Cystic lesion of the ventriculus terminalis: proposal for a new clinical classification

Cystic dilatation of the ventriculus terminalis: A narrative review

Introduction

The terminal ventricle, also known as the fifth ventricle, is a tiny relic cavity in the conus medullaris of the human spinal cord. Our purpose in bringing attention to this condition is to get the word out about the signs and symptoms, diagnostic hurdles, and therapeutic options available for it.

Methods

All relevant studies involving patients diagnosed with ventriculus terminalis (VT) were retrieved from PubMed, Google Scholar, and Scopus. Studies published in complete English language reports were included. The terms VT, terminal ventricle, and 5th ventricle. Age, gender, presenting symptoms, magnetic resonance imaging findings, treatment, and outcome of patients with ventriculus terminalis were all included and recorded.

Results

The average age of the patients was 39 years, and there were 13 men among them (14.4%). Motor deficits and sciatica were the most commonly reported symptoms in 38 and 34 patients (42.2%, 37.7%), respectively. In 48 patients (53.3%), cyst fenestration was performed, and in 25 patients (27.7%), myelotomy was performed. Fifty-eight patients (64.4%) saw a reduction in cyst size after surgery. The majority of patients reported an improvement in their symptoms in 64 cases (51.1%), with only three cases (3.3%) reporting a worsening.

Conclusions

In cases where the VT is the source of symptoms such as motor, sensory, or bladder dysfunction, surgical intervention is recommended. This review compiles information from the available literature to shed light on the anatomy, clinical presentation, imaging, and treatment options for this variant. It also aims to pinpoint any potential drawbacks or restrictions connected to the surgical techniques.

Cystic Dilatation of the Ventriculus Terminalis: Examining the Relevance of the Revised Operative Classification Through a Systematic Review of the Literature, 2011-2021

The literature features limited evidence on the natural history of the cystic dilatation of the ventriculus terminalis (CDVT) and its response to treatment. The goal of this study is to ascertain which impact the revised operative classification of CDVT had on the management of patients diagnosed over the past 10 years.Ten new clinical articles presenting a total of 30 cases of CDVT were identified and included for qualitative analysis. Two take-home messages can be identified: (1) Adequate consideration should be given to designing national pathways for referral to tertiary centers with relevant expertise in the management of lesions of the conus medullaris, and (2) we suggest that type Ia should be, at least initially, treated conservatively, whereas we reckon that the signs and symptoms described in types Ib, II, and III seem to benefit, although in some patients only partially, from surgical decompression in the form of cystic fenestration, cyst-subarachnoid shunting, or both.While the level of evidence gathered in this systematic review remains low because the literature on CDVT consists only of retrospective studies based on single-center series (level of evidence 4 according to the Oxford Centre for Evidence-Based Medicine (OCEBM)), the strength of recommendation for adopting the revised operative classification of CDVT is moderate.

Toward the End of the Funnel: The Ventriculus Terminalis-The State of Art of an Ancient Entity with a Recent History

PURPOSE

The ventriculus terminalis (VT), also called the fifth ventricle, is a small cavity containing cerebrospinal fluid (CSF) that is in the conus medullaris in continuity with the central canal of the spinal cord. In adults, persistent VT is a very rare entity, and the diagnosis is incidental in most cases. Rarely, VT may become symptomatic for still-uncertain reasons but most often for its cystic dilatation. The management of these selected cases is still controversial and sometimes associated with unsatisfactory outcomes.

METHODS

We performed a critical review of the existing literature on the management of symptomatic VT in adults. The etiology, pathophysiology, and treatment of VT are presented and discussed, focusing on the best timing for surgery.

RESULTS

Conservative management, marsupialization, or the placement of a T drain have been reported. The existing classifications describe the most correct approach for each clinical presentation, but scarce importance has been given to the delay from symptoms' onset to surgical treatment.

