Ventriculoperitoneal Shunt For Hydrocephalus Research Articles

Perioperative nursing care for patients undergoing ventriculoperitoneal shunting for hydrocephalus

Objective To analyze and explore perioperative nursing care for patients undergoing ventriculoperitoneal shunting for hydrocephalus.Methods The data on perioperative nursing care for 68 patients who had undergone ventriculoperitoneal shunting for hydrocephalus during the period of January 2010 to June 2012 were retrospectively analyzed.Results After treatment and careful nursing,all of the 68 patients undergoing ventriculoperitoneal shunting for hydrocephalus satisfactorily recovered and were relieved from hospital in good conditions.Conclusions Preoperative preparation and psychological nursing,postoperative basic nursing,observation,shunt and incision nursing,nursing for complications,and post-discharge guidance is key to the successful procedure. Key words: Hydrocephalus; Ventriculoperitoneal shunting; Perioperation; Nursing care

Laparoscopic cecal cancer resection in a patient with a ventriculoperitoneal shunt: A case report

INTRODUCTIONThe presence of a ventriculoperitoneal shunt has been considered to be a contraindication for laparoscopic surgery till date; however, laparoscopic cholecystectomy was recently reported as safe for patients with this shunt. PRESENTATION OF CASEWe present the first case, to the best of our knowledge, of laparoscopic colectomy for cecal cancer in a patient with a ventriculoperitoneal shunt. A 59-year-old woman with a ventriculoperitoneal shunt for hydrocephalus was referred to our hospital with cecal cancer. Laparoscopic cecal cancer resection was performed successfully and uneventfully by manipulating the shunt. DISCUSSIONClamping of the shunt catheter at the subcutaneous region was performed before insufflation of carbon dioxide to prevent adverse effects from the pneumoperitoneum. CONCLUSIONWe believe that laparoscopic colectomy for colon cancer can be performed safely in patients with a ventriculoperitoneal shunt by optimal manipulation of the shunt.

Length of peritoneal end of shunt catheters in hydrocephalus in children and rate of complications

Objectives: In the present study, we reviewed our experience with full-length low- and medium-pressure peritoneal shunts and recorded any additional complications/benefits caused by using these shunts. Materials and Methods: This study was conducted from May 2005 to December 2006 in the Department of Surgery, Government Medical College Hospital, Jammu. Over the study period, all the children who underwent ventriculoperitoneal shunt for hydrocephalus were included. Ventriculoperitoneal shunt was placed in all the cases by using the Chhabra 'Slit n spring' hydrocephalus shunt system. In all the cases, the shunt was placed on the right side with a common technique of insertion. In the present study, the full length of the distal catheter was placed in the peritoneal cavity in all the cases. Before placing the peritoneal catheter into the abdomen, the length of the inserted peritoneal tube was measured. All patients were followed up on a fortnightly basis for the first three months and thereafter on a three-monthly basis. Results: A total of 30 children underwent right ventriculoperitoneal shunt for congenital hydrocephalus during the study period. Mean age of the patients was 11.1 months (range: 1-36 months, SD: 11.0963, median: 7 months). There were 16 male and 14 female patients and 75% children were less than 17 months of age. In the present study, the full length of the distal catheter was placed into the peritoneal cavity and it was observed that the minimum length of the distal catheter placed inside was 44 cm and the maximum length was 52 cm. Twenty-five children (83.3%) had normal shunt functioning with no clinical or radiological evidence of shunt complications at a follow-up at one year. Five children (16.6%) had features of shunt malfunction and were evaluated further. Conclusion: In accordance with the literature, we find that the length of the peritoneal catheter of the shunt tube does not increase the distal complication rate; however, the use of adequate length of the peritoneal catheter does eliminate the need to lengthen the peritoneal catheter as the child grows.

