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.

Spinal Cord Subependymoma Surgery: A Multi-Institutional Experience

OBJECTIVE: A spinal cord subependymoma is an uncommon, indolent, benign spinal cord tumor. It is radiologically similar to a spinal cord ependymoma, but surgical findings and outcomes differ. Gross total resection of the tumor is not always feasible. The present study was done to determine the clinical, radiological and pathological characteristics of spinal cord subependymomas.METHODS: We retrospectively reviewed the medical records of ten spinal cord subependymoma patients (M : F=4 : 6; median 38 years; range, 21–77) from four institutions.RESULTS: The most common symptoms were sensory changes and/or pain in eight patients, followed by motor weakness in six. The median duration of symptoms was 9.5 months. Preoperative radiological diagnosis was ependymoma in seven and astrocytoma in three. The tumors were located eccentrically in six and were not enhanced in six. Gross total resection of the tumor was achieved in five patients, whereas subtotal or partial resection was inevitable in the other five patients due to a poor dissection plane. Adjuvant radiotherapy was performed in two patients. Neurological deterioration occurred in two patients; transient weakness in one after subtotal resection and permanent weakness after gross total resection in the other. Recurrence or regrowth of the tumor was not observed during the median 31.5 months follow-up period (range, 8–89).CONCLUSION: Spinal cord subependymoma should be considered when the tumor is located eccentrically and is not dissected easily from the spinal cord. Considering the rather indolent nature of spinal cord subependymomas, subtotal removal without the risk of neurological deficit is another option.

Spinal Cord Subependymoma Surgery: A Multi-Institutional Experience

OBJECTIVE: A spinal cord subependymoma is an uncommon, indolent, benign spinal cord tumor. It is radiologically similar to a spinal cord ependymoma, but surgical findings and outcomes differ. Gross total resection of the tumor is not always feasible. The present study was done to determine the clinical, radiological and pathological characteristics of spinal cord subependymomas. METHODS: We retrospectively reviewed the medical records of ten spinal cord subependymoma patients (M : F=4 : 6; median 38 years; range, 21–77) from four institutions. RESULTS: The most common symptoms were sensory changes and/or pain in eight patients, followed by motor weakness in six. The median duration of symptoms was 9.5 months. Preoperative radiological diagnosis was ependymoma in seven and astrocytoma in three. The tumors were located eccentrically in six and were not enhanced in six. Gross total resection of the tumor was achieved in five patients, whereas subtotal or partial resection was inevitable in the other five patients due to a poor dissection plane. Adjuvant radiotherapy was performed in two patients. Neurological deterioration occurred in two patients; transient weakness in one after subtotal resection and permanent weakness after gross total resection in the other. Recurrence or regrowth of the tumor was not observed during the median 31.5 months follow-up period (range, 8–89). CONCLUSION: Spinal cord subependymoma should be considered when the tumor is located eccentrically and is not dissected easily from the spinal cord. Considering the rather indolent nature of spinal cord subependymomas, subtotal removal without the risk of neurological deficit is another option.

Infratentorial and Intraparenchymal Subependymoma in the Cerebellum: Case Report

Subependymomas are rare benign tumors located in the ventricular system. Intraparenchymal subependymoma is extremely rare; only 6 cases have been reported, and all were located in the supratentorial region. We describe a case of infratentorial, intraparenchymal subependymoma in a 28-year-old man with intermittent headache. Imaging revealed a well-demarcated cystic and solid cerebellar mass near the fourth ventricle. The mass had a microcystic component and calcification without contrast enhancement. Complete surgical excision was performed, and histopathology confirmed a subependymoma.

Intramedullary Subependymoma of the Thoracic Spinal Cord

An Intramedullary subependymoma of the spinal cord is a rare tumor with only 43 reported cases in the literature. Most of them are reported to be localized within the cervical spinal cord. We report a rare case of a thoracic spine intramedullary subependymoma in a 37-year-old female who presented with back pain and radiating leg pain. Subtotal resection and post-operative radiotherapy were performed. Subependymomas developing in the spinal cord are benign with a low proliferative potential. Complete resection of the tumor appears to be the optimal method for a complete cure. However aggressive surgery may cause severe neurological deficit. Therefore, if severe neurological deficits are expected after complete removal, a partial removal and postoperative radiation therapy is an alternative method for treatment in selected cases. A large-scale randomized study is mandatory to clarify the effectiveness of radiotherapy and to establish the recurrence rate and prognosis with respect to the surgical removal of these tumors.