CONCLUSION

Although different cases have been described in the literature, this rare pathology remains unknown to most neurosurgeons.

Recurrent terminal ventricle cyst: a case report

The terminal ventricle (TV) of Krause is a rare cystic dilation of the conus' central canal. Due to limited understanding surrounding its pathophysiology, optimal management remains controversial. We report a 25-year-old female presenting with acute paraparesis. Magnetic resonance imaging spine revealed a cystic conus medullaris lesion in keeping with an incidental TV cyst. However, the patient experienced a rapid resolution of symptoms. We hypothesize that the TV cyst spontaneously ruptured and auto-decompressed. To our knowledge, this is the first reported case of an enlarging symptomatic TV cyst with spontaneous rupture and resolution of symptoms, highlighting the variable natural history of this condition.

Enlarging Ventriculus Terminalis in a Patient With Polyarteritis Nodosa

Ventriculus terminalis (VT) is a cystic embryological remnant within the conus medullaris that normally regresses after birth. In rare cases, it may persist into adulthood and give rise to neurologic symptoms. The pathogenesis remains unclear but is thought to be related to failed embryonic regression with other proposed possible etiologies including vascular disturbances. We present an intriguing case of a slow-growing VT in a woman with progressive neurologic symptoms who experiences symptomatic relief following thoracic laminectomy and fenestration. Our case is the first to present a unique association with polyarteritis nodosa and only the third to report a case of documented enlargement of the VT over time successfully treated with surgical fenestration.

Surgical treatment for symptomatic ventriculus terminalis: case series and a literature review

BACKGROUND

Ventriculus terminalis is a cystic embryological remnant within the conus medullaris that normally regresses after birth. In rare cases, it may persist into adulthood and give rise to neurological symptoms, for which the optimal treatment remains uncertain. The aim of this study was to present our experience from a population-based cohort of patients with ventriculus terminalis and discuss our management strategy as compared to the existing literature.

METHODS

A retrospective review was conducted of all adult (≥ 15 years) patients with ventriculus terminalis who were referred to the Karolinska University Hospital between 2010 and 2018.

RESULTS

Fourteen patients were included. All patients were symptomatic at the time of referral, and the most common symptom was lower limb weakness (n = 9). Microsurgical cyst fenestration was offered to all patients and performed in thirteen. Postoperative imaging confirmed cyst size reduction in all surgically treated patients. No surgical complications were reported. Eleven of the surgically treated patients showed clinical improvement at long-term follow-up. One patient declined surgery, with progression of the cyst size and clinical deterioration observed at follow-up.

CONCLUSIONS

Surgery for ventriculus terminalis seems to be a safe and effective option for relief of symptoms. We propose that surgery should be offered to all patients with symptomatic ventriculus terminalis.

Intramedullary spinal tumor-like lesions

The development of magnetic resonance imaging (MRI) has led to an increasingly frequent detection of changes in the spinal cord. The most common intramedullary lesions are: demyelinating; vascular; inflammatory; infectious; and congenital, largely called tumor-like lesions. Spinal cord tumors are relatively rare, as compared with brain tumors. The hardest task is to conclude whether the spinal cord lesion is a tumor or a tumor-like lesion. This review is intended to help evaluate the spinal cord and gives an overview of the tumor-like lesions occurring in the spinal cord along with their characteristic.

Symptomatic Thoracic Intramedullary Arachnoid Cyst: "A Rare Entity" Report of Two Cases with Short Review of Literature

Spinal arachnoid cysts are uncommon benign lesions of spine axis and most commonly present as compressive myelopathy. Intramedullary arachnoid cyst is uncommonly seen, hence, not much discussed in literature. Due to rarity of this entity, many questions are yet to be answered and should be addressed properly, particularly related to etiopathogenesis, accustomed course, behavior, differential diagnosis, and the best treatment modality. We report the clinicopathological profile of thoracic intramedullary arachnoid cysts in two adult patients, and present a detailed review of available literature on the spinal intramedullary arachnoid cyst. Most of the literature concerning with intramedullary arachnoid cysts are in the form of case reports from pediatrics population. As far to the best of our knowledge, only a few cases excluding our two were found in both pediatrics and adult population.

