. Associated peritumoral edema was found in 3 patients and hydrocephalus was also found in 3 patients. All 5 meningiomas were removed with the help of neuronavigation (Fig. 3) via a transcortical approach. The cortex incision was between 2 and 3 cm. Histologic examination showed 2 meningotheliomatous, 1 transitional, 1 fibroblastic, and 1 microcystic meningioma. Postoperative results were good in 3 patients. One patient had a new hemiparesis postoperatively and one patient showed aphasia. A ventriculitis was a complication in one patient. Neuropsychological deficits were dependent on the site of the lesion. Meningiomas of the left side led to speech impairment, whereas the tumor on the right side led to visual-spatial deficits. Moreover, these patients showed deficits in attention and memory tests. The speed of the visual-motor examination became quicker postoperatively. Four of the patients had better results in the postoperative tests, whereas in one patient with a huge meningioma of the left trigonum, the deficits persisted and the aphasia worsened (Table 1). 4. Discussion There are only few publications dealing with neuropsychological examinations in patients with intraventricular tumors. It is still controversial and unclear whether neurobehavioral outcome relates more to initial tumor size and location or surgical factors [1]. Petrucci et al [8] raised the question whether the cognitive status after third ventricular operation was not the same as the preoperative status, which is a result of the tumor itself. Also, they mention that perhaps ventricular dilatation or raised intracranial pressure contributes to longer-lasting cognitive changes independent of operative consequences. Hutter et al [5] examined cognition and quality of life in patients after transcallosal microsurgery for midline tumors and found that the deficits
found could not be explained by surgical damage to the corpus callosum itself. Friedman et al [3] found that there were no differences in mean neuropsychological scores between patients with third ventricle tumors who underwent surgery and those who did not. There were no differences in mean performance on the basis of surgical approach, tumor infiltration, or history of cranial irradiation. Fliessbach et al [2] showed that there was no gross decline of cognitive functions in patients with primary central nervous system lymphoma who received high-dose systemic and intraventricular chemotherapy. Tumors involving the floor and walls of the third ventricle are frequently associated with memory impairment [1]. The severity of memory impairment after colloid cyst removal appears to be related to the severity of fornix damage [7]. King et al [6] compared pediatric patients with third ventricle region tumors with children with cerebellar tumors, and their results support the hypothesis that pediatric patients with third ventricle region tumors are more likely to be impaired on verbal recall tasks, whereas patients with cerebellar tumors were more impaired on the basic repetition and attention span tasks. Neuropsychological evaluation of patients with section of the corpus callosum has not revealed any significant deficit provided that the incision was small and limited to the callosal trunk [4]. The modified transcallosal approach is a safe procedure that provides good neuropsychological outcomes for most patients [9]. Petrucci et al [8] support a transcallosal parafornical approach to preserve cognitive abilities. They found better results compared with the transcortical approach. A similar good postoperative outcome in cases when the surgical approach to the third ventricle was through the right frontal lobe was reported by McMackin et al [7]. Hydrocephalus might influence the neuropsychological behavior of the patient. Interestingly, in our patients, those with astrocytoma and ependymoma and no associated hydrocephalus showed normal neuropsychological results. Therefore, the patients with the usually small colloid cysts and resulting hydrocephalus all showed neuropsychological deficits. In patients with meningiomas, the tumor is usually larger compared with colloid cysts so that it is difficult to distinguish whether the impairment is related to the size of the tumor, location, or associated hydrocephalus. In our small patient group, it seems that the neuropsychological impairment might be more contributed to the dilated ventricles than on the tumor size. Winkler et al [9] found that with respect to verbal memory functions, also the time of postoperative neuropsychological testing was an important variable. When tested within 4 weeks postoperatively, nearly 50% of the patients exhibited reduced performance in verbal recall. In tests performed later, deficits in verbal memory were only
R. Buhl et al. / Surgical Neurology 64 (2005) 500 – 503
rarely observed and were not related to the surgical procedure itself. It is obvious that further detailed neuropsychological studies pre- and postoperatively are necessary to get more information about the impairment of cognitive function by the tumors, location, associated hydrocephalus, surgical approaches, or other factors. These results are also important for the follow-up including rehabilitation and reintegration into work and social life of the patients. References [1] Donnet A, Schmitt A, Dufour H, et al. Neuropsychological follow-up of twenty two adult patients after surgery for craniopharyngioma. Acta Neurochir (Wien) 1999;141:1049 - 54. [2] Fliessbach K, Urbach H, Helmstaedter C, et al. Cognitive performance and magnetic resonance imaging findings after high-dose systemic and intraventricular chemotherapy for primary central nervous system lymphoma. Arch Neurol 2003;60:563 - 8.