Visual Disturbance Following Shunt Malfunction in a Patient With Congenital Hydrocephalus

A 25-year-old woman presented with complaints of nausea and headache. She had been treated with a ventriculoperitoneal shunt for hydrocephalus when she was 7 months old. Her bilateral optic discs showed moderate atrophy. Right visual acuity allowed only perception of hand movement and left visual acuity was 0.02 (1.2). Computed tomography (CT) showed mild ventricular dilation but no periventricular lucency. Intracranial pressure (ICP) was not high when the shunt valve was punctured. Her visual acuity deteriorated 5 days after the consultation. She was referred again 8 days after the first consultation. The bilateral optic discs were completely pale. Both pupils were dilated on admission, and the bilateral direct light reflexes were absent. The patient could slightly detect only green light stimulus. CT showed moderate enlargement of the ventricle. ICP was 47 cmH(2)O when the shunt valve was punctured. Shuntgraphy showed obstruction of the shunt at the distal end of peritoneal catheter. Emergent total shunt revision was performed. She could detect dark stimulus and the still-dilated left pupil had recovered direct light reflex on the next day. The visual acuity was 0.01 (0.7) on the left 6 months after the operation, although she was blind in the right eye and the bilateral optic discs were completely pale. Visual loss associated with shunt failure remains a major morbidity in shunted congenital hydrocephalus. Early diagnosis and shunt revision may allow visual recovery.

Clinical Analysis of Subdural Hematoma after Ventriculoperitoneal Shunt for Hydrocephalus

Clinical Analysis of Subdural Hematoma after Ventriculoperitoneal Shunt for Hydrocephalus

Malignant Course of a Metastatic Melanoma During Pregnancy: A Case Report

Cutaneous melanoma can metastasize to any organ, including brain and spinal cord. A 27-year-old lady, four months after conception presented with generalized seizures and was diagnosed to have subarachnoid hemorrhage. Further investigation did not reveal aneurysm. She underwent right ventriculo-peritoneal shunt for hydrocephalus and MTP for unprotected radiation from CT scan. Six weeks later she came to our institution with symptoms of dorsal compression. Imaging showed multiple intradural extramedullary spinal lesions at D3-D4, D8 and D10-D11. Surgical excision of the lesions was done and histopathology was consistent with metastatic deposits from malignant melanoma which was confirmed by immunohistochemistry studies also. Her conscious level deteriorated on the second postoperative day and CT scan showed multiple small tumor emboli with evidence of right temporal bleed and diffuse cerebral edema. In spite of aggressive treatment she could not be saved. This reported case concludes that pregnancy aggravates the clinical course of metastatic melanoma. doi:10.4021/wjon285w

Ventriculoperitoneal shunt for hydrocephalus caused by central nervous system metastasis

The development of better diagnostic tools and therapeutic modalities has increased the incidence of central nervous system (CNS) metastasis in malignant tumor patients. Hydrocephalus can result from CNS metastasis and frustrate cancer treatment. The authors sought to investigate the outcomes and the roles of ventriculoperitoneal shunts (VPS) in patients with CNS metastasis. The medical records of 50 consecutive patients who underwent VPS for hydrocephalus related to CNS metastasis were analyzed retrospectively. Data included features of primary malignancies, CNS involvement, clinical course and surgical outcome. Median patient age was 55.0years (range 25-77), and 30 female and 20 male patients were included in the study. At the time of VPS, 10 patients had parenchymal metastases only and 40 patients had leptomeningeal seeding (LMS). Symptom improvement was observed postoperatively in 40 patients (80%), mean Karnofsky performance status (KPS) scale change was from 37.8 to 46.0, and median survival from VPS was 3.0months (2days to 54months). A ventricular opening pressure of >30cmH(2)O (HR 6.44, 95% CI 1.26-32.9, P=0.02) and further cancer treatment after VPS (HR 0.17, 95% CI 0.07-0.42, P<0.0001) were found to be independent risk factors of poorer and better survival, respectively. Hydrocephalus in CNS metastasis requiring VPS is commonly associated with LMS. VPS is an effective palliative measure and an adequate cancer treatment after VPS may provide the best means of improving survival.

Laparoscopic management of associated abdominal complications of ventriculoperitoneal shunt: case report

BACKGROUND: Abdominal complications after ventriculoperitoneal (VP) shunt placement are reported in 5–47% of cases. Abdominal cerebrospinal fluid (CSF) pseudocyst is an uncommon complication of a VP shunt, the majority being reported in children. Abdominal pseudocysts and intra-abdominal catheter migration are rare in adult patients. Ventriculoperitoneal shunt obstruction or malfunction results in elevated intracranial pressure, representing an indication for immediate intervention. METHODS: Case report. RESULTS: The authors report a case of successful laparoscopic management in a 20-year-old female patient who developed CSF pseudocyst combined with migration of the fractured catheter in the abdominal cavity nine years after VP shunting for hydrocephalus. CONCLUSIONS: Laparoscopic approach is a safe and useful treatment modality for combined peritoneal complications of VP shunt.