Incidentalomas in Spine and Spinal Cord Imaging

Incidentalomas are common in magnetic resonance imaging (MRI) of the spine. These incidental findings (IFs) can be seen involving the spinal cord, nerve root, vertebral body, posterior arch and the extraspinal region. This review article describes the imaging findings, stratifies the IFs similar to the computed tomography (CT) colonography reporting and data system and briefly mentions the current recommendations for further evaluation and management of IFs. Radiologists are the first to detect these lesions, suggest further evaluation and management of IFs. It is therefore mandatory for them to be aware of recommendations in clinical practice in order to avoid increased patient anxiety, excessive healthcare expenditure and inadvertent therapeutic procedures.

The cystic dilation of ventriculus terminalis with neurological symptoms: Three case reports and a literature review

CONTEXT

The ventriculus terminalis (VT) is a very small ependymal-lined residual lumen in the conus medullaris. It is normally present in all subjects during fetal development. VT in adults appears as an unusual pathology with an uncertain pathogenesis.

FINDINGS

In this paper, we described three case reports of symptomatic fifth ventricle cystic dilations. All of them were female and their mean age was 59 years. We treated them surgically and all three patients were improved based on clinical and imaging assessments.

CONCLUSION

Our cases suggested that surgical decompression was a safe and effective treatment in symptomatic patients and the neurosurgeons should be aware of such rare situations. A complete list of differential diagnosis about other cystic dilations of the conus medullaris should be emphasized to select the correct clinical approach.

How to Explore Fetal Sacral Agenesis Without Open Dysraphism: Key Prenatal Imaging and Clinical Implications

The estimated prevalence of fetal caudal dysgenesis is 1 per 100,000 births. The functional prognosis of sacral agenesis is dominated by the large spectrum of associated caudal malformations. Except for cases associated with hydrocephalus secondary to open spinal dysraphism or chromosomal anomalies, association with mental deficiency is rare. We propose a systematic prenatal approach to cases of fetal sacral agenesis based on 9 etiologic items: clinical context, type of sacral dysgenesis, associated spinal cord malformations, mobility of lower limbs, investigation of the presacral region, analysis of the gastrointestinal tract, analysis of the genitourinary tract, associated vertebral defects, and cytogenetic analysis.

Surgery or not? A case of ventriculus terminalis in an adult patient

The ventriculus terminalis (VT) is an intramedullary cavity containing cerebrospinal fluid (CSF), usually located at the conus, and represents an unsuccessful regression of a normal embryological phase of the development of the neural tube. Symptoms are not univocal and may vary from aspecific signs to sphincter dysfunctions and focal neurological deficits. The correct management of this condition is still an object of debate due to its rarity and its unpredictable behaviour in adult patients. Two different studies have proposed a distinction for patients with cystic dilatation of VT based on their symptoms, suggesting that only those patients with neurological deficits clearly related to the terminal ventricle could benefit from surgery. We describe a case of an adult patient with a progressive dilatation of a diagnosed VT that we treated surgically. A management flowchart for this condition is also proposed based on our experience and a review of the literature.