503
[3] Friedman MA, Meyers CA, Sawaya R. Neuropsychological effects of third ventricle tumor surgery. Neurosurgery 2003;52:791 - 8. [4] Giorgi C, Riva D. Stereotactically guided transfrontal removal of intraventricular midline tumors in children. Neurosurgical and neuropsychological considerations. J Neurosurg 1994;81:374 - 80. [5] Hutter BO, Spetzger U, Bertalanffy H, et al. Cognition and quality of life in patients after transcallosal microsurgery for midline tumors. J Neurosurg Sci 1997;41:123 - 9. [6] King TZ, Fennell EB, Williams L, et al. Verbal memory abilities of children with brain tumors. Neuropsychol Dev Cogn Sect C Child Neuropsychol 2004;10:76 - 88. [7] McMackin D, Cockburn J, Anslow P, et al. Correlation of fornix damage with memory impairment in six cases of colloid cyst removal. Acta Neurochir (Wien) 1995;135:12 - 8. [8] Petrucci RJ, Buchheit WA, Woodruff GC, et al. Transcallosal parafornicial approach for third ventricle tumors: neuropsychological consequences. Neurosurgery 1987;20:457 - 64. [9] Winkler PA, Ilmberger J, Krishnan KG, et al. Transcallosal interforniceal-transforaminal approach for removing lesions occupying the third ventricular space: clinical and neuropsychological results. Neurosurgery 2000;46:879 - 90.
Neoplasm
Neuropsychological findings in patients with intraventricular tumors Ralf Buhla,T, Hongguang Huangb, Birgit Gottwalda, Zoran Mihajlovica, H. Maximilian Mehdorna a b
Department of Neurosurgery, University of Kiel, 24105 Kiel, Germany Department of Neurosurgery, University of Zhejiang, Hangzhou, China Received 4 October 2004; accepted 25 April 2005
Abstract
Background: Intraventricular tumors are quite rare and become symptomatic with hydrocephalusrelated signs such as headache, double vision, and seizures. Also, most of the patients show neuropsychological deficits, especially memory problems and lack of attention. Methods: We reviewed the charts and computed tomographic/magnetic resonance images of 15 patients with tumors of the lateral and third ventricle, who were also examined by a neuropsychologist pre- and postoperatively. Neuropsychological testing included tests of attention, memory, executive functions, and concentration. Results: Between 1995 and 2003, 7 patients with colloid cysts of the third ventricle (3 men, 4 women; mean age, 38 years), 5 patients with meningiomas of the lateral ventricle (2 men, 3 women; mean age, 51 years), and 3 patients with astrocytomas and ependymoma (2 men, 1 woman; mean age, 38 years) were treated. All patients with colloid cysts and meningiomas showed mental changes, especially attention and memory deficits. Symptoms improved markedly after surgical intervention. The 3 patients with astrocytoma and ependymoma showed normal results pre- and postoperatively. Conclusion: Neuropsychological testing is very useful in patients with intraventricular lesions and important for follow-up examinations. It should be included in every workup examination in this small patient group. D 2005 Elsevier Inc. All rights reserved.
Keywords:
Intraventricular tumors; Neuropsychological examination
1. Introduction Intraventricular tumors are quite rare and usually become symptomatic with hydrocephalus-related signs such as headache, double vision, and seizures. Also, most of the patients show neuropsychological deficits, especially memory problems and lack of attention. Neuropsychological examinations in patients with subarachnoid hemorrhage are performed regularly, and some papers have been published [5]. Few publications have dealt with patients with intraventricular tumors and most of them dealt with the surgical approach such as the transcallosal
Abbreviations: HAWIE-R, Hamburg-Wechsler Intelligence Test; WMS-R, Wechsler Ged7chtnistest; TMT, Trail-Making Test. T Corresponding author. Tel.: +49 0431 5974801. E-mail address: [email protected] (R. Buhl). 0090-3019/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2005.04.040
approach. But there is also some uncertainty whether neurobehavioral outcome relates more to initial tumor size and location or surgical factors [1]. Moreover, it is controversial whether associated ventricular dilatation or raised intracranial pressure contributes to longer-lasting cognitive changes independent of operative consequences [8]. 2. Methods We reviewed the charts and computed tomographic/ magnetic resonance images of 15 patients with tumors of the lateral and third ventricle, who were also examined by a neuropsychologist pre- and postoperatively. Neuropsychological testing included tests of attention, memory, executive functions, and concentration, namely, MehrfachWortwahl Test, HAWIE-R, WMS-R, Rey Osterrieth Figur
501
R. Buhl et al. / Surgical Neurology 64 (2005) 500 – 503
(preoperative)/Taylor Figur (postoperative), TMT, Testbatterie zur Aufmeksamkeitsprqfung, and Test zur Wortflqssigkeit. 3. Results Between 1995 and 2003, 7 patients with colloid cysts of the third ventricle (3 men, 4 women; mean age, 38 years), 5 patients with meningiomas of the lateral ventricle (2 men, 3 women; mean age, 51 years), and 3 patients with astrocytomas and ependymoma (2 men, 1 woman; mean age, 38 years) were treated. All patients with colloid cysts and meningiomas showed mental changes, especially attention and memory deficits. This was independent of tumor size or associated hydrocephalus. Symptoms improved markedly after surgical intervention. The 3 patients with astrocytoma and ependymoma showed normal results pre- and postoperatively. Two patients were operated on because of an astrocytoma (World Health Organization grade I) located in the left frontal horn of the lateral ventricle (Fig. 1). Both tumors were 1 cm in diameter and there was no associated hydrocephalus. They became symptomatic with headache. The patients were 43 and 56 years old. With navigation-guided endoscopy, both tumors could be removed completely. There were no neuropsychological deficits pre- and postoperatively. A 15-year-old girl complained of headache, dizziness, and visual deterioration for 1 month. The tumor in the right frontal horn of the lateral ventricle was 4 cm in diameter and there was only little hydrocephalus. The tumor was removed completely via a transcortical approach with neuronavigation. There were no neuropsychological deficits pre- and postoperatively.
