Case report: A choroidal fissure pial arteriovenous malformation inducing venous congestive edema of the medulla oblongata and cervicothoracic spinal cord presented with proximal arm predominant weakness.

Intracranial dural arteriovenous fistula (DAVF) can induce remote myelopathy via spinal perimedullary venous drainage. In the present study, we report a rare case of intracranial pial arteriovenous malformation (AVM)-related myelopathy. A 52-year-old man presented with progressive, predominantly proximal weakness and muscle atrophy in bilateral upper limbs, urinary retention, and hyperreflexia in bilateral upper and lower limbs. Brain and cervicothoracic MRI showed longitudinal myelopathy extending from the medulla oblongata to the T6 level, with perimedullary enlarged veins from the C1 to T12 level, and remarkable enhancement in bilateral anterior horns from the C2 to C7 level. Cerebral angiography revealed a choroidal fissure AVM, which was supplied by the left anterior choroidal artery and drained exclusively by an inferior ventricular vein descending toward the spinal perimedullary veins. After endovascular embolization of the feeding pedicle, nidus, and proximal segment of the draining vein, the patient's neurological deficits rapidly improved, and a significant recovery was achieved 3 months after the procedure. This rare case indicates that intracranial pial AVM can also cause extensive congestive myelopathy with similar mechanisms underlying intracranial and craniocervical DAVF cases, and gray matter in the spinal cord might be more susceptible to ischemia induced by intraspinal venous hypertension.

Posterior-Transcallosal Approach to a Choroidal Fissure Arteriovenous Malformation: Video of Adapting a "Bridging Vein Free" Corridor to This Complex Region.

Choroidal fissure arteriovenous malformations (ChFis-AVMs) are uncommon and challenging to treat due to their deep location and pattern of supply.1 The choroidal fissure lies between the thalamus and fornix, from the foramen of Monroe to the inferior choroidal point.2 AVMs in this location receive their supply from the anterior, lateral posterior choroidal artery and medial posterior choroidal arteries and drain to the deep venous system.3 The anterior-transcallosal corridor to the ChFis is favored due to the ease in opening the taenia fornicis from the foramen Monroe, and it increases in length for lesions located more posteriorly.4-7 We present a case of a posterior ChFis-AVM. The patient, a previously healthy woman in her 20s, presented with a sudden severe headache. She was diagnosed with intraventricular hemorrhage. This was managed conservatively with subsequent magnetic resonance imaging and digital subtraction angiography revealing a ChFis-AVM at the body of the left lateral ventricle, between the fornix and superior layer of the tela choroidae. It received its supply from the left lateral posterior choroidal artery and medial posterior choroidal artery and drained directly into the internal cerebral vein, classified as Spetzler-Martin grade II.8 A posterior-transcallosal approach to the ChFis was chosen to reduce the working distance and afford a wider corridor by avoiding cortical bridging veins (Video 1). Complete resection of the AVM was achieved with no additional morbidity. Microsurgery in experienced hands offers the best chance of cure for AVMs.9 In this case we demonstrate how to adapt the transcallosal corridor to the choroidal fissures for safe AVM surgery in this complex location.

Surgical treatment of a patient with a giant choroidal fissure cyst: a case report.

INTRODUCTION: Choroidal fissure cysts (CFC) are usually an incidental finding on imaging and lead to morbidity only in rare cases. The aim of this study was to present the case of a patient with a giant CFC and its treatment. CASE REPORT: The patient was a male infant of 9 days of life that presented with symptoms of intracranial hypertension. A CFC measuring 56 × 70 × 86 mm was diagnosed. Endoscopic fenestration of the cyst was performed; however, the communication closed thereafter. A reservoir catheter was inserted, which subsequently became infected and was then replaced by a ventriculoperitoneal shunt. DISCUSSION: The choroidal fissure is a C-shaped cleft located between the fornix and the thalamus separated from the temporal horn by the layer of tela choroidea. The pathophysiology of CFC is still unclear. In our case, initial endoscopic treatment was decided on to avoid shunt-related complications. Currently, there are no guidelines for the best surgical treatment for CFC. CONCLUSION: We describe an atypical case of CFC and analyze the surgical treatment performed. Although endoscopic treatment is recommended for CFC, currently no guidelines exist regarding the best management of the entity.