Cystic dilation of a ventriculus terminalis. Case report and review of the literature

The ventriculus terminalis (VT) is a small ependyma-lined cavity within the conus medullaris that is in direct continuity with the central canal of the spinal cord. Cystic dilatation of the ventriculus terminalis on its own is an extremely rare pathological event in adults whose pathogenesis is uncertain. VT has been described in children as a normal developmental phenomenon. These lesions are often diagnosed incidentally during imaging and are in most cases asymptomatic, especially in children. Symptomatic dilatation of VT in adults is a rare condition with 61cases being reported to date. Symptomatic dilatation of VT in children has not been reported till now. We present a 5 year-old-boy with a sphincteric and walking disorder. The patient was assessed by clinical, electrophysiological and urodynamic investigations as well as magnetic resonance imaging (MRI) of the lumbar-sacral segment with and without gadolinium enhancement. Lumbar-sacral MRI demonstrated the presence of a cystic lesion containing cerebrospinal fluid (CSF), which did not enhance after gadolinium, compatible with the diagnosis of the ventriculus terminalis dilation.The patient underwent laminectomy and the cyst wall was fenestrated with a midline myelotomy. In 6-month of follow-up, urinary problems and gait disturbance improved.

Cystic Dilation of the Ventriculus Terminalis: Report of 6 Surgical Cases Treated with Cyst-Subarachnoid Shunting Using a T-Catheter

BACKGROUND

Cystic dilation of the ventriculus terminalis (CDVT) is a rare anatomic variation that and may become symptomatic. Literature regarding CDVT is limited, and thus the clinical characteristics and management strategy of CDVT are unclear. Here we report 6 cases of CDVT seen in our institution, and provide a review of the current literature.

METHODS

The study cohort comprised 6 patients with CDVT seen at Beijing Tiantan Hospital between September 2010 and June 2015. All 6 patients were managed surgically. Data on age, sex, clinical presentation, radiologic features, operative methods, and surgical outcomes were reviewed retrospectively. We evaluated the clinical outcomes and postoperative radiologic changes of these patients and compared them with findings of similar previous reports.

RESULTS

All 6 patients were female, with a median age of 50.0 years (interquartile range [IQR], 25.8-54.0 years). Surgical management of cyst-subarachnoid shunting using T-catheter after myelotomy was successfully performed in all patients. During an average follow-up of 41 months, relief of clinical symptoms, especially low-back pain and sciatica, were observed in all 6 patients. No patients experienced symptom recurrence during follow-up, and postoperative magnetic resonance imaging revealed no regrowth of the lesion. Patients with focal neurologic deficits and sphincter disorders also achieved symptom relief from the procedure.

CONCLUSIONS

CDVT is an extremely rare cause of conus medullaris syndrome with an unclear treatment strategy. Our successful surgical management of 6 cases through cystic-subarachnoid shunting using a T-catheter for CDVT drainage provides a potential option for treating CDVT.

The Slowly Enlarging Ventriculus Terminalis

Background

A cerebral spinal fluid (CSF) cavity within the conus medullaris has been described by the term ventriculus terminalis (VT) or the fifth ventricle. The finding of a VT on MRI imaging of the lumbar spine is often incidental but may be found in patients with low back pain or neuromuscular deficits. These lesions, when identified, are thought to regress or remain stable in terms of size, although some have been described to enlarge in the presence of post-traumatic meningeal hemorrhages or deformities of the vertebral canal.

Case Report

We describe a case of a slowly growing VT in a patient with progressing lower limb weakness without any history or imaging findings of trauma or spinal canal abnormalities.

Conclusions

We present an intriguing case of a slowly growing VT in a woman with progressive neurological symptoms. Surgical fenestration provided complete symptomatic relief and follow-up imaging two years after surgery demonstrated no evidence of recurrence. This, to our knowledge, is the first described case of a slowly enlarging VT independent of any other imaging findings.

Microsurgical fenestration of idiopathic intramedullary cysts in adult patients

PURPOSE

The aim of this study is to describe the findings in one of the largest series of microsurgically treated intramedullary cysts investigated by magnetic resonance imaging (MRI), focusing on the peri- and intraoperative setup including detailed neurological and radiological outcome analyses.

