Cavernoma of the foramen of Monro

Neuroendoscopic Surgery for Intraventricular Cavernous Malformations: A Review on Indications and Surgical Considerations

BACKGROUND

Intraventricular cavernous malformations (IVCs) are rare vascular lesions of the central nervous system. Surgical resection remains a challenging endeavor, with conventional microsurgical techniques associated with morbidity due to direct brain tissue manipulation. Neuroendoscopic approaches offer a minimally invasive alternative, though their efficacy and safety in treating IVCs remain underexplored.

METHODS

A narrative review was conducted to analyze all documented cases of IVCs treated exclusively with endoscopic transventricular approaches. Reviews, original research papers, and case reports published from 1990 to May 2024 were included. When available, surgical videos were also reviewed.

RESULTS

Seventeen patients with IVCs primarily located in the foramen of Monro were identified. The mean size of the IVCs was 17 mm (range: 7-29 mm). Neuroendoscopic procedures achieved gross total resection in all cases, leading to the resolution of clinical symptoms. Except for one patient who experienced memory impairment postsurgery, no persistent neurological dysfunctions were observed. Intraoperative bleeding, a significant challenge in IVC resection, was managed with continuous warm irrigation and dedicated coagulation instruments. Additionally, 6 cases of neuroendoscopic procedures such as endoscopic third ventriculostomy and septum pellucidotomy were reported for managing hydrocephalus.

CONCLUSIONS

Neuroendoscopic surgery offers several advantages in treating IVCs, including minimally invasive access, precise visualization, and reduced brain tissue manipulation. Our findings support the efficacy and safety of endoscopic transventricular approaches, underscoring its potential as a valuable therapeutic strategy for selected IVCs.

Virtual endoscopy assisted pure ventriculoscopic resection of cavernomas occluding foramen of Monroe: Technical note and literature review

OBJECTIVE

Cavernomas at Foramen of Monroe (FoM) are rare cases among the intracranial cavernomas. Pure ventriculoscopic removal of cavernoma at FoM through a single burr hole is challenging and rarely reported.

METHODS

We herein introduced the virtual endoscopy (VE) assisted ventriculoscopic resection to treat the cavernomas at FoM. Two cases diagnosed with cavernomas at FoM, a 31-year-old male patient (case 1) and a 26-year-old male patient (case 2), were included. Both of them suffered from headache, nausea and vomiting. The pre-operative MRI revealed masses at the FoM. We reconstructed the VE on a free and open-source platform (3D Slicer) for the pre-surgical evaluation. And then ventriculoscopic operation through a single burr hole was made to remove the cavernomas at FoM.

RESULTS

The VE displayed a 14×19×16 mm lesion in case 1 and an 18×20×29 mm lesion in case 2 and both cases revealed some attachment between the lesions and the periventricular tissue. The ventriculoscopic operations indicated by VE were performed to achieve total resection of the cavernomas without neurological deficit.

CONCLUSIONS

Although the neuroendoscopic treatment to cavernoma at FoM through a single burr hole was rarely reported among the previous literatures, it was a quite effective and useful method in our cases. And the application of VE before ventriculoscopic operation could help to provide a three-dimensional and panorama view of the intraventricular lesions.

Third Ventricle Cavernous Malformation and Obstructive Hydrocephalus Thought to Be a Colloid Cyst

BACKGROUND

Third ventricle cavernous malformations (CMs) associated with ventriculomegaly and obstructive hydrocephalus are quite rare in patients. Preoperative surgical planning can be challenging due to the lesion's non-specific appearance on CT and magnetic resonance imaging that can mimic other intraventricular pathologies, such as a colloid cyst. Management of these lesions can be varied in the setting of obstructive hydrocephalus.

CASE DESCRIPTION

The patient is a 78-year-old woman who first presented to her primary care provider with balance difficulties and inability to ambulate on her own. She also had bladder incontinence and progressive, severe headaches. Imaging of the brain demonstrated entrapment of the right lateral ventricle and obstructive hydrocephalus due to a lesion in the third ventricle obstructing the right foramen of Monro, thought to be a colloid cyst. A right frontal neuroendoscopic approach with direct visualization, however, confirmed a third ventricle CM. A septal pellucidum fenestration was performed to restore cerebrospinal fluid communication and no resection of the lesion was performed. The patient recovered well after the operation and at clinical follow-up reported no headaches and was walking well without a walker and with no neurological deficits.

