SPONTANEOUS VENTRICULAR RUPTURE IN HYDROCEPHALUS, WITH SUBTENTORIAL CYST FORMATION

Third ventricular diverticulum of the suprapineal recess can be a rare and confounding complication of chronic hydrocephalus: A case report with 2-year follow-up

PURPOSE

Chronic hydrocephalus is rarely seen in developed countries due to the widespread availability of CT scans for diagnosis and early treatment. In developing countries, it is more frequently encountered along with its rare complication of diverticulum formation.

METHODS

We report a case of a previously healthy 6 year old girl who presented with a 10 day history of headache, 3 day history of drowsiness and a single episode of generalized tonic clonic seizures. We review the literature on such cases and include imagining studies at follow up.

RESULTS

A CT scan done outside our hospital had been reported to be demonstrating a posterior fossa arachnoid cyst with resultant obstructive hydrocephalus. We first placed an external ventricular drain and performed an MRI of the brain to further characterize the lesion. It was again reported as an arachnoid cyst but on further scrutiny it was appreciated that it was in fact a third ventricular diverticulum of the suprapineal recess. She underwent ventriculoperitoneal shunt placement which led to resolution of the hydrocephalus as well as the diverticulum.

CONCLUSION

These diverticulae develop secondary to ventricular rupture in the setting of chronic untreated hydrocephalus. This pathology was first described in 1940 and over the years its identification has decreased due to a much lower incidence of chronic untreated hydrocephalus.

Women Neuroscientist Disciples of Pío del Río-Hortega: the Cajal School Spreads in Europe and South America

Pio del Rio-Hortega was not only the discoverer of the microglia and oligodendroglia but also possibly the most prolific mentor of all Santiago Ramon y Cajal’s disciples (Nobel awardee in Physiology or Medicine 1906 and considered as the father of modern Neuroscience). Among Río-Hortega’s mentees, three exceptional women are frequently forgotten, chronologically: Pio’s niece Asunción Amo del Río who worked with Río-Hortega at Madrid, Paris, and Oxford; the distinguished British neuropathologist Dorothy Russell who also worked with Don Pío at Oxford; and Amanda Pellegrino de Iraldi, the last mentee in his career. Our present work analyzes the figures of these three women who were in contact and collaborated with Don Pío del Río-Hortega, describing the influences received and the impact on their careers and the History of Neuroscience. The present work completes the contribution of women neuroscientists who worked with Cajal and his main disciples of the Spanish Neurological School both in Spain (previous work) and in other countries (present work).

Spontaneous hemispheric ventricular collapse and subarachnoid haemorrhages in a dog with congenital hydrocephalus internus

Background

Overdrainage and collapse of the hemispheres is a potential severe complication after surgical treatment of internal hydrocephalus using ventriculoperitoneal shunts. Here we describe a case of a spontaneous hemispheric ventricular collapse in an untreated dog with congenital hydrocephalus internus.

Case presentation

A twelve-week-old, male, intact Golden Retriever was presented with a history of peracute obtundation, impaired vision, and progressive gait abnormalities of all limbs for three days. Neurological examination revealed a dome shaped skull, a broad-based stance and a moderate cerebellar ataxia. The postural responses were markedly delayed in all limbs. Moderate ventro-lateral strabismus, vertical nystagmus and absent menace response were observed bilaterally. Clinical signs indicated multifocal localisation (forebrain, cerebellum). Magnetic resonance imaging (MRI) showed dilation of all cerebral ventricles, irregular thinning of the periventricular white and grey matter, consistent with internal hydrocephalus. In addition, the hemispheres were collapsed at the right temporal and left frontal lobe with haemorrhage filling the adjacent subarachnoid space. The dog underwent left frontal and right temporal craniotomy for removal of the haemorrhage. The dog improved on all neurological signs and was discharged after seven days. A repeat MRI three months postsurgical intervention showed reexpansion of the cerebral hemispheres. Subarachnoid haemorrhages were markedly reduced.