METHODS

Retrospective analysis of patients with intramedullary cyst who had undergone microsurgical fenestration at our department between 2006 and 2011. Preoperative three-dimensional constructive interference of steady-state MRI was conducted to optimize surgical planning. Intraoperative electrophysiological monitoring included motor-evoked potentials, somatosensory-evoked potentials, and electromyogram. Clinical outcome as well as pre-, postoperative and long-term MRI scans were evaluated.

RESULTS

Eight female patients (median age 58.0 years, range 32-72 years) with a median clinical follow-up of 48.0 months (range 2-69 months) were included. Seven cysts were located in the conus medullaris, one in the cervical spine. Overall, 25.0% (2/8) showed complete remission of preoperative symptoms, 62.5% (5/8) improved, and 12.5% (1/8) asymptomatic patients remained unchanged. Pain syndromes (4/4) as well as motor deficits (2/2) improved in all affected patients and bladder dysfunction (3/4) displayed a high tendency for improvement. Postoperative MRI scans showed permanently decreased cyst volumes by ~80%.

CONCLUSION

Microsurgical fenestration of intramedullary cysts using preoperative high-resolution imaging and intraoperative electrophysiological monitoring is a safe and effective treatment option for symptomatic patients.

Spinal intradural cystic venous angioma originating from a nerve root in the cauda equina

A spinal intradural extramedullary venous angioma is extremely rare and has not been previously reported. In this paper, the authors report on this entity with morphological and immunohistochemical evidence, and discuss the surgical strategy for its treatment. A 54-year-old woman presented to Nagoya University Hospital complaining of left-sided pain in the hip, thigh, and inguinal and perianal regions, with progressive worsening during the previous 2 weeks. Lumbar spine MRI showed an intradural extramedullary cyst at the level of T12–L1, which extended from the conus medullaris to the cauda equina. The cyst wall was not enhanced on T1-weighted MRI with Gd. Intraoperatively, a midline dural opening allowed the authors to easily visualize a dark-reddish cyst behind the spinal nerve rootlets in the cauda equina adjacent to the conus medullaris. The cyst was believed to originate from one of the spinal nerve rootlets in the cauda equina and a cluster of veins was identified on the cyst wall. The cyst was resected with the affected nerve rootlet. The surgery left no detectable neurological deficit. Based on the morphological and immunohistochemical evidence, the lesion was diagnosed as a venous angioma. No tumor recurrence was confirmed based on MRI at the time of the 2-year follow up. This is the first report of an intradural extramedullary cystic venous angioma that was successfully resected.

Multilobed cystic dilation of the ventriculus terminalis (CDVT)

The cystic dilation of ventriculus terminalis (CDVT) is a rare anatomical variant in adulthood. In this report we describe a new case of an adult with multilobed CDVT, causing low-back pain and subjective disturbances in walking. A myelotomy with fenestration of the cyst was performed with a good clinical and radiological outcome.

Massive cystic dilatation within a tethered filum terminale causing cauda equina compression and mimicking syringomyelia in a young adult patient

BACKGROUND

The ventriculus terminalis (VT) is formed during early embryonic development of the spinal cord and can only be identified histologically in both children and adults. Cystic dilatation of the VT can be seen in young children, but it rarely persists through adulthood.

CLINICAL CASE

We describe a 27-year-old female with paraparesis secondary to a massive and tethered cystic dilatation of the VT mimicking syringomyelia. Symptoms appearing in early childhood were ignored, probably leading to the much prominent presentation in early adulthood. The preoperative presentation and surgical treatment are discussed in relation to childhood history.

CONCLUSIONS

Although extremely rare, symptomatic dilatation of the VT can be seen in young adults, usually with previous manifestations in early childhood. This entity should be considered while treating tethered cord spectrum.

Ventriculus terminalis in adults: unusual magnetic resonance imaging features and review of the literature

OBJECTIVE

The ventriculus terminalis (VT) in adults is a rare pathology. We report various MR imaging features of the adult VT.

