Clinical rarity: simultaneous choroid plexus papilloma and extraventricular neurocytoma presenting as intraventricular hemorrhage in an adolescent

We present a patient with an intraventricular hemorrhage. Imaging identified a left atrial intraventricular mass and a vague adjacent second periventricular cystic lesion. A guided trans-sulcal approach via a left parietal craniotomy resulted in a gross total resection of both lesions. These represented two distinct lesions, the periventricular cystic lesion was an extraventricular neurocytoma (EVN) and a World Health Organization grade 1 choroid plexus papilloma (CPP). The neurocytoma required methylation studies for confirmatory diagnosis. The patient had an uneventful recovery with a normal neurological exam at 12-weeks. This documents the occurrence of two distinct central nervous system tumors, a CPP and an EVN presenting with an intraventricular hemorrhage.

Exoscopic removal of the fourth ventricle choroid plexus papilloma with use of a midline suboccipital osteoplastic craniotomy

Choroid plexus papillomas are relatively rare vascular tumors. In this video, the authors present a pediatric patient who underwent exoscopic removal of the fourth ventricle choroid plexus papilloma with the use of a midline suboccipital osteoplastic craniotomy. The exoscope in the fourth ventricle lesion helps to improve visualization in all directions, with the surgeon being able to maintain a comfortable position throughout the procedure. In addition, the midline suboccipital osteoplastic craniotomy helps to reduce the potential risks of complications, in particular, CSF leak and craniovertebral junction instability. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23106.

Stereotactic radiotherapy outcomes for intraventricular brain tumours in 11 dogs

Published radiotherapy data for canine intraventricular tumours are limited. In this retrospective, longitudinal study (9/2011-2018), 11 dogs with intraventricular masses were treated with stereotactic radiotherapy (SRT). Pathologic diagnosis was available from surgery or necropsy in 6/11 cases, revealing choroid plexus papilloma (3) or carcinoma (2), and ependymoma (1). The remainder were magnetic resonance imaging (MRI)-diagnosed as suspected choroid tumours or ependymomas. Tumours were located in the third or lateral ventricle (8), fourth ventricle (2), and cerebellopontine angle (1). Surgery was performed in three dogs prior to radiotherapy, and all showed gross residual/recurrent disease at treatment. Dogs received 8 Gray × 3 fractions (7), or 15 Gray × 1 fraction (4). Ten dogs were deceased at analysis, and one was living. The estimated median overall survival time (OS) from first SRT treatment was 16.9 months (515 days, 95% CI 33-1593 days). The survival time for two pathology-diagnosed carcinoma dogs were 24 and 133 days, respectively, and survival time for dogs with moderate to marked ventriculomegaly (4/11) ranged from 24 to 113 days. A total of 10/11 showed clinical improvement per owner or clinician, but two had short-lived benefits and were euthanized within 6 weeks of SRT. Limited conclusions on radiation-specific complications are possible due to the small dataset and limited follow-up imaging. This study provides preliminary evidence that radiotherapy outcomes are variable with intraventricular tumours, and some long-term survivors are noted.

The Importance of Intratumoral Venous Drainage Preservation in Two-Stage Surgery of Large Hypervascular Choroid Plexus Papilloma: A Case Report

Two-stage surgery may be necessary when total tumor removal cannot be accomplished in the first surgery; however, the extent and condition in which the remaining tumor should be before the next surgery have not yet been established. There is a risk of postoperative hemorrhage in the residual tumor, especially in hypervascular tumors. We report a case of hypervascular choroid plexus papilloma (CPP) in a 22-year-old male patient where the preservation of intratumoral venous drainage was considered important to avoid hemorrhagic complications during a two-stage surgery. In the first surgery, it was difficult to control the bleeding from the debulked tumor, and the surgery was terminated due to severe blood loss. Large draining veins running in the tumor were preserved as it was suspected that these were important drainage routes of the bloodstream of the tumor. The preserved draining red veins changed to normal venous color in the second surgery performed after one week. The residual tumor was not vascularized during the second surgery and underwent gross total resection with less blood loss. The patient was discharged without sequelae. There was no recurrence of the tumor and no neurological deficit during the three-year follow-up. To prevent postoperative hemorrhage associated with a residual tumor, it may be important to preserve venous drainage of the tumor in hypervascular tumor resection.

