Floor Of Third Ventricle Research Articles

Extended endoscopic endonasal approach for resecting anterior intrinsic third ventricular craniopharyngioma.

BackgroundThe surgical treatment of the extended endoscopic endonasal approach (EEEA) is a safe and effective treatment for suprasellar craniopharyngiomas. However, due to damage to the hypothalamus and third ventricle floor (TVF), EEEA is generally regarded as unsuitable in treating intrinsic third ventricle craniopharyngioma (ITVC) that is entirely within the third ventricle. Until now, there have been only a small number of reports using EEEA to treat TVC via a supra-infrachiasmatic approach. Given that the translamina terminalis (TLT) corridor was used in the transcranial subfrontal approach, EEEA via a suprachiasmatic approach may be feasible and practical to treat ITVC. In the current study, we accumulated experience applying the suprachiasmatic translamina terminalis (STLT) corridor for anterior treatment of ITVC.MethodsFrom March 2016 to December 2020, 14 patients with ITVC in our center were analyzed retrospectively. All patients underwent surgery by EEEA via an STLT corridor. The multilayer reconstruction technique was adopted to achieve skull base reconstruction. Data concerning the patient’s tumor resection, vision, hypophyseal hormone, and complications were collected.ResultsGross-total resection was achieved in 13 (92.8%) of14 patients, with achievement of near-total (90%) resection in the remaining 1 patient. Nine cases (64.3%) were papillary craniopharyngiomas, and the other 5 cases were adamantinomatous subtypes. Postoperatively, 3 patients with pituitary insufficiency received hormone replacement therapy. No permanent diabetes insipidus or hypothalamic obesity was found. All pairs showed significant improvement or stability in vision except 1 patient who encountered visual deterioration. No other neurological deficit occurred postoperatively. Observation results for the exudation of nasal tissue and the length of hospitalization were satisfactory. After a mean follow-up period of 26.2 months, tumor recurrence was not observed.ConclusionTLT is a minimally invasive corridor used in EEEA for treating anterior ITVC without increasing risks of visual and hormonal deficits. The multilayered reconstruction technique we used is a safe and effective method for achieving watertight closure and avoiding cerebrospinal fluid leaks and infection. The endonasal approach via STLT provides a new, safe and efficacious operative strategy that should be considered a surgical alternative in treating ITVC.

SURG-09. Hypothalamic involvement in pediatric craniopharyngiomas;how to define and to realize optimal neurosurgical resections

Abstract The optimal neurosurgical strategy for pediatric craniopharyngiomas is on debate with shifts from gross total resection to limited resections in combination with local radiotherapy. The most relevant question underlying this ongoing discussion is how to prevent additional surgical morbidity to the hypothalamus. Limited neurosurgical resection in combination with local radiotherapy has been proved a safe alternative to gross total resection concerning tumor control. Pre-operative anatomical grading of hypothalamic involvement has been proposed by Puget et al using MRI discriminating between no hypothalamic involvement (grade 0), hypothalamic displacement (grade 1), and hypothalamic disruption (grade 2). Subsequently, post-operative hypothalamic damage can also be assessed on post-op MRI by the grading of the Vile et al in no discernable damage (grade 0), abnormality of floor of third ventricle (grade 1), or damaged or deficient floor of third ventricle (grade 2). Three questions remain to be settled: 1. How to define pre-operatively the extent of resection 2. How to realize per-operatively the intended limited resection, and three. How to determine post-operatively the (additional) surgical damage to the hypothalamus. We retrospectively evaluated a series of 25 children with craniopharyngioma being resected in our center from June 2018 until January 2022, with pre- and post-operative grading of hypothalamic involvement. In total 11 patients were downgraded on the post-operative compared to the pre-operative scale; either by 1 grade (n=6) or by 2 grades (n=5). These findings illustrate that the preoperative grading score does not always represent the actual hypothalamic involvement. This complicates the definition of limited surgery pre-operatively and illustrates the importance of both how to integrate per-operative findings in the realization of the intended limited resection and how to evaluate hypothalamic damage caused by tumor growth versus neurosurgical intervention. A more detailed treatment algorithm will be discussed.

Re-Do endoscopic third ventriculostomy. Retrospective analysis of 13 patients.