Microsurgical and Tractographic Anatomical Study of Transtemporal-Transchoroidal Fissure Approaches to the Ambient Cistern.

BACKGROUND: Approaching ambient cistern lesions is still a challenge because of deep location and related white matter tracts (WMTs) and neural structures. OBJECTIVE: To investigate the white matter anatomy in the course of 3 types of transtemporal-transchoroidal fissure approaches (TTcFA) to ambient cistern by using fiber dissection technique with translumination and magnetic resonance imaging fiber tractography. METHODS: Eight formalin-fixed cerebral hemispheres were dissected on surgical corridor from the temporal cortex to the ambient cistern by using Klingler's method. The trans-middle temporal gyrus, trans-inferior temporal sulcus (TITS), and trans-inferior temporal gyrus (TITG) approaches were evaluated. WMTs that were identified during dissection were then reconstructed on the Human Connectome Project 1021 individual template for validation. RESULTS: The trans-middle gyrus approach interrupted the U fibers, arcuate fasciculus (AF), the ventral segment of inferior frontoocipital fasciculus (IFOF), the temporal extensions of the anterior commissure (AC) posterior crura, the tapetum (Tp) fibers, and the anterior loop of the optic radiation (OR). The TITS approach interrupted U fibers, inferior longitudinal fasciculus (ILF), IFOF, and OR. The TITG approach interrupted the U fibers, ILF, and OR. The middle longitudinal fasciculus, ILF, and uncinate fasciculus (UF) were not interrupted in the trans-middle gyrus approach and the AF, UF, AC, and Tp fibers were not interrupted in the TITS/gyrus approaches. CONCLUSION: Surgical planning of the ambient cistern lesions requires detailed knowledge about WMTs. Fiber dissection and tractography techniques improve the orientation during surgery and may help decrease surgical complications.

Temporal choroidal fissure cyst: a rare cause of temporal lobe epilepsy.

Only a few cases of temporal choroidal fissure cyst are reported. We describe a new case of an 8 years old girl who manifested complex partial seizure. The diagnosis was made by magnetic resonance imagining (MRI). The signal intensity of the cyst was identical to the cerebrospinal fluid (CSF), and the underlying hippocampus was compressed by the cyst. The seizures were medically controlled. The value of MRI in the diagnosis and medical treatment will be discussed.

Endoscopic-Assisted Translateral Ventricular Transchoroidal Fissure Approach for Evacuation of Medial-Type Thalamic Hemorrhage: Case Series.

BACKGROUND: Although surgeries for intracerebral hemorrhage remain controversial, endoscopic surgery is considered a promising surgical treatment. The most fatal type of thalamic hemorrhage is the medial type, which is always combined with expansion of the hematoma into the third ventricle. The current endoscopic approach to this lesion involves injury to the mediodorsal nucleus of the thalamus (MDT). CASE DESCRIPTION: We report 5 cases of medial thalamic hemorrhage with third intraventricular involvement treated by an endoscopic-assisted translateral ventricular transchoroidal fissure approach. The preoperative average volume of the parenchymal hematomas was 9.63 mL, while the preoperative average volume of the intraventricular hematomas was 23.35 mL. The average surgical duration was 80.6 minutes. No intraoperative MDT incision was needed in any patient. The evacuation rates of parenchymal and intraventricular hematomas were 74.21%-98.84% and 85.89%-99.51%, respectively. Three months after the surgery, the average Glasgow Coma Scale scores improved to 13.8 from 7.2 preoperatively. No ventriculoperitoneal shunt was needed in any patient. CONCLUSIONS: The endoscopic-assisted translateral ventricular transchoroidal fissure approach is a safe and effective approach for evacuation of a medial thalamic hemorrhage with third intraventricular involvement. This approach allows parenchymal hematoma evacuation through the rupture of the third ventricle without incising the MDT in the lateral ventricle.

Choroidal fissure and choroidal fissure cysts: a comprehensive review.