Clinical, magnetic resonance imaging, and histological description of a choroid plexus papilloma with disseminated intraventricular and spinal cerebrospinal fluid drop metastases in a young adult dog: a case report

A 2-year-old male entire Cane Corso was presented for investigations into a 1-week history of ambulatory paraparesis and pelvic limb ataxia gradually deteriorating. Magnetic resonance imaging (MRI) revealed intraventricular space-occupying lesions affecting the fourth ventricle and lateral apertures and intradural-extramedullary space-occupying lesions at the level of C7 vertebra, L4-L5, and L7-S1 intervertebral disk spaces. Due to poor quality of life, the patient was euthanized. A post-mortem examination revealed partially encapsulated, multifocally infiltrative, and moderately cellular neoplastic masses. The histological description was similar for all masses. The cells appeared cuboidal with round central nuclei and a moderate amount of eosinophilic cytoplasm and were arranged almost exclusively in single-layered papilliform patterns supported by a fibrovascular stroma. Mitoses were rarely observed (1/2.37 mm2). The primary neoplasm was morphologically most consistent with a choroid plexus papilloma despite drop metastases. This is the first report of a histologically confirmed primary ventricular choroid plexus papilloma causing disseminated MRI-apparent intraventricular and spinal drop metastases.

Microscopic and endoscopic "chopstick" technique removal of choroid plexus papilloma in the third ventricle of an infant: a case report with systematic review of literature

Background

Choroid plexus papilloma (CPP) is rare and even rarer in infants and young children, and it usually occurs in the ventricles. Due to the physical peculiarities of infants, tumor removal by microscopic or endoscopic surgery alone is difficult.

Case Presentation

A 3-month-old patient was found to have an abnormally enlarged head circumference for 7 days. Cranial magnetic resonance imaging (MRI) examination revealed a lesion in the third ventricle. The patient underwent combined microscopic and endoscopic "chopstick" technique to remove the tumor. He recovered well after the surgery. Postoperative pathological examination revealed CPP. Postoperative MRI suggested total resection of the tumor. Follow-up for 1 month showed no recurrence or distant metastasis.

Conclusions

Combined microscopic and endoscopic "chopstick" technique may be a suitable approach to remove tumors in infant ventricles.

Purely endoscopic biportal and monoportal removal of the choroid plexus papilloma of the third ventricle with bilateral spread to the lateral ventricles

Modern neuroendoscopy makes it possible to treat tumors of various localizations with a reduced risk of intra- and postoperative complications. In this video, the authors present biportal and monoportal techniques for the removal of the choroid plexus papilloma of the third ventricle with bilateral spread to the lateral ventricles in a 1-year-old boy. For this operation, they successfully used a new instrument for neuroendoscopy, LigaSure, specially designed for intra-abdominal surgery. The video can be found here: https://stream.cadmore.media/r10.3171/2023.1.FOCVID22170.

Cystic dissemination of choroid plexus papilloma: illustrative cases

BACKGROUND

Choroid plexus papillomas are benign tumors of the choroid plexus. Although typically focal, they can metastasize. Rarely, patients may present with numerous cystic lesions throughout the craniospinal axis.

OBSERVATIONS

The authors present three cases of pathologically confirmed fourth ventricular World Health Organization (WHO) grade 1 choroid plexus papillomas presenting with numerous cystic lesions throughout the craniospinal axis. Two cases were treated with only resection of the fourth ventricular mass; one was treated with a partial cyst fenestration. During follow-up, there was only mild interval growth of the cystic lesions over time, and all patients remained asymptomatic from their cystic lesions. The authors summarize five additional cases of cystic dissemination in the published literature and discuss hypotheses for the pathophysiology of this rare presentation.

LESSONS

Choroid plexus papillomas may present with numerous, widely disseminated cystic lesions within the craniospinal axis. Thus, the authors recommend preoperative and routine imaging of the entire neuroaxis in patients with choroid plexus tumors, regardless of WHO grade. Although the role of adjuvant therapy and cyst fenestration in the treatment of these lesions remains unclear, watchful waiting may be indicated, especially in asymptomatic patients, because the lesions often demonstrate slow, if any, growth over time.

Infantile epileptic spasms syndrome as an initial presentation in infantile choroid plexus papilloma: A case report

We present an interesting report of a 5-month-old infant with epileptic spasms and developmental delay who presented with non-isolated ventriculomegaly in utero and whose brain magnetic resonance imaging revealed right ventricular choroid plexus papilloma (CPP). The epileptic spasms persisted even with the use of antiepileptic therapies but was apparently cured after the removal of a CPP.

Ascites: a loadstar for the diagnosis and management of an intracranial tumor

BACKGROUND

Ascites is defined as abnormal fluid retention in the peritoneal cavity and it can be encountered at any age including fetal life. Ascites mostly results from cirrhosis, chronic renal disease and heart failure in childhood. However, there are various reasons for cirrhotic and non-cirrhotic ascites in the pediatric age. Cerebrospinal fluid ascites is one of the rarest.