CONCLUSIONS

A third ventricle CM was discovered after a neuroendoscopic approach for resection of a presumed colloid cyst in a patient with obstructive hydrocephalus. A neuroendoscopic septostomy was performed to treat the obstructive hydrocephalus and no resection was attempted. The patient suffered no complications and is at her neurologic baseline with no deficits.

Purely Endoscopic Resection of Cavernoma of the Septum Pellucidum

The intraventricular location of a cavernoma is a rare entity and accounts for approximately 2.5% of all cavernomas of the central nervous system. They are commonly found in the lateral ventricle followed by the third and fourth ventricles. The location in the septum pellucidum is rare, and only four cases have been reported in the international literature. An open craniotomy was performed in all these cases. To the best of our knowledge, this is the first case of a cavernoma of the septum pellucidum successfully resected using a purely endoscopic transventricular approach.

Electromagnetic navigation-guided neuroendoscopic removal of radiation-induced intraforniceal cavernoma as a late complication of medulloblastoma treatment

INTRODUCTION

Medulloblastoma is the most frequent malignant brain tumour in children. Radiation-induced cavernous haemangiomas (RICHs) are a known late complication of radiation exposure, especially in young children.

CASE REPORT

We present a patient who underwent subtotal resection of posterior fossa medulloblastoma with subsequent chemotherapy and radiotherapy at the age of 10 years. A new lesion in the region of the left foramen of Monro appeared 16 years later. Based on the imaging results, metastasis or radiation-induced cavernoma was considered. The lesion had the same appearance on imaging as a rarely published intraventricular cavernoma of the foramen of Monro. Unlike the cavernoma of the foramen of Monro, this lesion was subependymal and intraforniceal. Using electromagnetic navigation and neuroendoscopy, the lesion was completely removed. Histopathological examination revealed a cavernous haemangioma.

CONCLUSION

This is a unique case of intraforniceal paraforaminal cavernoma that was successfully removed endoscopically using electromagnetic neuronavigation and without neurological sequelae.

Cavernous Angioma of the Cerebral Aqueduct

BACKGROUND

Among the rare intraventricular cavernomas, purely intra-aqueductal cavernomas are exceptionally rare.

CASE DESCRIPTION

A 62-year-old patient presented with progressive headache, memory loss, gait instability, and urinary incontinence. Magnetic resonance imaging showed the presence of a mass lesion located in the lumen of the cerebral aqueduct, associated with triventricular hydrocephalus.

CONCLUSIONS

We discuss the rationale that led us to treat hydrocephalus with neuroendoscopy, which offered the possibility to directly inspect the intra-aqueductal lesion, make the diagnosis of cavernoma, and treat symptoms resulting from hydrocephalus without increasing the risk of bleeding.

Endoscope-assisted resection of cavernous angioma at the foramen of Monro: a case report

INTRODUCTION

Intraventricular cavernous angiomas are rare pathological entities, and those located at the foramen of Monro are even rarer. We herein present a case of cavernous angioma at the foramen of Monro that was successfully treated by neuroendoscope-assisted surgical removal, and review the relevant literature.

CASE PRESENTATION

A 65-year-old woman had experienced headache and vomiting for 10 days before admission to another hospital. Magnetic resonance imaging (MRI) showed a mass at the foramen of Monro, and obstructive hydrocephalus of both lateral ventricles. The patient was then referred to our hospital. Neurological examination on admission to our hospital showed memory disturbance (Mini-Mental State Examination 20/30) and wide-based gait. A cavernous angioma at the foramen of Monro was diagnosed based on the typical popcorn-like appearance of the lesion on MRI. The lesion was completely removed by neuroendoscope-assisted transcortical surgery with the Viewsite Brain Access System (Vycor Medical Inc., Boca Raton, FL), leading to a reduction in the size of the ventricles. The resected mass was histologically confirmed to be cavernous angioma. The patient's symptoms resolved immediately and there were no postoperative complications.

CONCLUSION

Minimally invasive neuroendoscope-assisted surgery was used to successfully treat a cavernous angioma at the foramen of Monro.

Intraventricular foramen of Monro cavernous malformation

We present a 64-year-old woman who was evaluated after being found unresponsive. Imaging revealed a foramen of Monro cavernoma resulting in hydrocephalus. Supratentorial cavernomas are most frequently found in the cerebral cortex, and although ventricular cavernomas do occur, they are rarely located in the foramen of Monro. Foramen of Monro cavernomas are extremely dangerous, requiring aggressive management when identified.