In this paper, the authors discuss the embryology and anatomy of the choroidal fissure, as well as the pathophysiology and treatment of cerebrospinal fluid cysts of this structure. Understanding its anatomical relations to nearby structures plays an essential role during brain surgeries. With the advancement and availability of imaging techniques, lesions of the choroidal fissure are often found incidentally. Patients are usually asymptomatic or exhibit symptoms that do not correlate with anatomical location or do not require surgical treatment. The choroidal fissure is a key landmark used during brain surgery. Therefore, a comprehensive understanding of it and nearby anatomical structures is essential. Choroidal fissure cysts can be found incidentally, and well-known key features will allow one to differentiate them from other lesions. Surgical treatment should be reserved for symptomatic patients while asymptomatic patients should be monitored.

Endoscopic Transforaminal Transchoroidal Approach to the Third Ventricle for Cystic and Solid Tumors.

BACKGROUND: Endoscopic access to the third ventricle is limited by the confinements of the foramen of Monro and can be aided by opening of the choroidal fissure. OBJECTIVE: We describe the endoscopic transforaminal transchoroidal (ETTC) approach to the third ventricle with opening of the choroidal fissure to enlarge the posterior foramen of Monro for treatment of various third ventricular diseases. METHODS: We completed a retrospective review of a prospectively collected database at 3 tertiary academic facilities. The search included patients who underwent endoscopic transcranial procedures between 2005 and 2018. All 13 patients included in this study were treated using the ETTC approach for lesions in the third ventricle using a rigid 6-mm working endoscope. RESULTS: There were 7 women and 6 men with a mean age of 44 years (standard deviation, 16 years). Third ventricular diseases included colloid cyst, craniopharyngioma, anaplastic astrocytoma, subependymal giant cell astrocytoma, metastatic lung adenocarcinoma, and lymphoma. Resection was complete in 7 patients and near complete in 4. Two patients had biopsy of a thalamic tumor and third ventriculostomy. The mean follow-up time was 44 months (standard deviation, 36 months; range, 9-121 months). There were no intraoperative or postoperative complications related to the approach. CONCLUSIONS: ETTC approach is a safe and effective method for enlargement of the foramen of Monro. The approach improves maneuverability of the endoscope and allows a broad range of movement and increased angulation within the foramen of Monro. Attention to anatomy is paramount to avoid injury to the venous structures and fornix.

Microsurgical treatment for arteriovenous malformation of the corpus callosum and choroidal fissure.

The management of arteriovenous malformations (AVMs) of the corpus callosum and choroidal fissure is challenging because they commonly receive arterial feeders from the anterior and posterior circulation, and drain to deep veins. In this video the authors present the case of a 20-year-old man who presented with acute onset of headache, loss of consciousness, and nuchal rigidity. Computed tomography, MRI, and cerebral angiography performed in tandem revealed a ruptured, large, Grade IV AVM of the corpus callosum and choroidal fissure with two groups of arterial feeders: one from the pericallosal artery and the other from the medial and lateral posterior choroidal arteries. The treatment strategy included two stages. The first stage involved preoperative embolization of the arterial feeders from the posterior circulation, which promoted reduction of the nidus flow of the AVM. The second involved a microsurgical resection, using the interhemispheric approach, with the patient in the prone position, which allowed accessing the anterior circulation feeders and the complete resection of the AVM, without associated morbidity. The video can be found here: https://youtu.be/5wcYKhcJtls .

Contralateral transcallosal resection of a ventricular body arteriovenous malformation: 3D operative video.

A 46-year-old male presented with an incidentally discovered left ventricular body arteriovenous malformation (AVM). It measured 2 cm in diameter and had drainage via an atrial vein into the internal cerebral vein (Spetzler-Martin Grade III, Supplementary Grade 4). Preoperative embolization of the posterior medial choroidal artery reduced nidus size by 50%. Subsequently, he underwent a right-sided craniotomy for a contralateral transcallosal approach to resect the AVM. This case demonstrates strategic circumferential disconnection of feeding arteries (FAs) to the nidus, the use of aneurysm clips to control large FAs, and the use of dynamic retraction and importance of a generous callosotomy. Postoperatively, he was neurologically intact, and angiogram confirmed complete resection. The video can be found here: https://youtu.be/j0778LfS3MI .

Selective embolization of ruptured feeding artery aneurysm followed by resection of arteriovenous malformation.