CASE

A 3.5- year- old Sudanese boy who underwent right-sided ventriculoperitoneal shunt surgery for hydrocephalus 10 months ago was admitted to the Neurosurgery Intensive Care Unit for intracranial tumor surgery. He had neurologic deterioration and ascites accumulation for the last 4 months. He was consulted with the pediatric gastroenterologist to exclude the reasons causing ascites after admission. No chronic liver, renal or heart disease was shown. The gross appearance of ascitic fluid was so clear that it resembled the cerebrospinal fluid and laboratory analysis results were compatible with transudate. The magnetic resonance imaging identified a mass in the left lateral ventricle. From the pediatrician`s perspective, overproduction of cerebrospinal fluid from a tumor was assumed and shunt exclusion was proposed to alleviate ascites. After the externalization of the stunt and external ventricular device implementation, no further ascites occurred. The patient had a successful tumor excision and discharged after gaining oral feeding ability and sufficient weight gain.

CONCLUSION

In case of intractable ascites occurrence after a ventriculoperitoneal shunt placement, a pediatrician should consider etiologies resulting in imbalance of absorption and secretion function of cerebrospinal fluid.

Cerebello-pontine and Cerebello-medullary Fissure Choroid Plexus Papilloma in a Child - Case Report and Review of Literature

Choroid plexus papillomas (CPP) are commonly seen in the supratentorial compartment in children and only very rarely in the posterior fossa. CPP in the cerebello-pontine angle and cerebello-medullary fissure (CPA) in the pediatric age group are extremely rare with only seven previous cases reported in literature. The authors present the case of a 7-year-old girl who presented with neck tilt, imbalance, and headache. The MRI showed a lesion with a frond-like appearance in the CPA with heterogeneous enhancement. The tumor was excised radically using a cerebello-medullary fissure approach. The authors review and analyze the literature on this rare pediatric tumor, with specific attention to radiology and the surgical aspects.

Management Strategies for Brain Tumors Diagnosed during Pregnancy: A Case Report and Literature Review

Background and Objectives: Maternal brain tumors diagnosed during pregnancy are very rare, and their clinical course remains incompletely understood. We recently experienced a case of a brain tumor diagnosed at 30 weeks of gestation, and the treatment was initiated after delivery at 32 weeks of gestation. In this study, we reviewed case reports of brain tumors diagnosed during pregnancy, focusing on whether the brain tumor was treated during pregnancy or after termination of pregnancy and on the timing of therapeutic intervention. Materials and Methods: We searched PubMed and Ichushi-Web for articles published after January 2000 that reported cases of maternal brain tumors diagnosed during pregnancy. The patients were divided into two groups according to whether the tumor was treated during pregnancy (Group A) or after termination of pregnancy (Group B). Results: In total, 42 patients were included in the study (13 (31%) in Group A and 29 (69%) in Group B). The most common symptoms before diagnosis were those caused by increased intracranial pressure (57.1%). The diagnosis was made at 18 ± 6 weeks of gestation in Group A and 26 ± 9 weeks of gestation in Group B (p = 0.007). In all cases diagnosed after 34 weeks of gestation, termination of pregnancy was followed by treatment. Treatment was initiated within two weeks of diagnosis in 50% of patients in Group A and 30% in Group B. Conclusions: When severe symptoms caused by increased intracranial pressure last for several weeks, imaging tests should be considered. Termination of pregnancy is a good option for a brain tumor diagnosed after 34 weeks of gestation, while comprehensive treatment decisions should be made based on the severity of symptoms and the course of pregnancy in other cases.

Intra-fourth-ventricular choroid plexus papilloma miming ependymoma

ABSTRACT

Choroid plexus papilloma (CPP), a low incidence central nervous system (CNS) tumor, typically develops as an intraventricular neoplasm arising from the epithelium of the choroid plexus. Infratentorial CPP is predominantly clustered in adults with roughly 70% in the fourth ventricle, while supratentorial CPP commonly found in the lateral ventricles, is the most frequent location in children. The clinical and imaging features of CPP are not typical and may induce the misdiagnosis as other types of primary brain tumors. In this paper, we described a fourth-ventricular CPP that was misdiagnosed as ependymoma despite the manipulation of groundbreaking magnetic resonance imaging (MRI) sequences. These findings indicated that CPP should be considered when performing the differential diagnosis of intraventricular neoplasms.

Bilateral Choroid Plexus Papillomas Diagnosed by Prenatal Ultrasound and MRI

We present a rare prenatal diagnosis of bilateral choroid plexus papillomas by obstetrical ultrasound and fetal MRI at 20 weeks 6 days gestation. The fetus demonstrated bilateral enlarged, echogenic choroid plexus with increased Doppler flow suggestive of vascularized choroid tissue. Same-day fetal MRI demonstrated that the choroid plexus appeared enlarged bilaterally without definite hemorrhage. The combined features on ultrasound and MRI suggested bilateral choroid plexus papillomas with increased cerebrospinal fluid production, leading to ventriculomegaly and enlarged extra-axial spaces. The diagnosis was confirmed by postnatal pathology, which demonstrated WHO grade II atypical choroid plexus papillomas.