Indication for endoscopic third ventriculostomy (ETV) in the treatment for noncommunicating hydrocephalus is widely accepted. There is controversy regarding the indication of a second procedure (re-ETV) when the first has failed. The objective of this work is to revise ETV failures in a series in which re-ETV was performed and to describe the factors related to its prognosis. Retrospective study of pediatric patients with ETV failure treated by re-ETV between 2003 and 2018. Gender, age in first and second ETV, time to failure of first ETV, etiology of hydrocephalus, previous presence of shunt, ETV-SS in the first and second ETV, intraoperative findings, success of the second procedure and follow-up were collected. The ETV-SS result was grouped into high (≥80), moderate (50-70) or low (≤40) scores. Endoscopic procedure failure was considered clinical worsening or the absence of radiological criteria for improvement (reduction in ventricular size or presence of ETV flow artifact in the floor of third ventricle). Of 97 ETV carried out in this period, 47 failures were registered, with 13 re-ETV performed. Of these, 8 were classified as successful (61.53%). Re-ETV was successful in 4/4 cases in which etiology was tectal tumor or aqueduct stenosis. In the group with a high ETV-SS score there was a higher rate of success (75%) than in the group with a moderate score (40%). 9 patients presented shunt prior to first ETV and in them, success was 66.6% compared to 50% in the group without prior shunt. All re-ETV were performed without complications. In 11 of the 13 procedures a closed stoma was found and the remaining 2 cases, we found a punctate opening. The mean follow-up after re-ETV was 61.23 months. The selection of patients for re-VET should be cautious. Factors such as age, etiology, and previous shunt (ETV-SS factors) have prognostic influence. However, there are specific factors which indicate favorable prognostic for re-VET such as a longer time to failure of the first procedure, the finding of a closed/punctate stoma or the loss of flow artifact in the follow-up MRI.

The eagle sign: a new preoperative MRI-based tool for predicting topographic correlation between craniopharyngioma and hypothalamus

Accurate prediction of topographical correlation between craniopharyngiomas (CPs) and hypothalamus is important for treatment. This study sought to develop a predicting tool based on preoperative-MRI through radiological-surgical-pathological-outcome analysis. Third ventricle floor (TVF), mammillary bodies and cerebral peduncle were evaluated through preoperative-MRI. An eagle-head-like sign named "eagle sign" was observed. Normal TVF on sagittal-MRI was defined as the baseline. Variants of the sign were analyzed by comparing with the baseline and corresponding correlations of CPs with hypothalamus were verified using intraoperative records, histopathology and outcome evaluation. A total of 146 CPs patients, who undergone endoscopic endonasal procedure were divided into four groups based on the variants of "eagle sign". Group A: 24 patients with the upward sign; group B: 81 with the downward sign; group C: 21 with the anterior TVF upward sign and group D: 20 with the unidentifiable sign. Surgical-pathological analysis showed significant correlations between 95.8% CPs in group A and 95.2% in group C with tumor topography and tumor adherence to the hypothalamus. These CPs had their origins beneath the hypothalamus. In contrast, groups B and D, with hypothalamic origin, showed hypothalamic infiltration by tumor in 97.5% and 95% of cases in groups B and D, respectively. Outcomes of groups A and C were relatively better than groups B and D. Predictive sensitivity and specificity of "eagle sign" were more than 90%. "Eagle sign" is an accurate tool for predicting topographic correlations between CPs and hypothalamus with high sensitivity and specificity.

Re-Do endoscopic third ventriculostomy. Retrospective analysis of 13 patients

ObjetivesIndication for endoscopic third ventriculostomy (ETV) in the treatment for noncommunicating hydrocephalus is widely accepted. There is controversy regarding the indication of a second procedure (re-ETV) when the first has failed. The objective of this work is to revise ETV failures in a series in which re-ETV was performed and to describe the factors related to its prognosis. MethodRetrospective study of pediatric patients with ETV failure treated by re-ETV between 2003 and 2018. Gender, age in first and second ETV, time to failure of first ETV, etiology of hydrocephalus, previous presence of shunt, ETV-SS in the first and second ETV, intraoperative findings, success of the second procedure and follow-up were collected. The ETV-SS result was grouped into high (≥ 80), moderate (50−70) or low (≤ 40) scores. Endoscopic procedure failure was considered clinical worsening or the absence of radiological criteria for improvement (reduction in ventricular size or presence of ETV flow artifact in the floor of third ventricle). ResultsOf 97 ETV carried out in this period, 47 failures were registered, with 13 re-ETV performed. Of these, 8 were classified as successful (61.53%). Re-ETV was successful in 4/4 cases in which etiology was tectal tumor or aqueduct stenosis. In the group with a high ETV-SS score there was a higher rate of success (75%) than in the group with a moderate score (40%). 9 patients presented shunt prior to first ETV and in them, success was 66.6% compared to 50% in the group without prior shunt. All re-ETV were performed without complications. In 11 of the 13 procedures a closed stoma was found and the remaining 2 cases, we found a punctate opening. The mean follow-up after re-ETV was 61.23 months. ConclusionThe selection of patients for re-VET should be cautious. Factors such as age, etiology, and previous shunt (ETV-SS factors) have prognostic influence. However, there are specific factors which indicate favorable prognostic for re-VET such as a longer time to failure of the first procedure, the finding of a closed/punctate stoma or the loss of flow artifact in the follow-up MRI.

