Resección Tubular Microquirúrgica de un Subependimoma Extenso del Ventrículo Lateral Izquierdo: Video Operatorio en 2D / Microsurgical Tubular Resection of an Extensive Subependymoma of the Left Lateral Ventricle: Operative Video in 2D

Introducción: Los subependimomas intracraneales son raros, representan el 0.2-0.7% de todos los tumores del sistema nervioso central1,2 y se originan en los ventrículos laterales en el 30-40% de los casos.3 Los síntomas usualmente se asocian a hipertensión endocraneana secundaria a hidrocefalia obstructiva.4 La resección completa del tumor es curativa en esta patología.5 El abordaje trans-surcal es seguro para lesiones ventriculares profundas y el uso de los retractores tubulares minimizan la retracción del parénquima cerebral evitando la compresión directa con valvas. Esto permite disminuir la presión del tejido cerebral que puede ocluir los vasos y producir isquemia local generando una lesión neurológica permanente. Descripción del caso: Se presenta el caso de una paciente de 66 años, diestra, con cefalea crónica que aumenta en frecuencia en el último mes. La resonancia cerebral contrastada muestra un tumor extenso en el ventrículo lateral izquierdo con signos de hidrocefalia obstructiva. Intervención: Se coloca la paciente en posición supina. Se hace una incisión bicoronal y se hace un abordaje trans-surcal F1/F2 izquierdo. Se coloca un retractor tubular guiado con el puntero de neuronavegación, introduciéndolo directamente en el parénquima cerebral y fijándolo al soporte de Leyla. Se colocó un catéter de ventriculostomía contralateral y se retira a las 48 horas sin complicaciones asociadas. La resonancia contrastada postoperatoria demuestra una resección completa del tumor. El análisis de patología reveló un subependimoma grado I de la clasificación de la Organización Mundial de la Salud. La paciente presentó transitoriamente apatía y pérdida del control del esfínter urinario que resolvieron completamente a las 3 semanas después de la cirugía. Se firmó un consentimiento firmado para la publicación de la información utilizada en este trabajo. Conclusión: La resección completa microscópica de un subependimoma extenso del ventrículo lateral izquierdo es factible a través de un abordaje tubular transulcal.

Introduction: Intracranial subependymomas are rare, representing only 0.2-0.7% of all central nervous system tumors1,2 and arise in the lateral ventricles in 30-40% of the cases.3 Symptoms depend on tumor location and usually arise when the cerebrospinal fluid (CSF) is blocked, generating a consequent intracranial hypertension.4 Microsurgical gross-total resection is possible and curative for these tumors.5 The transcortical/trans-sulcal approach is a safe approach for the access of deep-seated intraventricular lesions. The use of tubular retractor systems minimizes retraction injury when passing through the cortex and deep white matter tracts. This allows a decrease in the pressure on brain tissue that can occlude the brain vessels and produce local ischemia and a consequent permanent neurological injury. Case description: This is a case of a 66-year-old woman who presented chronic headaches that increased in frequency in the last month. Enhanced-brain MRI demonstrated a large left ventricular lesion with signs of obstructive hydrocephalus. Procedure: Patient was positioned supine. A bicoronal incision was used to perform a left frontal craniotomy. An F1/F2 transcortical/trans-sulcal approach was used. A guided tubular retractor is placed with the neuronavigation pointer, inserting it directly into the brain parenchyma and fixing it to the Leyla support. Postoperative postcontrast MRI demonstrated a complete resection of the tumor. Histopathological analysis revealed a subependymoma (World Health Organization Grade I). The patient presented transient apathy and loss of urinary sphincter control that completely resolved 3 weeks after surgery. Written informed consent was obtained for publication of information used for this work. Conclusions: A complete microsurgical resection of a large left ventricular subependymoma is feasible through a trans-sulcal tubular approach.

Collision Tumor Composed of Meningioma and Cavernoma

A true collision tumor is a rare entity composed of two histologically distinct neoplasms coinciding in the same organ. This paper reports a unique case of cerebral collision tumor consisting of two benign components. On the first hand, meningioma which is usually a benign lesion arising from the meningothelial cell in the arachnoidal membrane. On the other, cerebral cavernoma which is a well-circumscribed, benign vascular hamartoma within the brain. To our knowledge, there is no previously documented case of cerebral collision tumor consisting of two benign components. A 56-year-old Caucasian male suffered in 2002 from an atypical meningioma WHO II° located in the left lateral ventricle. Three years after the tumor extirpation, the patient suffered from a hematoma in the fourth ventricle due to a recurrently haemorrhaged cavernoma. In 2008, a recurrence of the tumor in the left lateral ventricle was discovered. Additionally, another tumor located in the quadrigeminal lamina was detected. After surgical resection of the tumor in the left lateral ventricle, the pathological examination confirmed the diagnosis of a collision tumor consisting of components of a meningioma WHO II° and a cavernoma. Postoperatively, no adjuvant treatment was needed and no tumor recurrence is discovered up to the present. A possible explanation for the collision of those two different tumors may be migration of tumor cells mediated by the cerebrospinal fluid. After 5-years of follow-up, there is no sign of any tumor recurrence; therefore, surgical tumor removal without adjuvant therapy seems to be the treatment of choice.