Cavernous hemangioma of the third ventricle: a case report and review of the literature

Background

Although cavernous hemangiomas (CHs) can be found anywhere in the central nervous system, CHs of the third ventricle have been reported in only 29 patients (including our case). In the current case report, we discuss the clinical characteristics and surgical outcome of CHs of the third ventricle.

Case presentation

A 64-year-old female was admitted to our emergency room with a sudden decreased level of consciousness. Brain imaging studies demonstrated a multi-lobulated hemorrhagic mass in the third ventricle. The lesion was removed via the transcallosal-interforniceal approach and pathologically diagnosed as CH. Postoperatively, the patient had a transient neurological deficit due to hypothalamic injury and recovered to the normal status at 2 months after the operation. In the review of 29 cases, the mean age of the patients was 40 years with a slight female preponderance (female/male, 17/12). The majority of the patients complained of a mass effect with signs of increased intracranial pressure; only one case was asymptomatic. Gross total resection was achieved in 81% of the cases. Around 80% of the patients were asymptomatic or improved from the initial symptoms. Mortality rate was 6.9% and the most common complication was hydrocephalus.

Conclusions

As demonstrated in the review of the previous reports, the outcome is favorable after surgical excision for CH of the third ventricle. Hence, surgical excision appears to be the treatment of choice for CH located in the third ventricle, which tends to grow rapidly resulting in a mass effect.

Intraventricular cerebral cavernomas: a series of 12 patients and review of the literature

Object

Intraventricular cavernomas (IVCs) occur in only 2–10% of patients with cerebral cavernomas. Reports concerning IVC are scarce and are limited mostly to sporadic case reports. In this paper, the authors present a series of 12 patients with IVCs that were treated at a single neurosurgical department. In addition, the authors reviewed the literature.

Methods

All clinical data were analyzed retrospectively. Follow-up questionnaires were sent to all patients. Outcome was assessed using the Glasgow Outcome Scale. The authors also conducted a PubMed search and found 77 cases of IVC.

Results

The patients' median age was 47 years, and the male/female ratio was 2:1. A cavernoma occurred in the lateral ventricle in 6 patients, in another 5 it was in the fourth ventricle, and 1 had a lesion in the third ventricle. Almost all patients presented with acute headache on admission and in more than half, the symptoms were related to cavernoma bleeding. In total, 8 rebleedings occurred in 5 patients during a median of 0.4 years. Three patients with a cavernoma of the fourth ventricle presented with a cranial nerve deficit. In 8 cases, a cavernoma was surgically treated an average of 1.3 years after the diagnosis. Only 1 patient underwent surgery in the acute phase after a major intraventricular/intracerebral hemorrhage. The median follow-up time was 2 years. No patient was lost to follow-up, and no patient died. In total, on follow-up 9 patients improved and 3 had a persistent neurological deficit, of which 2 existed before surgery.

Conclusions

In the present series, the IVCs had a high tendency for rehemorrhage. Surgery is advocated when hemorrhages are frequent, and the mass effect causes progressive neurological deficits. Microsurgical removal of the IVC is safe, but in the fourth ventricle it can carry increased risk for cranial nerve deficits.

Trigonal cavernous angioma: a short illustrated review

PURPOSE

Intraventricular cavernomas are rare. Even more rare are those presenting in the trigone of the lateral ventricles.

METHODS

We performed a search of the literature of the last 30 years and identified all cases of intraventricular cavernous angiomas. Trigonal cavernomas were separately identified and analysed. Our search yielded a total of 13 trigonal cavernomas.

RESULTS

Of a total of 61 intraventricular cases, 13 were located in the trigone of the lateral ventricles. The most prominent presenting symptom was intracranial hypertension (68.9%), followed by seizures (18.2%) and hemorrhage (13.1%).The literature review revealed a trend of intraventricular cavernomas to present with intracranial hypertension rather than seizures or focal neurologic deficit, unlike their intraparenchymal counterparts. We feel that this difference has received little attention in the international literature. We discuss a possible pathogenetic mechanism for the presence of intracranial hypertension and address different aspects of diagnosis and treatment of this benign lesion.

CONCLUSIONS

Trigonal cavernomas are benign lesions that have an excellent outcome after radical excision. Symptoms and signs of intracranial hypertension and hydrocephalus may be the prominent initial presentation of this rare ailment.