Conclusions

Collapse of the hemispheres can occur spontaneously in dogs with hydrocephalus internus. Removal of the haemorrhage can improve clinical signs.

Joseph Buford Pennybacker, C.B.E., M.D., F.R.C.S. (1907-1983): Continuing Sir Hugh Cairns' Oxford Legacy and Pioneer of the Modern Management of Cerebral Abscesses

The authors examine the life and contribution of Joseph Buford Pennybacker to British neurosurgery and the modern management of cerebral abscesses. Pennybacker's inspirational journey began with him aspiring to follow in the footsteps of the pioneering surgeon, Ephraim McDowell. It saw him cross the Atlantic, learn medicine at Edinburgh, train in neurology at Queen Square in London, and study neurosurgery under Sir Hugh Cairns in Oxford. Pennybacker navigated a successful career through World War II and together with Cairns established the Radcliffe Infirmary in Oxford as a highly esteemed neurosurgical unit. By increasing the operative tempo yet uncompromising the meticulousness of his operative technique, Pennybacker challenged the Halstedian and Cushing traditions. The pioneering Pennybacker system of managing cerebral abscesses stood the test of time and the ethos of preoperative imaging, intervention, and postoperative monitoring-clinically, biochemically, and with imaging results-remains today. Pennybacker contributed significantly to British neurosurgery and the training of both home-grown and international neurosurgeons and he was also a remarkably kind-hearted and calm individual. These qualities inspired many of his contemporaries and junior colleagues, and we hope will continue to do so for generations to come.

MR assessment of pediatric hydrocephalus: a road map

PURPOSE

This study was conducted to design a rational approach to the MR diagnosis of hydrocephalus based on a pathophysiologic reevaluation of its possible mechanisms and to apply it to the different etiological contexts.

METHOD

A review of the literature reports describing new physiologic models of production and absorption and of the hydrodynamics of the CSF was made.

RESULTS

Besides the secretion of CSF by the choroid plexuses, and its passive, pressure-dependent transdural absorption (arachnoid villi, dural clefts, cranial, and spinal nerve sheaths), water transporters, aquaporins, allow water (if not ions and organic molecules) to exchange freely between the brain parenchyma and the CSF spaces across the ependymal and the pial interfaces (including the Virchow-Robin spaces). Consequently, the CSF bulk flow is not necessarily global, and situations of balanced absorption-secretion may occur separately in different CSF compartments such as the ventricular, intracranial, or intraspinal CSF spaces. This means that rather than from a hypothetical pressure gradient from the plexuses to the dural sinuses, the dynamics of the CSF depend on the force provided in those different compartments by the arterial systolic pulsation of the pericerebral (mostly), intracerebral, and intraventricular (choroid plexuses) vascular beds.

CONCLUSION

Using MR imaging, diverse varieties of hydrocephalus may tentatively be explained by applying those concepts to the correspondingly diverse causal diseases. Hopefully, this may have an impact on the choice of the treatment strategies also.

Unusual Complication of Neglected Hydrocephalus: Spontaneous Rupture with Growing Skull Fracture

Timely management of hydrocephalus in infants is critical as the initial treatment can have lifelong implications for survival and neurological outcome. In the developing countries, grossly enlarged heads are still not an uncommon occurrence. In extreme cases, there may be a spontaneous rupture of hydrocephalus either externally or internally, depending on the status of the sutures. Here, the successful management of a rare complication of spontaneous rupture of hydrocephalus in an infant is discussed. The management of the present case provides a novel approach to deal with this dreaded complication. Though the neurological outcome remains guarded in such cases, they need to be tackled cautiously to address the hydrocephalus and esthetic appearance of the infant.