Intracranial Aneurysms in Klippel-Trenaunay/Weber Syndromes

We present a comprehensive review of intracranial aneurysms in Klippel-Trenaunay and Klippel-Trenaunay-Weber syndromes (KTS/KTWS), and examine factors influencing the risks of surgery vs conservative management. A 58-year-old physician with KTS affecting the right extremities presented with left hemispheric cerebellar stroke and was discovered to harbor four intracranial aneurysms of the posterior circulation: fusiform mid and distal BA (2.6 x 2 x 2 cm), fusiform right proximal P1 (2 x 1.3 x 1.3 cm), fusiform right distal P1 (2.8 x 2.7 x 2 cm), and saccular left distal posterior inferior cerebellar artery (2.5 x 2.5 x 2.5 cm). Ten years later he had an infarct in the paramedian distribution of the basilar artery and a right internal capsule stroke. Two months later, he developed hydrocephalus, ultimately presenting in status epilepticus 4 months later secondary to ongoing aneurysm expansion and mass effect. Systemic anticoagulation for acute thrombosis with possible distal arterioarterial embolization from giant P1 aneurysms. Ventriculoperitoneal shunting for hydrocephalus. The patient died within 9 days after admission and 10 years after the initial discovery of aneurysms. Strict control of modifiable risk factors compromising vascular integrity and periodic neuroimaging are warranted in KTS/KTWS patients. KTS/KTWS patients are hypercoagulable, and may be predisposed to aneurysm thrombosis with increased risk for distal arterial microembolization. Stroke-related morbidity secondary to distal arterioarterial aneurysm thrombus embolization and acute aneurysm thrombosis may be decreased with systemic anticoagulation in this patient population. KTS/KTWS patients have significantly higher rates of DVT and PE than the general population, and should be classified in the high-risk category for venous thromboembolism prophylaxis. Both endovascular and open cerebrovascular techniques have been used successfully in KTS/KTWS patients with intracranial aneurysms.

About the operative management and post-operative neural development of patients with cloverleaf skull deformity

We present our treatment concept for cloverleaf skull deformity on the basis of two representative cases that had been presented to our multidisciplinary skull deformity board. Perioperatively, we monitored electrophysiologic parameters with median nerve somatosensory-evoked potentials (SSEP), tibial nerve (T) SSEP, brainstem acoustic-evoked potential and flush-elicited visual-evoked potential, as well as intracranial pressure. Both patients underwent decompressive bilateral vault craniectomy, frontal and occipital reshaping at an age of four months. Secondary fronto-orbital advancement and cranial vault reshaping was performed after maximal vault reossification was reached at an age of 8 and 12 months, respectively. Additionally, one of the patients underwent treatment of a Chiari malformation via suboccipital decompressive craniectomy and tonsillary resection, as well as ventriculoperitoneal shunting for hydrocephalus. The patients showed nearly unrestrained neural and neurophysiological development over a follow-up period of 5 years.

O.108 A registry for comparing catheter-related infection rates with and without antibiotic impregnated catheters after ventriculo-peritoneal shunts for hydrocephalus

O.108 A registry for comparing catheter-related infection rates with and without antibiotic impregnated catheters after ventriculo-peritoneal shunts for hydrocephalus

Anomalous venous drainage preventing safe posterior fossa decompression in patients with Chiari malformation Type I and multisutural craniosynostosis

The authors report on two children in whom an anomalous posterior fossa venous drainage pattern prevented safe posterior fossa decompression. Both patients had Chiari malformation Type I, multisutural craniosynostosis, and crowded posterior fossa structures. Both patients had been treated with ventriculoperitoneal shunts for hydrocephalus. Pfeiffer syndrome had been diagnosed in one of the patients, and the other was suspected to have osteogenesis imperfecta. Although both patients were believed to have symptoms resulting from brainstem compression, posterior fossa decompression was not offered due to profound venous anomalies noted on imaging studies that greatly increased the expected risks associated with surgery. These cases are presented to alert neurosurgeons to carefully evaluate the posterior fossa venous anatomy prior to considering posterior fossa decompression with or without occipitocervical fusion or calvarial vault remodeling procedures in patients with multisutural craniosynostosis.