Cervical Subependymoma Presenting as an Extramedullary Tumor

A rare case of cervical subependymoma in a 45-year-old man is described. The tumor appeared as an extramedullary mass lesion, but a discrete, less well-demarcated portion was observed in the anterolateral part of the cord at the C3-C7 level. Previous reports of spinal subepnedymomas are reviewed, and nosological possibilities of extramedullary presentation are discussed.

Immunohistochemical Study of Central Neurocytoma, Subependymoma and Subependymal Giant cell Astrocytoma Located around the Foramen of Monro

OBJECT: To gather information concerning ontogeny, the authors present the results of immunohistochemical stainings of neuronal and glial markers and the reverse transcriptase-prolongation chain reaction (RT-PCR) of nestin for three intraventricular tumors located around the foramen of Monro. METHODS: Seven cases of central neurocytomas(CN), three subependymomas(SE) and eight subependymal giant cell astrocytomas(SEGA), were included in this study. Antihuman monoclonal antibodies of synaptophysin(SNP)(DAKO, 1:20), chromogranin A(ChrA)(DAKO, 1:100), neuron specific enolase (NSE)(DAKO, 1:500) and nerve cell adhesion molecule(NCAM)(Zymed, 1:500) were utilized for neuronal markers and glial fibrillary acidic protein(GFAP)(DAKO, 1:300) functioned as a glial marker in immunohistochemical(IHC) stainings. Reverse transcriptase polymerase chain reaction(RT-PCR) for nestin was performed in all cases. RESULTS: For chromogranin A, positive reaction was found in three of the seven CN cases but none of the SE and SEGA cases. For IHC staining of synaptophysin, positive reaction was revealed in all CN cases but in none of the SE and SEGA cases. For NCAM, positive reaction was demonstrated in five of the eight SEGA cases and in all SE and CN cases. For NSE, positive reaction was exhibited in seven of the eight SEGA cases and in all SE and CN cases. Positive reactions for NSE and NCAM in the SEGA cases were manifested mainly in the cytoplasms of giant cells and their background. For IHC staining of GFAP, positive reaction was demonstrated in one of the seven CN cases, in three of the eight SEGA cases, and in all SE cases. RT-PCR product of nestin was expressed in two of the seven CN cases, in two of the three SE cases, and in one SEGA case. CONCLUSION: Many cells of CN, SE and SEGA, had expressed positive reactions for both neuronal and glial markers in IHC study and nestin in RT-PCR. It is suggested that origin cells of these tumors might express both neuronal and glial differentiation.

MR Diagnosis of Intracranial Subependymomas / 实用放射学杂志

Objective To study the MR imaging features of intracranial subependymomas and to improve the knowledge more about it. Methods The imaging features of intracranial subependymomas in 17 cases proved pathologically were retrospectively analyzed, among which 11 cases were male and 6 cases were female, 16 cases had MR images and 1 case only had CT images.Results MR appearances of intracranial subependymomas were as follows :16 cases were all hyperintense relative to the normal grey matter on T2-weighted images and hypointense or isointense on T1-weighted images. 12 cases showed no enhancement or minimal enhancement after Gd-DTPA administration . 9 of 16 cases were located in lateral ventricle, 2 were in septum pellucidum, and the rest 5 were in fourth ventricle ,third ventricle ,prepontine cistern, right CPA and chiasmatic cistern respectively. In one case , CT showed isodensity and was enhanced in CE-CT,the lesion was situated in fourth ventricle. In all 17 cases, 11 were accompanied with microcystic structures. Conclusion Intracranial subependymomas are best delineated by MR imaging. The diagnosis of intracranial subependymomas should be considered when above findings are confronted.

Symptomatic subependymoma: a case report

Subependymoma is a rare, slow-growing, benign noninvasive tumor of the central nervous system that may be located in the fourth ventricle, the septum pellucidum, the third and the lateral ventricles, the aqueduct, and the proximal spinal cord. Symptoms, if any, usually result either from direct compression of the brain stem or from acute hydrocephalus due to occlusion of the foramen of Monro or aqueduct of Sylvius. In this report, we describe a case of subependymoma of the lateral ventricle with headache in a young female patient. This is the first reported case subependymoma in Korea that was documented along with Magnetic resonance image.