The tectum and the aqueduct of Sylvius in hydrocephalus unassociated with myelomeningocele

The brains of 30 children with hydrocephalus (but not myelomeningocele) were examined. It was found that secondary pressures on the tectum and aqueduct resulting from the hydrocephalus were responsible for further obstruction at this level in 15 of the 30 children and that they contributed to axial distortion in another 11 children. Occlusion of the aqueduct occurred as a result either of these external pressures or of internal gliosis. These events form a self-sustaining cycle which, if broken early, may lead to a more satisfactory control of the hydrocephalus.

Endoscopic observation of pathophysiology of ventricular diverticulum

BACKGROUND

Although there have been reports dealing with ventricular diverticulum (VD) analyzed by cisternography and computed tomography (CT), those focusing on magnetic resonance imaging (MRI) or neuroendoscopic findings are rare.

CASE REPORT

We present a case of noncommunicating hydrocephalus caused by aqueductal stenosis with cystic lesion located in supracerebellar region. Third ventriculostomy was performed on this case. The conventional CT and MRI were compatible with usual VD, but neuroendoscopic examination suggested otherwise. The endoscopic view inside of the cystic lesion demonstrated passing veins and no membrane. We diagnosed this cystic lesion as a unique subtype of advanced VD mimicking spontaneous ventriculostomy. Endoscopic observation of the cyst was very useful for accurate diagnosis and safe treatment.

Pathogenesis and diagnostic pitfalls of ventricular diverticula: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Ventricular diverticula are local herniations of the ventricular system occurring in association with severe, long-standing hydrocephalus. Variability in the extent and location of these ventricular pouches may produce misleading radiological conformations and raise diagnostic challenges. In this report, we discuss the pathogenesis and differential diagnosis of ventricular diverticula on the basis of a case illustration.

CLINICAL PRESENTATION

We report the case of a 38-year-old woman presenting with hydrocephalus secondary to an obstructive lesion of the third ventricle. A large, dilated structure compressing the brainstem was present in the posterior fossa.

INTERVENTION

The posterior fossa lesion was identified as an atrial diverticulum by injection of contrast medium into the right lateral ventricle, which led to immediate enhancement of the infratentorial cavity. Ventricular drainage and removal of the third ventricular lesion, a colloid cyst, allowed progressive collapse of the diverticulum and symptom resolution.

CONCLUSION

This report discusses the pathogenesis of ventricular diverticula and demonstrates that ventriculography can be used to differentiate atrial diverticula from other posterior fossa lesions when time-consuming multiplanar magnetic resonance imaging cannot be afforded on an emergency basis.

Ventricular diverticula in obstructive hydrocephalus secondary to tumor growth

OBJECTIVE

The association of ventricular diverticula with intra- and paraventricular tumors causing obstructive hydrocephalus has rarely been reported.

METHODS

Records and imaging findings for 57 patients with obstructive hydrocephalus caused by tumors who were treated at our institution were reviewed for the presence of ventricular diverticula. For the anatomic study of ventricular diverticula, data were collected from five cadaveric heads.

RESULTS

Ventricular diverticula were identified on magnetic resonance imaging scans in five cases. Diverticula were similarly located in the quadrigeminal cistern but originated from the medial wall of the atrium of the lateral ventricle in three cases and from the superior portion of the fourth ventricle in two cases. Regression of diverticula occurred in all cases after either insertion of a shunt or removal of the obstructing tumor. The cadaveric study suggested that the choroidal fissure and the rostral portion of the superior medullary velum might be the origins of diverticula from the atrium and from the superior portion of the fourth ventricle, respectively.

CONCLUSION

Ventricular diverticula should be distinguished from other cystic lesions in the quadrigeminal region. Detection of an ostium of a diverticulum or communication between the cyst and the ventricular system is important for diagnosis.

Subtentorial diverticulum of the third ventricle associated with a mural cavernous angioma in a child

The authors describe a case of a large subtentorial supracollicular diverticulum of the third ventricle associated with a cavernous angioma in its wall in a 6-year-old girl who presented with developmental delay and obstructive hydrocephalus. This is the first case in which such association has been diagnosed and successfully treated. The literature is reviewed, and the possible relationship between these two rare lesions is discussed.