Treatment of subdural hematomas in infants

has a long and storied history. In Donald D. Matson’s classic text, there was an extensive discussion of this topic that included descriptions of the invasive procedures needed to make this diagnosis at a time when few imaging data were available; an unforgettable illustration from the text was a photograph showing tubes draining subdural fluid, which was tapped over time at the bedside to follow the progression of the SDH’s content. It is now understood that removing the xanthochromic fluid through punctures, drains, or subduroperitoneal shunts can eliminate subdural fluid collections. Most practitioners consider placement of a shunt as the last resort of many treatment options, because the placement of a shunt generally implies that the condition’s treatment will be lifelong. However, in their article in this issue of the Journal of Neurosurgery: Pediatrics, Kurschel and colleagues suggest that there is a very high likelihood of success in treating subdural fluid collections with the placement of a unilateral, valveless subduroperitoneal shunt, and they further indicate that such systems can be safely removed after the fluid collections have been evacuated. Because many of the concerns about treating subdural collections during infancy through shunts result from comparison with the use of ventriculoperitoneal shunts for hydrocephalus, a few differences should be stressed. The most important is that the treatment of subdural collections and the treatment of hydrocephalus have vastly different end points: elimination of the subdurals in the former and control of the hydrocephalus in the latter. This difference may be the reason that using a valveless shunt system works so well in the hands of the authors: when the fluid collection is completely gone, flow stops because there is no longer any fluid to flow through the system, and one hopes that there is permanent occlusion of the tubing. Thus, the authors of this study systematically removed virtually all of the catheters, a maneuver tolerated by their patients without problems. The most important point of this paper is that in this particular group of patients, removal of the shunt system can be done apparently with impunity. The protocol recommended for these patients, which does not distinguish between fluid collections following nonaccidental trauma and those collections from other causes, appears to be a reasonable course for the treatment of children with subdural fluid collections. We have had personal experience with patients who have undergone subdural fluid shunt treatment in the past who developed late symptoms, indicating that they were dependent on their subdural shunts; it is to be hoped that early removal of these shunts, as suggested by the authors of the present study, will reduce the likelihood of this occurrence.

A Case of Ventricular Drainage Infection with a Rare Pathogen in Cerebrospinal Fluid: Vancomycin-Resistant Enterococcus faecium

The purpose of this study was to describe a patient, 7-month-old child with ventriculoperitoneal shunts for hydrocephalus with ventriculitis caused by vancomycin-resistant Enterococcus faecium. Two ventriculoperitoneal shunts were inserted just after birth and on the second month. On the sixth month, both shunts were removed because of dysfunction, and external drainage was inserted. The child developed fever, and lumbar puncture revealed a high leukocyte count and protein concentration after external drainage. Cerebrospinal fluid (CSF) cultures yielded E. faecium, which was resistant to ampicillin, erythromycin, gentamicin, penicillin G, vancomycin, and teicoplanin and was susceptible to chloramphenicol, ciprofloxacin, streptomycin, levofloxacin, and rifampin, as determined by the disk diffusion method. As a result of the antimicrobial susceptibility tests, multidrug antibiotic therapy was changed from vancomycin and ceftazidime to chloramphenicol, rifampin, and meropenem. In addition, a rifampin-clindamycin-impregnated shunt (The Codman Hakim Bactiseal, Raynham, MA) was inserted. The patient became afebrile, and CSF cultures were sterile after 15 days of yielding E. faecium. Implantation of the rifampin-clindamycin-impregnated shunt and timely use of appropriate antibiotics for 10 days according to antimicrobial susceptibility testing seem to be important in the resolution of vancomycin-resistant enterococci infections, especially in countries where linezolid and quinupristin-dalfopristin are not in use yet.

Complete deficiency of the IL-12 receptor β1 chain: three unrelated Turkish children with unusual clinical features