[Intraventricular cavernoma in the foramen of Monro: particularities due to its atypical location]

Although cavernomas are relatively common vascular malformations in the central nervous system, they are rarely located in the ventricles and are even more rarely located in the region of the foramen of Monro. This atypical location results in a series of differential clinical and radiological characteristics that can make the diagnosis of these lesions extremely difficult and lead to inefficacious procedures like radiotherapy or a neuroendoscopic surgical approach or even to procedures that endanger the patient like stereotactic biopsy. We present a case of intraventricular cavernoma in the region of the foramen of Monro with the aim of illustrating the difficulties involved in the diagnosis of this rare lesion.

Enlarged thalamostriate vein causing unilateral Monro foramen obstruction. Case report

Causes of unilateral hydrocephalus resulting from an obstruction at the Monro foramen include foraminal atresia, tumors, gliosis, contralateral shunting, and infectious and inflammatory conditions. However, few reports in the literature cite vascular lesions as the cause of the obstruction. To their knowledge, the authors present the first report of unilateral hydrocephalus occurring due to an abnormally enlarged thalamostriate vein independent of an arteriovenous malformation or developmental venous angioma. The condition was treated successfully by endoscopic septum pellucidum fenestration. A 28-year-old man was referred for evaluation due to a 10-year history of chronic headaches that worsened in severity over the past year. A CT scan of the head revealed unilateral right ventricular dilation. Cranial MR imaging with and without contrast administration showed a dilated right thalamostriate-internal vein complex without any evidence of associated arteriovenous malformation or venous angioma. Endoscopic exploration of the right lateral ventricle showed an enlarged subependymal thalamostriate vein obstructing the Monro foramen. An endoscopic fenestration of the septum pellucidum was performed, resulting in alleviation of the patient's symptoms. Abnormally enlarged venous structures may cause obstructive unilateral hydrocephalus and can be a rare cause of chronic, intermittent headaches in adults. Endoscopic fenestration of the septum pellucidum is an effective treatment.

Endoscopic resection of cavernoma of foramen of Monro in a patient with familial multiple cavernomatosis

Intraventricular cavernomas are extremely infrequent and only 11 cases of cavernous hemangioma to occur at the foramen of Monro have been reported in the literature. This 56 years old patient was admitted with progressive and intractable headache of 10 days of evolution. He was known to suffer familial multiple cavernomatosis. Magnetic resonance imaging (MRI), revealed obstructive hydrocephalus due to a cavernoma located in the area of the left foramen of Monro. Under neuronavigation guidance, complete endoscopic resection of the cavernoma was performed and normal ventricular size achieved. The patient experienced transient recent memory loss that resolved within a month after surgery. In the literature attempted endoscopic resection is reported to be abandoned due to bleeding and ineffectiveness of piecemeal endoscopic resection. In this case, the multiplicity of the lesions made it advisable to resect the lesion endoscopically, to avoid an open procedure in a patient with multiple potentially surgical lesions. Endoscopic resection was uneventful with easy control of bleeding with irrigation, suction, and bipolar coagulation despite dense vascular appearance of the lesion. During the procedure, precise visualization of the vascular structures around the foramen of Monro allowed complete resection with satisfactory control of the instruments. To the best of the authors' knowledge, this is the first published cavernoma of foramen of Monro successfully resected using an endoscopic approach.

Intraventricular vascular malformations mimicking tumors: case reports and review of the literature

Vascular malformations of the ventricular system are rare, and their clinical and radiologic characteristics vary depending on the location of the lesions. Many types are described, but a comprehensive summary is lacking. Herein, we add two cases to the literature and review known types of ventricular vascular malformations. One case involved a 37-year-old woman who presented with headache due to hydrocephalus. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a lesion of the foramen of Monro. The other case involved a 7-year-old boy who had dizziness and headache due to hydrocephalus. CT and MRI demonstrated a lesion of the third ventricle. In both cases, the images mimicked those of tumors with or without bleeding. As a result, the malformations were misdiagnosed, though surgical treatment was successful. In both cases, the lesions were proven to be arteriovenous malformations on pathologic evaluation. Correct diagnosis of ventricular vascular malformations is sometimes difficult but essential for good treatment planning. Their incidence is low. However, their bleeding and rebleeding rate is high, and they commonly cause hydrocephalus. Treatment should be timely and based on the type of lesion and its presentation.