Diverticulum of the lateral ventricle causing cerebellar ataxia. Case report

A case of ventricular diverticulum causing cerebellar ataxia is presented. Computerized tomography clearly demonstrated the aperture of the diverticulum in the medial wall of the trigone and its extension into the posterior fossa. The diverticulum regressed and the cerebellar ataxia disappeared after placement of a ventriculoperitoneal shunt.

Spontaneous lateral ventriculocisternostomy documented by metrizamide CT ventriculography. Case report

In a patient with partially shunted obstructive hydrocephalus from a third ventricular astrocytoma, metrizamide ventriculography combined with computerized tomography demonstrated spontaneous ventriculocisternostomy with passage of contrast material from the atrium into the choroid fissure and posterior subarachnoid space.

Congenital ventriculocisternostomy. Case report

A case of congenital ventriculocisternostomy is reported. This infant presented with occipital meningocele. Conray ventriculography demonstrated a spontaneous ventriculocisternostomy and stenosis of the aqueduct. The case is discussed and pertinent literature reviewed.

Congenital atresia of the foramen of Monro

Two cases of congenital atresia of the foramen of Monro are described, one 8 days old and the other 2 months old. Both are associated with a parieto-occipital paraventricular diverticulum and spontaneous ventriculostomy with the passing of the cerebrospinal fluid to the posterior fossa and the formation of a cyst in the supracerebella region which compressed and displaced the structures of the posterior fossa.

Spontaneous rupture of the third ventricle in obstructive hydrocephalus: a radiographic diagnosis

Two cases of posterior fossa tumours with spontaneous rupture of the third ventricle are presented. In the first case there was dramatic relief of symptoms of raised intracranial tension. Rupture of the supra-pineal recess was demonstrated by Conray ventriculography in both cases.

Occipital encephalocele: a pathologic and anatomic analysis

The brain from an infant with a cystic occipital mass present at birth is examined in serial section. The occipital mass proved to be a rhombic roof ventriculocele. Within the posterior fossa, it was bound to an occipital lobe encephalocele which issued as a diverticulum of the left lateral ventricle through a microgyric cortical defect in the territory of the left posterior cerebral artery. The posterior medial aspects of both cerebral hemispheres were herniated downward into the widened tentorial gap. Craniolacunae were prominent on the inner aspect of the skull. The aqueduct and central canal of the spinal cord were widely dilated, although the lateral ventricles were collapsed. It is suggested that hydrocephalus secondary to obstruction to flow of CSF through the rhombic roof entrained a sequence of events giving rise to the rhombic roof ventriculocele and causing occlusion of the posterior cerebral artery and subsequent diverticulation of the lateral ventricle through an infarcted region of the posterior-medial hemisphere.

Uncommon third ventricle herniation with cyst formation as a possible result of obstructive hydrocephalus

An adult man with an unusual cyst formation, originating from the suprapineal recess is described. The cyst may partly be caused by and may partly have contributed to aqueductstenosis.

Hydrocephalus related to pulsion diverticulum of lateral ventricle

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Spontaneous cerebral ventriculostium: two cases

Two cases of `spontaneous cerebral ventriculostium' are reported. In one case the diagnosis was made during life, and the hydrocephalus was not relieved by the ostium. The unique feature of the other has been the presence of a large defect in the skull bones, posteriorly, which has been a `nature's help' towards maintaining the hydrocephalus stationary, after an initial period of progression.

Paraventricular porencephalic diverticulum with latent hemiparesis as a complication of ventriculography

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DIVERTICULUM OF THE LATERAL VENTRICLE EXTENDING INTO THE POSTERIOR CRANIAL FOSSA: REPORT OF A CASE SUCCESSFULLY RELIEVED BY OPERATION

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