This is the case of a man in his 40s who suffered sudden collapse into a deep coma as a result of a ruptured arteriovenous malformation (AVM) feeding artery aneurysm within the lateral ventricle. The ruptured aneurysm was successfully treated with Onyx embolization of the feeding pedicle. The AVM and the feeding artery aneurysm were then removed via a transcallosal approach. This case highlights the utility of interrogating the AVM with microcatheterization of the feeding pedicles in order to define the exact anatomical features necessary for treatment planning. It also reviews the anatomy of the choroidal fissure. The video can be found here: https://youtu.be/UeqFzhTRU1Q .

Growing Hemorrhagic Choroidal Fissure Cyst.

Choroidal fissure cysts are often incidentally discovered. They are usually asymptomatic. The authors report a case of growing and hemorrhagic choroidal fissure cyst which was treated surgically. A 22-year-old female presented with headache. Cranial MRI showed a left-sided choroidal fissure cyst. Follow-up MRI showed that the size of the cyst had increased gradually. Twenty months later, the patient was admitted to our emergency department with severe headache. MRI and CT showed an intracystic hematoma. Although such cysts usually have a benign course without symptoms and progression, they may rarely present with intracystic hemorrhage, enlargement of the cyst and increasing symptomatology.

Growing Hemorrhagic Choroidal Fissure Cyst

Choroidal fissure cysts are often incidentally discovered. They are usually asymptomatic. The authors report a case of growing and hemorrhagic choroidal fissure cyst which was treated surgically. A 22-year-old female presented with headache. Cranial MRI showed a left-sided choroidal fissure cyst. Follow-up MRI showed that the size of the cyst had increased gradually. Twenty months later, the patient was admitted to our emergency department with severe headache. MRI and CT showed an intracystic hematoma. Although such cysts usually have a benign course without symptoms and progression, they may rarely present with intracystic hemorrhage, enlargement of the cyst and increasing symptomatology.

Incidental findings on brain and spine imaging in children.

In recent years, the utilization of diagnostic imaging of the brain and spine in children has increased dramatically, leading to a corresponding increase in the detection of incidental findings of the central nervous system. Patients with unexpected findings on imaging are often referred for subspecialty evaluation. Even with rational use of diagnostic imaging and subspecialty consultation, the diagnostic process will always generate unexpected findings that must be explained and managed. Familiarity with the most common findings that are discovered incidentally on diagnostic imaging of the brain and spine will assist the pediatrician in providing counseling to families and in making recommendations in conjunction with a neurosurgeon, when needed, regarding additional treatments and prognosis.

Neuroanatomical correlation between choroid plexus mass in thechoroidal fissure and the interventricular foramen area

Introduction: Our aim was to evaluate the correlation between choroid plexus mass (g) in the choroidalfissure and the ipsilateral interventricular foramen area, bilaterally. Material and methods: We analyzed sevencadaveric specimens with exposed brain, reaching the transcallosum access in all specimens, dissecting thecorpus callosum to reach the left and right choroidal fissure. After identifying the thalamostriate and septalveins, we localized the interventricular foramen scrapping all the choroid plexus in that region as well asits posterior extension allowing us to completely visualize the III ventricle. The area of the interventricularforamen was calculated with a pachimeter using the formula ðR2. The choroid plexus mass was measured withan appropriate scale. The choroid plexus mass and ipsilateral interventricular foramen correlation was evaluatedby the Pearson correlation. Results and conclusion: Neither difference between right and left choroid plexusmass was observed (Student t test – p = 0.374) nor with interventricular foramen area (p = 0.345) andwe decided to evaluate the 14 results together. There was correlation between choroid plexus mass and itsrespective IF (r = 0.6863; p < 0.01). A better knowledge of the choroidal fissure is very important to a moreprecise approach to the pathologic processes that affect the III ventricle. Different from the transforaminal,interforniceal, subchoroidal, and subforniceal, the choroidal fissure access is a natural approach. We speculatethat undetermined etiology hydrocephaly may have its origins in a deficit of ventricular drainage or in thechoroid plexus excess.

Newborn with prenatally diagnosed choroidal fissure cyst and panhypopituitarism and review of the literature.