Posterior petrosal approach for retrochiasmatic craniopharyngioma

Craniophyringiomas are histologically benign tumors arising from embryonic epithelial cells of the craniopharyngeal duct. They are locally aggressive and their location in the sellar/supra-sellar region is associated with a high rate of recurrence and morbidity. It is generally recognized that surgical resection is the first treatment option. Craniopharyngiomas located in the retrochiasmatic area are among the most challenging to treat. They grow superiorly pushing floor of third ventricle, and posteriorly in the prepontine and interpeduncular cisterns. Different skull base approaches have been utilized to tackle tumors in this location. In this video we illustrate the surgical steps and nuances for resection of a large retrochiasmatic craniopharyngioma in a 25 YO RHF who presented with progressive headaches and visual decline. On neurological examination she was found to have bi-temporal hemianopia. An MRI scan of the brain showed a 4.5 × 3.2 × 4.3 cm mixed solid and cystic suprasellar mass with obstructive hydrocephalus located behind the optic chiasm. A brain CTA showed no displacement of the anterior communicating artery confirming the retrochiasmatic location of the tumor. The preoperative endocrine work up showed central hypothyroidism and low cortisol levels. Postoperatively the patient was extubated in the operating room, she had intact extra-ocular movements. She developed Diabetes insipidus and oculomotor nerve palsy on postoperative day 3. Her third nerve palsy recovered when she was seen 3 weeks postoperatively. The histopathology showed an adamantinomatous craniopharyngioma. The posterior petrosal approach should be considered in treating patients with Retrochiasmatic Craniopharyngiomas. The consent was obtained.

Relationship between craniopharyngioma and the third ventricle floor meninges based on QST classification

Objective To explore the relationship between craniopharyngioma based on QST classification with invovlement of the third ventricle floor and the third ventricle floor meninges and its clinical significance. Methods The clinical data of 17 primary craniopharyngioma patients with involvement of the third ventricle floor (6 cases of Q type, 3 cases of S type and 8 cases of T type) undergoing total tumor resection under neuroendoscopy from January 2018 to October 2019 at Neurosurgery Department of Nanfang Hospital, Southern Medical University were retrospectively analyzed. Tumor tissue samples were taken from all patients during operation. The specimens of the normal sellar region were derived from the fetus (8 cases) of the artificial or spontaneous abortion at Nanfang Hospital of Southern Medical University during the same period. Samples were stained by hematoxylin eosin (HE) and immunofluorescence double staining. The dura was labelled with vimentin antibody, arachnoid with type I collagen antibody, pia with glial fibrillary acidic protein antibody and laminin antibody, adenohypophysis with CK18 antibody and craniopharyngioma with CK5 / 6 antibody. We then observed the meningeal staining of fetal brain tissue and relationship between different QST types of craniopharyngioma tissue and the third ventricle floor meninges. Results The dura mater, arachnoid and pia mater of 8 fetuses were labelled successfully. HE staining and immunofluorescence double staining of craniopharyngioma showed that in type Q tumor (6/6), there were dura mater (diaphragma sellae) between tumor and the third ventricle floor. In type S tumor (3/3), there were arachnoid membrane and pia mater between tumor and the third ventricle floor. There were 3 patterns regarding the relationship between type T tumor and the third ventricle floor: mantle-like relationship, moat-like and mortise-like types. There was pia mater between type T tumor (8/8) and the third ventricle floor, and the pia mater could gradually disappear at the origin point of tumor. Although the tumor could remarkably compress the third ventricle and occupy the space of ventricle, the ependymal layer of the third ventricle remained intact. Conclusions All QST types of craniopharyngioma could involve the third ventricle floor and there are various membrane layers between tumor and the third ventricle floor, which could provide natural interface for safe removal of craniopharyngioma with the third ventricle floor involvement. Key words: Craniopharyngioma; Third ventricle; Sella turcica; Meninges; Pathology

Craniopharyngiomas: An Appropriate Surgical Treatment based on Topographical and Pathological Concepts