Complete interleukin-12 receptor β1 deficiency is the most frequent known genetic etiology of the syndrome of Mendelian susceptibility to mycobacterial diseases (MSMD, OMIM 209950). Eleven disorders caused by different types of mutations in five different gene defects related to the IL-12 and IL-23/interferon (IFN)-γ axis have been described to date [2]. Refer to Fig. 1 for the pathways of IL-12/IL-23-dependent interferon IFN-gamma immunity. Patients with MSMD are vulnerable to the BacillusCalmette-Guerin (BCG) vaccine species Mycobacterium bovis, environmental mycobacteria and M. tuberculosis. Infectious diseases other than those caused by Salmonella species, the latter of which infect almost one-half of all patients, are rare [1, 3, 6]. We report here various and unusual clinical manifestations of three unrelated patients with complete IL-12Rβ1 deficiency due to three different mutations in the IL-12RB1 gene, of which two are novel (711insC, 628–644dup). The first patient was an 1-year-old infant girl who had BCG lymphadenitis at 6 months of age and disseminated mycobacterial infection complicated with spontaneous pneumomediastinum and subcutaneous emphysema at 12 months of age. She was treated with isoniazide, rifampin, ethambutol, amikacin, clarithromycin and clofazimine. Pre-tracheal fasciotomy was undertaken for subcutaneous emphysema. A complete IL-12 receptor β1 deficiency associated with the 711insC mutation in IL-12RB1 was detected (Fig. 2). The patient is still in remission. The second patient was an 19-month-old infant boy who presented with five episodes of infections attributable to Salmonella and two episodes of Salmonella enteritidis meningitis. There was no mycobacterial disease, including no adverse reaction to BCG immunization that was practiced at the age of 2 months. He was treated with meropenem, rIFN-γ and external ventricular drainage and then ventriculo-peritoneal shunting for hydrocephalus. Immunologic and molecular genetic examinations revealed complete IL-12Rβ1 deficiency and a IL-12RB1 783+ 1G>A mutation (Fig. 2) [3]. The third patient, a 4.5-year-old boy, had fistulized BCG lymphadenitis in early childhood followed by disseminated mycobacterial infection and splenic abscess with Salmonella bacteremia at 44 months of age. He was treated with meropenem and with isoniazide, rifampin, ethambutol, clarithromycin and amikacin. The patient improved; however, he was lost to follow-up and has been reported to have died. DNA sequencing revealed a 628–644dup mutation in IL-12RB1 (Fig. 2). A complete IL-12 receptor β1 deficiency is suspected. All three patients had persistent oral moniliasis. Among a total of 56 cases of IL-12 receptor β1 deficiency reported in the literature, the rate of infection with BCG M. bovis is 73% (27/37), environmental mycobacteria 21% (22/56), non-typhoidal Salmonella species 46% (26/56) and tuberculosis 7% (4/56) [4–6]. Paracoccidioides brasiliensis-disseminated disease has also recently been reported in an IL-12Rβ1-deficient patient. None of the 37 patients with BCG disease subsequently G. Tanir (*) . N. Tuygun . C. Aydemir . E. C. Boduroglu Dr. Sami Ulus Children Health and Diseases Training and Research Center, Hosdere Caddesi 166/3, Yukari Ayranci, 06550 Ankara, Turkey e-mail: gonultanir58@yahoo.com Fax: +90-312-3170353

Blindness following ventriculoperitoneal shunt block in a child with spinal dysraphism: Case report

A six-year-old boy presented with a week history of increasing headache, visual loss and convulsions. He had repair of myelomeningocele early in life and later had insertion of a ventriculoperitoneal shunt for hydrocephalus after the repair. He was treated for meningitis at the referring hospital without improvement. Computed tomography scan of the brain showed ventricular enlargement. The shunt was found to be broken and blocked and was revised. This was followed by rapid improvement but vision was never regained. Shunt malfunction in patients with spinal dysraphism can lead to visual loss but the features may mimic those of meningitis, and delayed referral and treatment. Early shunt revision should prevent this complication.

Acute Abdomen Caused by Migration of Ventriculoperitoneal Shunt Catheter into Transverse Colon: Report of a Case

Migration of ventriculoperitoneal (VP) shunt into the transverse colon (T-colon) is a rare complication. A 76-year-old female who had undergone the insertion of a VP shunt for hydrocephalus about 3 months previously complained of nausea and progressive abdominal pain in the past two days. Physical examination revealed mild tenderness in the epigastric region. Under the impression of suspected infection, the patient received an operation to remove the VP shunt. During the exploratory laparotomy, migration of the VP shunt into the T-colon was noted. After wedge resection and repair of the T-colon, together with re-implantation of the VP shunt 1 month later, the condition of the patient improved.