Little has been reported on fetal diagnosis of choroidal fissure cysts and prediction of the clinical complications that can result. We describe the case of a near-term male infant with prenatally diagnosed choroidal fissure cyst and bilateral clubfeet. His prolonged course in the neonatal intensive care nursery was marked by severe panhypopituitarism, late-onset diabetes insipidus, placement of a cystoperitoneal shunt, and episodes of sepsis. Postnatal genetic evaluation also revealed an interstitial deletion involving most of band 10q26.12 and the proximal half of band 10q26.13. The patient had multiple readmissions for medical and surgical indications and died at 6 months of age. This case represents the severe end of the spectrum of medical complications for children with choroidal fissure cysts. It highlights not only the importance of comprehensive evaluation and multidisciplinary management and counseling in such cases, but also the need for heightened vigilance in these patients.

Temporal choroidal fissure cyst and temporal lobe epilepsy: report of two cases / Cistos da fissura coroidal temporal e epilepsia do lobo temporal: dois relatos de casos

STUDY DESIGN: Two case reports of a choroidal fissure cyst in the temporal horn associated with complex partial seizure. OBJECTIVES: To describe the clinical course, image findings and literature review of choroidal fissure cysts. SUMMARY AND BACKGROUND DATA: there are few reported cases of choroidal fissure cysts. RESULTS: We report two patients with complex partial seizures and temporal choroidal fissure cysts. The seizures were controlled in both patients. CONCLUSION: The choroidal fissure cyst diagnosis must highlight the importance of considering this lesion in the differential diagnosis of temporal lobe cyst and temporal lobe seizure.

DESENHO DO ESTUDO: Dois relatos de caso de cisto de fissura coroidal no corno temporal associado com crise parcial complexa. OBJETIVOS: Descrever o curso clínico, achados radiológicos e fazer uma revisão da literatura a respeito de cistos da fissura coroidal. RESUMO DOS DADOS DA LITERATURA: existem poucos casos descritos de cistos da fissura coroidal. RESULTADOS: Nós descrevemos dois pacientes com crises parciais complexas e cistos de fissura coroidal. As crises foram controladas em ambos os pacientes. CONCLUSÃO: O diagnóstico de cisto da fissura coroidal deve ser levado em conta no diagnóstico diferencial de cistos do lobo temporal e em crises de lobo temporal.

Microsurgical Anatomy of the Choroidal Fissure

The authors had studied the microsurgical anatomy of the choroidal fissure and the operative approaches directed through the fissure. In this study, eight formalin-fixed cadaveric hemisheres were examined. In four hemispheres, the intracranial vessels were perfused with colored silicone latex. The choroidal fissure is divided into three portion : (a) body portion, (b) atrial portion, and (c) temporal portion. Dissection through the body portion of the choroidal fissure exposes the velum interpositum, internal cerebral vein, and third ventricle. The quadrigeminal cistern, pineal region, and posterior part of the ambient cistern can be exposed through the atrial portion of the choroidal fissure. Opening through the temporal portion of the choroidal fissure exposes the structures in the ambient cistern, which include the basal vein, posterior cerebral artery, anterior and lateral posterior choroidal arteries, and hippocampal formation. This study provides valuable knowledges of microsurgical approaches to the third ventricle and basal cistern by demonstrating the neural nd vascular relaionship around the choroidal fissure.

MR imaging of choroidal fissure cyst of the brain / 中华放射学杂志

Objective To investigate the MR manifestations and diagnostic value in patients with choroidal fissure cyst of the brain. Methods Characteristic MR findings in 16 patients with choroidal fissure cyst were retrospectively analyzed, and the correlation between MR imaging and clinical manifestations was reviewed. Results The cysts were situated within the choroidal fissure in all cases, representing as cystic lesion with clear border, no detectable soft tissue mass in the cyst wall or adjacent area, homogenous signal intensity identical to CSF on all sequences, with the average size of 0.9 cm?1.3 cm?1.5 cm, and no associated edema. Gd-DTPA was performed in 6 cases and revealed no evidence of enhancement. Conclusion The choroidal fissure cyst of the brain is a benign and congenital developmental abnormality, and has minor clinical significance. Because of its specific anatomic location, the choroidal fissure cysts simulate intraparenchymal cystic lesions on axial images. Coronal and sagittal MR imaging can be used to delineate its extraaxial location and make the correct diagnosis, and, thus, differentiate with other cystic lesions.