Meningiomas intraventriculares: reporte de 7 casos y revisión bibliográfica / Intraventricular meningiomas: report of 7 cases and bibliographic review

Introducción: Los meningiomas intraventriculares tienen una baja prevalencia. Dado su origen en plexos coroideos o tela coroidea presentan predilección por los ventrículos laterales. Suelen ser de gran tamaño al momento diagnóstico y de histología preponderantemente benigna. Materiales y Métodos: Realizamos revisión retrospectiva de historias clínicas de pacientes operados de estos tumores durante el período 1999-2014, en nuestra institución junto a una revisión bibliográfica. Resultados: Se operaron siete pacientes con meningiomas intraventriculares de los cuales seis tuvieron localización atrial, cinco fueron derechos y uno izquierdo; el caso restante corresponde a una lesión del IV ventrículo. Todos fueron de sexo femenino con edad promedio de 49 años. La presentación clínica prevalente fue cefalea, trastorno cognitivo leve y hemianopsia homónima en los tumores supratentoriales. Disfunción trigeminal y facial periférica izquierda, disfagia y ataxia troncal se observaron en la lesión del IV ventrículo. Se realizaron dos abordajes parietales, uno precuneal, tres temporales y un abordaje telovelar. En el postoperatorio, 2 pacientes presentaron hemianopsia homónima secuelar. Dos pacientes presentaron signos de atipia por lo cual recibieron radioterapia postoperatoria. Conclusión: Dada su escasa prevalencia el objetivo quirúrgico en meningiomas intraventriculares es la remoción completa con la menor morbilidad postoperatoria posible. En los casos atípicos sugerimos realizar radioterapia postoperatoria para reducir el riesgo de recidivas.

Introduction: Intraventricular meningioma’s have a low prevalence. Given its origin in choroid plexus or tela choroidea presents predilection by the lateral ventricles. They tend to be large at the time of diagnosis and predominantly benign histology. Methods: We performed retrospective review records of patients operated of intraventricular meningioma’s during the period 1999-2014 in our institution with a review of the literature. Development: We operated seven patients with these tumors, six with atrial location, five were right and one left; the remaining case corresponds to a lesion in the fourth ventricle. All were female with an average age of 49 years. The prevalent clinical presentation was headache, mild cognitive disorder and homonymous hemianopsia in supratentorial tumors. Trigeminal and peripheral left facial dysfunction, dysphagia and central ataxia were observed in the lesion of the fourth ventricle. Parieto-occipital two approaches, one interhemispheric precuneal approach, three temporal and a telovelar approach were carried out. Postoperatively, two patients had homonymous hemianopsia. Two patients presented signs of atypia which received postoperative radiation therapy.Conclusion: Given its low prevalence the surgical goal in intraventricular meningiomas is complete removal with less possible postoperative morbidity. In atypical cases we suggest to perform postoperative radiotherapy to reduce risk of recurrence.

Neuroendoscopia / Neuroendoscopy

O procedimento endoscópico tem sido bastante utilizado na neurocirurgia para tratamento de várias patologias. Atualmente, vários procedimentos são realizados de forma mais simples com melhores resultados para o paciente. Os autores deste artigo fazem uma revisão do tratamento neuroendoscópico para as hidrocefalias, tumores intraventriculares e os cistos de aracnoide...

Meningeoma de terceiro ventrículo em criança / Third ventricle meningioma in a child

Meningeomas localizados nos ventrículos são bastante raros, ocorrendo em torno de 1,5% a 2% dos casos, e no terceiro ventrículo localizam-se apenas 15% desses. O processo torna-se mais raro quanto menor a idade. Apresentamos um caso de meningeoma de terceiro ventrículo, com expansão para os ventrículos laterais, principalmente o direito, em uma criança de 11 anos. Segundo a família, aos 9 anos apresentou cefaléia e, na época, atendida por neurologista, foi medicada com fenitoína, tendodesaparecido o quadro. Três meses antes de procurar o nosso Serviço, começou novamente a ter cefaléia di fusa, de caráter progressivo. Foi submet ida a exames que most raram processo expansivo no terceiro ventrículo, com expansão para ventrículos laterais, bastante vascularizado, bem delimitado e originando-se ao nível do plexo coróide. Foi submetida à cirurgia e o diagnóstico histopatológico foi de meningeoma psamomatoso.

Meningiomas located in the cerebral ventricles are quite rare, being reported in 1.5% to 2% of all cases, and only 15% of these are located in the third ventricle. The process becomes rarer as the age decreases.We present a case of meningioma of the third ventricle, with expansion into the lateral ventricles, mainly to the right, in a 11 year-old girl. According to her family, two years before admission in our Service she presented headache; phenytoin prescribed elsewhere had alleviated the complaint.Three months before she started again to have diffuse and progressive headaches. She was submitted to CT and MRI that showed a well delimited tumor in the third ventricle with expansion into the lateral ventricles.She was submitted to surgery and the histopathology confirmed the diagnosis of psamomatosus meningioma.