Symptomatic pleural effusion without intrathoracic migration of ventriculoperitoneal shunt catheter

Symptomatic pleural effusion following ventriculoperitoneal (VP) shunt insertion is very rare. The patient was an 8-year-old girl who had VP shunt for hydrocephalus as a result of aqueductal stenosis. Six weeks after surgery, she presented with headache, vomiting and drowsiness. She developed respiratory distress with pain in the right lower chest region and right hypochondrium on admission. Chest X-ray confirmed right hydrothorax and showed the tip of the peritoneal catheter in the right suprahepatic subphrenic space. Her symptoms abated after the catheter was repositioned from the subphrenic region to the general peritoneal cavity. Repeat chest X-ray confirmed the resolution of the hydrothorax. Shunt review without thoracocentesis or thoracostomy is an effective treatment of symptomatic hydrothorax following VP shunt, especially when there is no intrathoracic shunt migration.

Suppurative intracranial complications of sinusitis in children

Objective: A review of suppurative intracranial complications of sinusitis in children. Methods: Case series review over a two-year period from 1998 to 1999 in a children's hospital, Singapore. Results: There were seven cases, all male, and age range 9 to 14. Six had subdural empyemas and one had meningitis. The most common presenting symptoms included fever, headache and vomiting. Sinusitis was suspected as the cause in only one patient initially. The intracranial infections were not apparent from the initial brain CT of two patients and were only confirmed later on repeated imaging. Four patients had lumbar punctures without any adverse effects. All seven children had infections involving the frontal, ethmoid and maxillary sinuses and two also had sphenoid involvements. All were treated with high-dose intravenous antibiotics together with drainage of both the intracranial (n=six) and sinus (n=seven) suppurations. Five needed repeated intracranial drainages. Streptococcus species were isolated in five cases. Three patients developed seizures post-operatively which resolved on follow-up. One patient needed a ventriculo-peritoneal shunt for hydrocephalus. All patients had a good Glasgow Outcome Score. The hospital stay ranged from 30 to 89 days with a median of 43 days. Conclusions: Only males were identified in this review, collaborating the feeling that teenage males are at greatest risk of developing intracranial infections from sinusitis. We recommend that radiologic imaging of the brain for suspected intracranial infection should always include the sinuses as this aids early identification of actual cause. Initial CT imaging may be negative and hence repeated scans are warranted if the index of suspicion is high. The successful outcome of the children in this series supports the opinion that combined aggressive surgical and medical treatment is preferable in this patient population.

Thalamic cavernous malformations

BACKGROUND Only few anecdotal reports and small series of thalamic cavernous malformations have been reported. It follows that the clinical behavior and management are poorly understood; in particular, experiences with the surgical treatment of these lesions are scarce. METHODS The clinical course, treatment, and outcome of 12 patients (10 females and 2 males, mean age 36 years) with symptomatic cavernous malformations of the thalamus are reviewed. Eight patients (66%) presented with cerebral hemorrhage, one with progressive neurological deficit and three with hydrocephalus/increased intracranial pressure; associated venous anomalies were found in three cases. Treatment consisted of radical surgery in four cases with progressive neurological decline or recurrent disabling hemorrhage, radiosurgery (one case), evacuation of a chronic satellite hematoma (one case), ventriculoperitoneal shunt for hydrocephalus (one case) and observation (five cases). Operative treatment in four cases included transcallosal, trigonal, and occipital interhemispheric approaches. RESULTS In the surgical group, one patient died, two improved after operation, and one remained the same. Of the patients not operated on radically, one had recurrent hemorrhage 4 months after radiosurgery, one remains stable 8 years after ventriculoperitoneal shunt, and one 3 years after aspiration of a satellite hematoma. Five other patients presenting with thalamic hemorrhage were treated conservatively; recurrent hemorrhage occurred in two cases at 1 month and at 2 years, leaving a mild residual deficit in both cases. Overall, rehemorrhage occurred in four cases (50%) at a mean interval of 18 months after the first bleeding; the annual hemorrhage rate was 6.1%. CONCLUSIONS Thalamic malformations are more likely to be symptomatic from small hemorrhages compared with lesions in the cerebral hemispheres; progressive growth may also occur with third ventricle invasion or caudal extension to the midbrain. Their high-risk location deters heavy-handed management, but they should not be left long untreated. Both surgery and radiosurgery have been used in the management of thalamic cavernomas reported in the literature. Definite surgical indications include progressive neurological decline and recurrent hemorrhages of malformations abutting the ventricular surface or the posterior incisural space; the complex anatomy of the deep venous system and the association with unexpected venous anomalies complicates the removal of these lesions.