Treatment of craniopharyngiomas (CPs) represents a neurosurgical challenge, the major reason being their close relationship with the hypothalamus and the third ventricle (3V) boundaries. Nevertheless, CPs are generally defined as “suprasellar” lesions, an imprecise and frequently faulty term. Despite being heterogeneous lesions, CPs are actually characterized by repeating pathological patterns which depend on their point of origin along the pituitary-hypothalamic axis. Preoperative understanding of the accurate CP-hypothalamus relation is fundamental for planning proper surgery for each tumor. The two opposing therapeutic strategies usually advocated for CP treatment, radical versus conservative removal, should be replaced by a tailored plan to pursue the maximal tumor resection while minimizing the likelihood of hypothalamic injury in each case. Our topographical scheme, based on the accurate definition of the CP-third ventricle floor relationship, has proven useful to predict the degree of hypothalamic distortion and adherence to the tumor, fundamental information to predict the surgical risk associated with radical tumor removal. Apart from the sellar-suprasellar category of CPs, formed by tumors growing below a non-distorted third ventricle floor (TVF), four major CP topographies can be considered: i) suprasellar-pseudointraventricular CPs, which grow below an intact but upward displaced TVF; ii) suprasellar-secondary intraventricular CPs, which originate below the TVF but break through it and invade the 3V; iii) not-strictly intraventricular or infundibulo-tuberal CPs, which originate within the TVF itself and predominantly expand into the 3V; and iv) strictly intraventricular CPs that wholly develop within the 3V, above an intact TVF. The most extensive and strongest CP-hypothalamic adhesions occur in the secondary intraventricular and infundibulo-tuberal categories. A hypothalamic position around the middle portion of the tumor, an amputated pituitary stalk and an elliptical tumor shape on preoperative MRI are reliable signs to predict a high-risk CP adherence severity level. In these cases a limited removal is strongly advocated.

Inflammatory response in craniopharyngiomas and its clinical significance

Objective To investigate the clinical significance of inflammatory reaction in craniopharyngiomas. Methods Antibody microarray was employed for detection of inflammatory cytokines expression in craniopharyngiomas and other common tumors in sellar region (including the pituitary adenoma, meningioma, pilocytic astrocytoma). The methods of qPCR and ELISA were further used for verifying the expression of inflammatory factors in each group. At the same time, the mouse brain neuron cell line (CATH.a) was treated with supernatant of the primary culture medium of craniopharyngiomas, and the apoptotic state of neurons was explored by flow cytometry. Results The craniopharyngioma was more likely to have an inflammatory response than other sellar tumors. The results of antibody microarray showed that the relative expression levels of monocyte chemotactic protein-1 (MCP-1), interleukin 6 (IL-6) and interleukin 1 (IL-1) in adamantinomatous craniopharyngiomas (ACP) (7±1, 6±1, 8±2) were significantly higher than those in papillary craniopharyngiomas (PCP) (2±1, 2±1, 2±1), pilocytic astrocytomas (2±1, 1±0, 2±1), pituitary adenomas (1±0, 2±1, 2±1) and meningiomas (1±0, 1±0, 1±0) (all P<0.05). The qPCR results further verified that the transcriptional levels of 3 inflammatory factors mentioned above in ACP (180±24 pg/ml, 266±19 pg/ml, 243±31 pg/ml) were significantly higher than those in PCP (68 ±14 pg/ml, 98 ±29 pg/ml, 154±21 pg/ml), pilocytic astrocytomas (60±14 pg/ml, 142±29 pg/ml, 149±39 pg/ml), pituitary adenomas (180±24 pg/ml, 266±19 pg/ml, 134±27 pg/ml) and meningiomas (56±14 pg/ml, 89±19 pg/ml, 121±21 pg/ml) (all P<0.05), while Elisa results showed that three kinds of inflammatory factors in the ACP primary cell culture medium supernatant (168±19 pg/ml, 155±34 pg/ml, 228±31 pg/ml) were significantly higher than those in PCP (66±24 pg/ml, 89±19 pg/ml, 112±21 pg/ml) (all P<0.05). After CATH.a cells were stimulated by ACP medium supernatant, their apoptosis increased significantly, while the promotion of apoptosis by supernatant of PCP medium was not obvious. Immunohistochemistry results showed that the inflammatory response in ACP tissue was characterized by infiltration of macrophage inflammatory cells; and activated microglias were observed in the front area between tumor and the third ventricle floor. Conclusions Inflammatory reaction could be found in the craniopharyngioma and the levels of MCP-1, IL-6 and IL-1 were higher in ACP than PCP. The inflammatory reaction of craniopharyngioma seems toxic to CATH.a cells. Key words: Craniopharyngioma; Inflammation reaction; Prognosis; Endocrine