MATERIALS AND METHODS

Ten patients were included in this retrospective review.. All patients had undergone magnetic resonance (MR imaging with a surface coil that used two different 1.5T MR systems. All patients had undergone initial and follow-up MR imaging with contrast enhancement using gadopentate dimeglumine. Three patients underwent additional MR imaging using the echocardiogram-gated spatial modulation of magnetization (SPAMM) technique. If a shift in tagging band during the systolic phase was less than half of the band space, it was defined as a "non-pulsatile fluid". Two neuroradiologists independently reviewed these images, while clinical symptoms and outcomes were statistically analyzed between the treated and non-treated group.

RESULTS

All cases presented an intramedullary cystic lesion in the conus medullaris and showed the same signal intensity as CSF. Three VTs had intracystic septation and cord edema, which were pathologically confirmed after surgery; two of these were associated with kyphotic deformity and spinal arteriovenous malformation. SPAMM-MRI of 3 patients demonstrated non-pulsatile fluid motion within the VT. In the treated group, clinical symptoms improved better than the non-treated group.

CONCLUSION

The adult VT shows some unusual imaging features, including septation, cord edema, and coexistence of a spinal AVM, as well as the typical findings. Surgical maneuvers may be considered as a treatment option in adult VT with progressive neurological symptoms.

Cystic dilation of the ventriculus terminalis

Object

The ventriculus terminalis, an embryological remnant consisting of the ependymal-lined space of the conus medullaris, can occasionally become symptomatic after cystic dilation. In the existing literature, consisting of 32 cases, the preferred type of management (conservative vs surgical) is still debated. The object of this study was to report the surgical results in a consecutive series of 10 adult patients with cystic dilation of the ventriculus terminalis (CDVT), to match them with data retrieved from the relevant literature, and specifically to validate a new recent clinical classification.

Methods

The authors reported 13 new cases of CDVT treated in the Department of Neurosurgery at University Hospital in Verona, Italy. Treatment modalities and clinical and radiological outcomes, both early and at follow-up, were analyzed and compared with a preoperative classification of clinical presentation, as established by de Moura Batista and colleagues (2008).

Results

Surgical treatment seemed to guarantee the resolution of CDVT. Dorsolumbar laminotomy, myelotomy, and cystic drainage were performed in 10 patients. Patients with Type I symptoms (nonspecific complaints) often presented with comorbidities (herniated disc or facet hypertrophy) confusing their clinical status. The surgical treatment of patients with Type I symptoms promoted good results only if the diagnosis of CDVT was definitive and symptoms had rapidly evolved. In patients with Type II (focal neurological deficits) and III (sphincter disturbances) symptoms, surgical treatment sustained improvement even at the late follow-up.

Conclusions

While confirming the usefulness of de Moura Batista and colleagues' classification in its impact on prognosis, the authors propose a revision of the classification with subgroups Type Ia (nonspecific symptoms without clear relation to CDVT), which is best treated conservatively, and Type Ib (rapid onset and invalidating unspecific complaints without comorbidities), which may benefit from surgical evacuation.

Intramedullary lesions of the conus medullaris: differential diagnosis and surgical management

The medullary conus represents a distinct entity of the spinal cord regarding its anatomical, clinical and microsurgical features. An overview of the pathologic processes of this region is provided. Epidemiological, clinical and neuroradiological characteristics of neoplastic (glial tumors, non-glial tumors, metastasis, primary melanomas) and non-neoplastic lesions (granulomatous lesions, abscess, parasitic infections, vascular, demyelinating and dysembryogenetic lesions) are discussed. Main MR imaging characteristics used to differentiate neoplastic from non-neoplastic lesions consist in pathological spinal cord expansion, gadolinium-enhancement and tumoural cyst formation. Management strategies differ substantially, depending on the kind of lesion. According to the suspected pathological entity radical resection, biopsy or conservative treatments are reasonable options. Intraoperative electrophysiological monitoring is a fundamental part of the surgical setting.