Fig. 2.
3.1. Colloid cysts Seven patients with colloid cysts were operated via a right frontal transcortical transventricular approach with neuronavigation-guided endoscopy. Mean age was 38 years (range, 29-58 years). There were 3 male and 4 female patients. Symptoms were headache in 5 patients, double vision in 4 patients, and dizziness in 2 patients. Hydrocephalus was also associated in every patient. Memory and concentration deficits were found in all patients. These patients also showed deficits in attention and in their visualspatial performance. Postoperatively, in 5 patients, these deficits improved, whereas in 2 patients, these symptoms persisted and were better 3 months after surgery. 3.2. Meningioma Five patients were operated on because of a meningioma. There were 3 female and 2 male patients. Mean age was 51 years (range, 38-69 years). Three were located in the left trigonum, one in the right trigonum, and one in the right ventricle, near the cella media (Fig. 2). This patient also had hyperparathyroidism and he presented with loss of weight, hypercalcaemia, and a lack of performance. The tumor size was between 1.5 and 7 cm (mean, 4.2 cm). Symptoms were headache in 3 patients, dizziness and double vision in 2 patients, and hemiparesis and gait disturbances in
Fig. 1.
Fig. 3.
502
R. Buhl et al. / Surgical Neurology 64 (2005) 500 – 503
Table 1 Neuropsychological findings pre- and postoperatively of representative tests HAWIE (digit span), WMS (logical memory), and TMT
Colloid cysts AS SG GR GP CG JP IK Meningioma RM RL PM SS ES
HAWIE
WMS
TMT (s)
Clinical Outcome
10/12 10/14 4/6 6/7 11/11 7/8 10/12
62/70 54/64 34/30 40/38 68/74 54/70 64/72
45/26 52/35 60/53 70/68 30/18 60/52 50/36
Better Better Worse Worse Better Better Better
10/12 11/11 3/3 11/11 11/11
68/73 52/61 23/20 50/57 68/75
64/59 67/49 68/81 58/50 69/33
Better Better Worse Better Better
Standardized data.