PB 3 Abnormal height of basilar artery bifurcation in adults with Pompe disease

Introduction The evidence for an involvement of the cerebral arteries in adults with Pompe disease is increasing.Typical changes are dilation, elongation and distension of the vertebrobasilar arteries ( [Laforet et al., 2008] , [Sacconi et al., 2010] , [Hensel et al., 2014] , [Montagnese et al., 2016] ). Methods In 15 adults with Pompe disease (age 57 ± 13 years, 8 females) and 12 controls with comparable age and cardiovascular risk factors (age 53 ± 6 years, 4 females) the cerebral arteries were examined with a time of flight MR-angiography.The angle of departure of the superior cerebellar artery (SUCA) was measured from the basilar artery (BA) ( Figs.1 and 2 ).In addition, the level of the bifurcation of the BA was evaluated by a Smoker’s criteria based definition ( Smoker et al., 1986 ) (score at or below the dorsum sellae, score 1 within suprasellar cistern, score 2 at the level of third ventricle floor, score 3 indenting and elevating floor of third ventricle). Results In adults with Pompe disease the angle of SUCA departure was 59° (sum left and right 119°, controls: left 75° and right 83°, sum 159°).Compared with a preliminary MR-angiography five years before ( Hensel et al., 2014 ) the angle of departure decreased from 5 to 11° (n = 5 patients).In 11/15 Pompe patients, the bifurcation of the BA was abnormally high (Smoker score 0: 0 patients, score 1: 4 patients, score 2: 5 patients and score 3: 6 patients).In controls this was rarer and less pronounced (Smoker score 0: 6 patients, score 1: 5 patients, score 2: 0 and score 3: 1 patient).The Smoker score was lower among young Pompe patients than in older patients.In 7/15 (47%) of Pompe patients and in 1/12 (8%) of the controls the proximal posterior cerebral artery (PCA) indenting the hypothalamus (arrow in Fig.3 ).One patient developed a hemorrhage in the thalamus, which was supplied by the displaced superiorly PCA. Discussion The results indicate a upwards displacement of the distal basilar artery in adults with Pompe disease.Such upwards displacement in patients with dolichoectasia of other origin is associated with any stroke and subsequently increased dolichoectatic progress ( Passero and Rossi, 2008 ). In our patients the degree of displacement increases with patient age or duration of the disease. These could represent an accelerated destruction of vertebrobasilar arteries in adults with Pompe disease. The abnormal height of basilar bifurcation could represent an early and easy recognizable sign for cerebrovascular involvement as well.

Craniopharyngioma adherence: a comprehensive topographical categorization and outcome-related risk stratification model based on the methodical examination of 500 tumors.

OBJECTIVE Craniopharyngioma (CP) adherence strongly influences the potential for achieving a radical and safe surgical treatment. However, this factor remains poorly addressed in the scientific literature. This study provides a rational, comprehensive description of CP adherence that can be used for the prediction of surgical risks associated with the removal of these challenging lesions. METHODS This study retrospectively analyzes the evidence provided in pathological, neuroradiological, and surgical CP reports concerning 3 components of the CP attachment: 1) the intracranial structures attached to the tumor; 2) the morphology of the adhesion; and 3) the adhesion strength. From a total of 1781 CP reports published between 1857 and 2016, a collection of 500 CPs providing the best information about the type of CP attachment were investigated. This cohort includes autopsy studies (n = 254); surgical studies with a detailed description or pictorial evidence of CP adherence (n = 298); and surgical CP videos (n = 61) showing the technical steps for releasing the attachment. A predictive model of CP adherence in hierarchical severity levels correlated with surgical outcomes was generated by multivariate analysis. RESULTS The anatomical location of the CP attachment occurred predominantly at the third ventricle floor (TVF) (54%, n = 268), third ventricle walls (23%, n = 114), and pituitary stalk (19%, n = 94). The optic chiasm was involved in 56% (n = 281). Six morphological patterns of CP attachment were identified: 1) fibrovascular pedicle (5.4%); 2) sessile or patch-like (21%); 3) cap-like (over the CP top, 14%); 4) bowl-like (around the CP bottom, 13.5%); 5) ring-like (encircling central band, 19%); and 6) circumferential (enveloping the entire CP, 27%). Adhesion strength was classified in 4 grades: 1) loose (easily dissectible, 8%); 2) tight (requires sharp dissection, 32%); 3) fusion (no clear cleavage plane, 40%); and 4) replacement (loss of brain tissue integrity, 20%). The types of CP attachment associated with the worst surgical outcomes are the ring-like, bowl-like, and circumferential ones with fusion to the TVF or replacement of this structure (p < 0.001). The CP topography is the variable that best predicts the type of CP attachment (p < 0.001). Ring-like and circumferential attachments were observed for CPs invading the TVF (secondary intraventricular CPs) and CPs developing within the TVF itself (infundibulo-tuberal CPs). Brain invasion and peritumoral gliosis occurred predominantly in the ring-like and circumferential adherence patterns (p < 0.001). A multivariate model including the variables CP topography, tumor consistency, and the presence of hydrocephalus, infundibulo-tuberal syndrome, and/or hypothalamic dysfunction accurately predicts the severity of CP attachment in 87% of cases. CONCLUSIONS A comprehensive descriptive model of CP adherence in 5 hierarchical levels of increased severity-mild, moderate, serious, severe, and critical-was generated. This model, based on the location, morphology, and strength of the attachment can be used to anticipate the surgical risk of hypothalamic injury and to plan the degree of removal accordingly.

Third ventricular cavernoma: Report of two cases.

Sir/Madam, Cerebral parenchyma is the most common site for a cavernoma in the nervous system. Intraventricular cavernomas are rare and constitute 2.5-10.8% of cerebral cavernomas.[1] Third ventricular cavernomas are even rare, only 25 cases have been reported in the literature.[2] We report two more cases of third ventricular cavernomas. The first patient was a 54-year-old man, who presented with acute headache and vomiting. He was unconscious on arrival in casualty. CT scan showed third ventricular hemorrhage [Figure 1a]. He underwent external ventricular drainage, followed by ventriculo-peritoneal (VP) shunt later. An MRI done at 10 days after ictus showed a mixed density lesion with hemorrhagic component occupying the third ventricle with broad base on the floor [Figure 1b]. He underwent tranacallosal-interhemispheric approach and total excision of the lesion. The tumor was arising from the floor of the third ventricle. Histopathology was cavernoma. After surgery the patient developed diabetes insipidus, which was managed with desmopressin. Figure 1 (a) CT scan showing hemorrhage in third ventricle. (b) MRI showing a heterogeneous lesion in the third ventricle with bleed The second patient was a 6-year-old girl who presented with headache and vomiting for 2 months. CT scan showed a calcified in third ventricle with hydrocephalus [Figure 2a]. MRI showed a heterogeneous lesion occupying the entire third ventricle [Figure 2b]. There was no evidence of recent hemorrhage. She underwent VP shunt followed by subfrontal approach, and only partial excision of the lesion as the lesion was densely adherent to the floor of the third ventricle. Histopathology was cavernoma. After surgery she developed transient hyponatremia, which was managed medically. Figure 2 (a) CT scan showing calcified tumor in third ventricle. (b) MRI showing a heterogeneous lesion in the third ventricle Third ventricular cavernomas can present with signs and symptoms of any third ventricular tumors, however they usually present with symptoms of hydrocephalus.[2] Presentation as intraventriuclar hemorrhage is uncommon, and only three cases have been reported.[2] Our first patient presented with hemorrhage, and second with hydrocephalus. They can arise from the suprachiasmatic region, foramen of Monroe, lateral wall or floor of third ventricle.[3] Both of our patients had cavernomas arising from floor of third ventricle. The imaging appearance is that of typical cavernomas. The close differential diagnosis in the absence of hemorrhage is third ventricular craniopharyngioma. The natural history of intraventricular cavernoma is not known. There is a risk of hemorrhage and acute hydrocephalus if the lesion is not excised completely. However, there is risk of hypothalamic damage in case of complete resection of lesion arising from floor of third ventricle, as it happened in our first case. It may be worthwhile doing only a VP shunt for hydrocephalus if the lesion is arising from the floor of the third ventricle.[4]

The role of habenula in sensory and emotional modulation

Background The habenula is a small bilateral structure on the floor of the third ventricle,which locates in the posterior-medial aspect of the dorsal thalamus and is divided into the medial habenula (MHb) and the lateral habenula (LHb).Recent studies show that the habenula is involved in the regulation of behavioural responses to pain,reward-aversion,depression and maternal behavior.Objective Elucidate the important role of habenula nucleus in the regulation of sensory and emotion and provide new ideas for related clinical research.Content This article reviews the mechanisms and circuits through which habenula participates in sensory and emotional modulation.Trend With further research,the habenula may become the therapeutic targets of multiple sensory or emotional disease in the furture. Key words: Habenula; Reward-aversion ; Pain ; Depression; Addiction ; Cognition

Necrotizing Infundibuloneurohypophysitis: Case Report and Literature Review

Several conditions may lead to pituitary necrosis: Sheehan syndrome, increased intracranial pressure, traumatic pituitary injury, thrombosis of the vessels perfusing the pituitary, ischemia, as well as various infections and autoimmune processes. Necrosis may develop in the anterior and posterior lobes, as well as in the pituitary stalk and infundibulum. Hypophysitis is a chronic inflammatory disorder resulting from an autoimmune process (primary hypophysitis) [1, 2] or from an identified agent, such as infection (secondary hypophysitis) [3]. By histology, in various forms of hypophysitis, necrotic areas may be apparent. Necrosis is usually small and focal in primary hypophysitis [4]. To date, to our knowledge, there are only a few published cases where necrosis occupied large portions of the hypophysis [4, 5]. We report the case of a 13-year-old female with central diabetes insipidus (DI) and hypopituitarism. Magnetic resonance imaging (MRI) showed homogeneous gadolinium enhancement in the upper pituitary stalk and on the floor of the third ventricle. The lesion was surgically removed. The histologic, immunohistochemical, and electron microscopic examinations of the surgical specimen revealed necrotizing infundibuloneurohypophysitis.