2 patients. Associated peritumoral edema was found in 3 patients and hydrocephalus was also found in 3 patients. All 5 meningiomas were removed with the help of neuronavigation (Fig. 3) via a transcortical approach. The cortex incision was between 2 and 3 cm. Histologic examination showed 2 meningotheliomatous, 1 transitional, 1 fibroblastic, and 1 microcystic meningioma. Postoperative results were good in 3 patients. One patient had a new hemiparesis postoperatively and one patient showed aphasia. A ventriculitis was a complication in one patient. Neuropsychological deficits were dependent on the site of the lesion. Meningiomas of the left side led to speech impairment, whereas the tumor on the right side led to visual-spatial deficits. Moreover, these patients showed deficits in attention and memory tests. The speed of the visual-motor examination became quicker postoperatively. Four of the patients had better results in the postoperative tests, whereas in one patient with a huge meningioma of the left trigonum, the deficits persisted and the aphasia worsened (Table 1). 4. Discussion There are only few publications dealing with neuropsychological examinations in patients with intraventricular tumors. It is still controversial and unclear whether neurobehavioral outcome relates more to initial tumor size and location or surgical factors [1]. Petrucci et al [8] raised the question whether the cognitive status after third ventricular operation was not the same as the preoperative status, which is a result of the tumor itself. Also, they mention that perhaps ventricular dilatation or raised intracranial pressure contributes to longer-lasting cognitive changes independent of operative consequences. Hutter et al [5] examined cognition and quality of life in patients after transcallosal microsurgery for midline tumors and found that the deficits
found could not be explained by surgical damage to the corpus callosum itself. Friedman et al [3] found that there were no differences in mean neuropsychological scores between patients with third ventricle tumors who underwent surgery and those who did not. There were no differences in mean performance on the basis of surgical approach, tumor infiltration, or history of cranial irradiation. Fliessbach et al [2] showed that there was no gross decline of cognitive functions in patients with primary central nervous system lymphoma who received high-dose systemic and intraventricular chemotherapy. Tumors involving the floor and walls of the third ventricle are frequently associated with memory impairment [1]. The severity of memory impairment after colloid cyst removal appears to be related to the severity of fornix damage [7]. King et al [6] compared pediatric patients with third ventricle region tumors with children with cerebellar tumors, and their results support the hypothesis that pediatric patients with third ventricle region tumors are more likely to be impaired on verbal recall tasks, whereas patients with cerebellar tumors were more impaired on the basic repetition and attention span tasks. Neuropsychological evaluation of patients with section of the corpus callosum has not revealed any significant deficit provided that the incision was small and limited to the callosal trunk [4]. The modified transcallosal approach is a safe procedure that provides good neuropsychological outcomes for most patients [9]. Petrucci et al [8] support a transcallosal parafornical approach to preserve cognitive abilities. They found better results compared with the transcortical approach. A similar good postoperative outcome in cases when the surgical approach to the third ventricle was through the right frontal lobe was reported by McMackin et al [7]. Hydrocephalus might influence the neuropsychological behavior of the patient. Interestingly, in our patients, those with astrocytoma and ependymoma and no associated hydrocephalus showed normal neuropsychological results. Therefore, the patients with the usually small colloid cysts and resulting hydrocephalus all showed neuropsychological deficits. In patients with meningiomas, the tumor is usually larger compared with colloid cysts so that it is difficult to distinguish whether the impairment is related to the size of the tumor, location, or associated hydrocephalus. In our small patient group, it seems that the neuropsychological impairment might be more contributed to the dilated ventricles than on the tumor size. Winkler et al [9] found that with respect to verbal memory functions, also the time of postoperative neuropsychological testing was an important variable. When tested within 4 weeks postoperatively, nearly 50% of the patients exhibited reduced performance in verbal recall. In tests performed later, deficits in verbal memory were only
R. Buhl et al. / Surgical Neurology 64 (2005) 500 – 503
rarely observed and were not related to the surgical procedure itself. It is obvious that further detailed neuropsychological studies pre- and postoperatively are necessary to get more information about the impairment of cognitive function by the tumors, location, associated hydrocephalus, surgical approaches, or other factors. These results are also important for the follow-up including rehabilitation and reintegration into work and social life of the patients. References [1] Donnet A, Schmitt A, Dufour H, et al. Neuropsychological follow-up of twenty two adult patients after surgery for craniopharyngioma. Acta Neurochir (Wien) 1999;141:1049 - 54. [2] Fliessbach K, Urbach H, Helmstaedter C, et al. Cognitive performance and magnetic resonance imaging findings after high-dose systemic and intraventricular chemotherapy for primary central nervous system lymphoma. Arch Neurol 2003;60:563 - 8.
503
[3] Friedman MA, Meyers CA, Sawaya R. Neuropsychological effects of third ventricle tumor surgery. Neurosurgery 2003;52:791 - 8. [4] Giorgi C, Riva D. Stereotactically guided transfrontal removal of intraventricular midline tumors in children. Neurosurgical and neuropsychological considerations. J Neurosurg 1994;81:374 - 80. [5] Hutter BO, Spetzger U, Bertalanffy H, et al. Cognition and quality of life in patients after transcallosal microsurgery for midline tumors. J Neurosurg Sci 1997;41:123 - 9. [6] King TZ, Fennell EB, Williams L, et al. Verbal memory abilities of children with brain tumors. Neuropsychol Dev Cogn Sect C Child Neuropsychol 2004;10:76 - 88. [7] McMackin D, Cockburn J, Anslow P, et al. Correlation of fornix damage with memory impairment in six cases of colloid cyst removal. Acta Neurochir (Wien) 1995;135:12 - 8. [8] Petrucci RJ, Buchheit WA, Woodruff GC, et al. Transcallosal parafornicial approach for third ventricle tumors: neuropsychological consequences. Neurosurgery 1987;20:457 - 64. [9] Winkler PA, Ilmberger J, Krishnan KG, et al. Transcallosal interforniceal-transforaminal approach for removing lesions occupying the third ventricular space: clinical and neuropsychological results. Neurosurgery 2000;46:879 - 90.