Endoscopic third ventriculostomy in tubercular meningitis with hydrocephalus

Endoscopic third ventriculostomy (ETV) is increasingly being used as an alternative treatment in tubercular meningitis (TBM) hydrocephalus. This study is aimed to evaluate the role of ETV in TBM hydrocephalus. This is a prospective study of 59 patients with TBM and obstructive hydrocephalus. The diagnosis was confirmed by a computed tomography scan and/or magnetic resonance imaging scan preoperatively. The procedure was performed using the standard technique or water jet dissection. Three (5.1%) patients had blocked stoma, 31 (53%) had associated malnutrition, and 13 (22%) had complex hydrocephalus. Clinical improvement was seen in 34 (58%) after ETV and in 47 (80%) patients after ETV with lumber peritoneal shunt. Thirteen patients with patent stoma and complex hydrocephalus did not improve after ETV alone; an additional lumber peritoneal shunt was required. Clinical outcome was significantly better in good grade. Early recovery was observed in 81%. Results of ETV were better in patients without cisternal exudates, good nutritional status, thin and identifiable floor of third ventricle compared to cases with cisternal exudates, malnourished, thick and unidentifiable floor respectively, although the difference was statistically insignificant. There was no operative death. Three patients with normal ICP did not show any improvement. The radiological recovery after 3 weeks of surgery was 52%; follow-up ranged between 7 and 54 months. Six patients developed CSF leak. Endoscopic third ventriculostomy was safe and effective in TBM hydrocephalus. Complex hydrocephalus and associated cerebral infarcts were the major causes of failure to improve. Good results were observed in better grades.

Use of endoscopic third ventriculostomy in hydrocephalus of tubercular origin

The purpose of this paper was to study the feasibility of endoscopic third ventriculostomy (ETV) as a treatment modality in patients with hydrocephalus of tubercular origin. Literature on ETV in hydrocephalus of tubercular origin has been reviewed, and we have gathered experiences of neurosurgeons from various institutions in our country practicing ETV. Hydrocephalus, a common complication of tubercular meningitis, may be of communicating type or of obstructive variety. The communicating type is treated by medical therapy in 70-92% cases, whereas the obstructive type requires surgical intervention. The outcome of surgery depends upon gradation of disease. Shunting however has been a nightmare for neurosurgeons treating such patients (Smyth et al., Pediatr Neurosurg 39: 258-263, 2003). The shunts tend to get blocked with debris. Having found ETV as a successful modality of treatment in obstructive hydrocephalus of other etiology, neurosurgeons have attempted it in hydrocephalus of tubercular origin. Though various authors have had a success rate of 65-68%, failure has been quite high in acute cases due to thickening of the floor of third ventricle and distorted anatomy. The success rate is higher in chronic and burnt out cases. Tubercular meningitic hydrocephalus is difficult to treat endoscopically as compared with other forms of meningitic hydrocephalus and requires adequate expertise and experience, especially in acute cases. Therefore, one would be justified in avoiding the use of ETV in acute cases and wait till patient presents with a failed shunt. Use of ETV in subacute and chronic cases seems to be justified as the first line of treatment.

Is the distance between mammillary bodies predictive of a thickened third ventricle floor?

Object The aim of this study was to correlate intraoperative endoscopic third ventriculostomy (ETV) findings in hydrocephalic patients with the MR imaging appearance of the mammillary bodies (MBs), the fundamental anatomical landmarks of the third ventricle floor (TVF) region. Methods The authors reviewed brain MR images and intraoperative ETV records in 23 patients with hydrocephalus as well as MR imaging data from 120 randomized control volunteers of various ages to define the normal intermammillary distance (IMD). Results In control volunteers, no measurable IMD ("kissing" configuration) was observed in 91 (85%) of 107 cases, and there was mild MB splitting (mean +/- standard deviation, 0.18 +/- 0.12 cm) in only 16 cases with age-related cerebral atrophy. Among the 21 patients with complete MR imaging and ETV data sets, 12 ETV procedures were hindered by anatomical anomalies such as a thickened TVF or an "upward ballooning" phenomenon. On preoperative MR imaging in these 12 patients, there was an increased IMD (0.55 +/- 0.41 cm) compared with that in the remaining 9 patients (0.27 +/- 0.25 cm) who had a normal thin TVF during ETV and in the control group (0.03 +/- 0.08 cm). Magnetic resonance imaging and ETV data concordantly displayed nonsplit MBs in 6 of 9 cases with a thin TVF and split MBs in 10 of 12 cases with a thick TVF. Conclusions The normal configuration of MBs is no measurable IMD, with mild splitting occurring in patients with age-related brain atrophy. In hydrocephalic patients, a thickened TVF was present almost exclusively with an increased IMD on preoperative MR imaging and separated MBs on endoscopic viewing. Large retrospective series are needed to confirm that a preoperative increased IMD is predictive of a thickened TVF during ETV.

Assessment of the influence of operative factors in the success of endoscopic third ventriculostomy in children

To determine if operative factors correlate with success of endoscopic third ventriculostomy (ETV) in the treatment of hydrocephalus. The ETV procedure video of 33 hydrocephalic children was reviewed. Mean age at operation was 76 months (range: 1-196). Success was defined as no need for shunt in the long term. We calculated the relative size of stoma as the percentage of stoma diameter to the distance between posterior clinoid-basilar artery. Factors analysed were: intra-operative haemorrhage, stoma size, thick/double third ventricular floor, pre-pontine adhesions presence, brisk cerebro-spinal fluid (CSF) flow through the stoma as well as hydrocephalus cause, previous shunt presence, CSF infection or haemorrhage and previous ETV. Analysis was performed using chi-square, linear regression, and one-way ANOVA. Overall ETV success rate was 42%. Mean stoma size was 37%. For the entire group, none of the operative factors correlated statistically with success. Previous shunt presence adversely correlated with success (p=0.008). The highest success rate was in the aqueduct stenosis group. In patients without previous shunt (n=17), stoma size over 30% tended towards significance (p=0.094), CSF leak was adversely associated with ETV success (p=0.041) and mean stoma size was 41.3% in successful ETV and 27.8% in unsuccessful ETV (p=0.072). In patients with previous shunt (n=16), thin third ventricular floor was a negative predisposing factor (p=0.057). This study did not demonstrate a correlation between the presence of pre-pontine adhesions, double or thickened floor of third ventricle and ETV success. In patients without previous shunt, stoma size may correlate with success. CSF leak was strongly associated with failure.

Choroid plexus adenoma: case report and review of the literature

An 8-month-old infant with macrocephaly was found to have hydrocephalus and a cystic third ventricular tumour; biopsy of the tumour showed a choroid plexus adenoma. The tumour was attached to the ependymal lining and was strongly adherent to the walls and floor of the anterior third ventricle. After biopsy, it was felt that a radical resection would carry a high risk of injury to the floor of the third ventricle and cause new neurological deficits. Therefore, an external ventricular drain was inserted and bilateral ventriculo-peritoneal shunts were inserted 1 week post-operatively. In view of the benign nature of the tumour, no adjuvant radiotherapy or chemotherapy was given. There was no further tumour growth or clinical deterioration over a 6-year follow-up period.

Post-traumatic migration and emergence of a novel cell line upon the ependymal surface of the third cerebral ventricle in the adult mammalian brain.

This investigation describes the migration and emergence of significant numbers of what appear to be neuron-like cells upon the surface of the median eminence of the adult rodent neurohypophyseal system of the endocrine hypothalamus following the trauma of hypophysectomy. These cells appear to migrate through the neuropil of the underlying median eminence and emerge in large numbers upon the surface of the third cerebral ventricle within 7 days following hypophysectomy (axotomy) of supraoptic (SON) and paraventricular neurites (PVN) of the adult neurohypophyseal system. Previous investigations have demonstrated regeneration of the neural stem and neural lobe in a variety of mammalian species (Adams et al., J Comp Neurol, 1969;135:121-144; Beck et al., Neuroendocrinology, 1969;5:161-182; Scott et al., Exp Neurol, 1995;131-1:23-39; Scott and Hansen, Vir Med 1997;124:249-261). It also has been demonstrated that the process of regeneration is invariably accompanied by the up-regulation of nitric oxide synthase (NOS), the enzyme that catalyzes arginine to nitric oxide (NO) and that both neurohypophyseal regeneration, as well as migration and emergence of neuron-like cells upon the surface of the adjacent third cerebral ventricle, is associated with the up-regulation of NOS and increased expression of NO. It also has been amply demonstrated that this entire process of neurohypophyseal regeneration and cell migration is completely inhibited by the introduction of the antagonist of nitric oxide, namely, nitroarginine (Scott et al., Exp Neurol, 1995;131-1:23-39; Scott and Hansen, Vir Med, 1997;124:249-261). The emergence and migratory dynamics of this novel cell line upon the floor of the rodent third cerebral ventricle are discussed with respect to the role of the ubiquitous free radical NO and the implications and potential clinical applications of neuronal migration following trauma in the human central nervous system (CNS).