Molecular insights into malignant progression of atypical choroid plexus papilloma

Choroid plexus tumors are rare pediatric neoplasms ranging from low-grade papillomas to overtly malignant carcinomas. They are commonly associated with Li–Fraumeni syndrome and germline TP53 mutations. Choroid plexus carcinomas associated with Li–Fraumeni syndrome are less responsive to chemotherapy, and there is a need to avoid radiation therapy leading to poorer outcomes and survival. Malignant progression from choroid plexus papillomas to carcinomas is exceedingly rare with only a handful of cases reported, and the molecular mechanisms of this progression remain elusive. We report a case of malignant transformation of choroid plexus papilloma to carcinoma in a 7-yr-old male with a germline TP53 mutation in which we present an analysis of molecular changes that might have led to the progression based on the next-generation genetic sequencing of both the original choroid plexus papilloma and the subsequent choroid plexus carcinoma. Chromosomal aneuploidy was significant in both lesions with mostly gains present in the papilloma and additional significant losses in the carcinoma. The chromosomal loss that occurred, in particular loss of Chromosome 13, resulted in the losses of two critical tumor suppressor genes, RB1 and BRCA2, which might play a possible role in the observed malignant transformation.

Next generation DNA sequencing of atypical choroid plexus papilloma of brain: Identification of novel mutations in a female patient by Ion Proton

Choroid plexus papilloma (CPP) is a rare benign tumor of the central nervous system that is usually confined to the cerebral ventricles. According to the World Health Organization, CPP corresponds to a grade I atypical CPP (a-CPP); however, it can become more aggressive and reach grade II, which can rarely undergo malignant transformation into a choroid plexus carcinoma (grade III). To the best of our knowledge, identification of these tumors mutations by next generation DNA sequencing (NGS) has not been yet reported. In the present study, NGS analysis of an a-CPP case was performed. Data were analyzed using Advaita Bioinformatics i-VariantGuide and Ion Reporter 5.6 programs. The results from NGS identified 12 novel missense mutations in the following genes: NOTCH1, ATM, STK36, MAGI1, DST, RECQL4, NUMA1, THBS1, MYH11, MALT1, SMARCA4 and CDH20. The PolyPhen score of six variants viz., DST, RECQL4, NUMA1, THBS1, MYHI1 and SMARCA4 were high, which suggested these variants represents pathogenic variants. Two novel insertions that caused frameshift were also found. Furthermore, two novel nonsense mutations and 14 novel intronic variants were identified in this tumor. The novel missense mutation detected in ATM gene was situated in c.5808A>T; p. (Leu1936Phe) in exon 39, and a known ATM mutation was in c.5948A>G; p. (Asn1983Ser). These novel mutations had not been reported in previous database. Subsequently, the quality statistics of these variants, including allele coverage, allele ratio, P-value, Phred quality score, sequencing coverage, PolyPhen score and alleles frequency was performed. For all variants, P-value was highly significant and the Phred quality score was high. In addition, the results from sequencing coverage demonstrated that 97.02% reads were on target and that 97.88% amplicons had at least 500 reads. These findings may serve at determining new strategies to distinguish the types of choroid plexus tumor, and at developing novel targeted therapies. Development of NGS technologies in the Kingdom of Saudi Arabia may be used in molecular pathology laboratories.

Choroid plexus papilloma presenting as an occipital mass with neck pain: Case report

RATIONALE

Choroid plexus papillomas are rare benign central nervous system neoplasms arising from choroid plexus epithelium. They are most often located in the lateral ventricle, followed by the fourth and third ventricles and, rarely, in the cerebellopontine angle.

PATIENT CONCERNS

We report an uncommon case of a 17-year-old boy who presented with neck pain that had lasted for more than 1 month, with accompanying pain and numbness in his upper extremities. His conditions included slight dizziness, nausea, diplopia, paresthesia, and an unsteady gait. Magnetic resonance imaging (MRI) showed huge cerebellopontine angle tumor that extended to the front medulla oblongata.

DIAGNOSIS

Choroid plexus papilloma (WHO I) was diagnosed in this patient.

INTERVENTIONS

The patient was referred for neurosurgical intervention. The very large neoplasm was subtotally resected.

OUTCOMES

The symptoms of the patient were gradually alleviated after surgery and subsequent radiotherapy treatment, but unfortunately, follow-up of 2 years later revealed that the disease was recurrent and the young man passed away.

LESSONS

Neck pain is related to many factors. The case provided an awareness of the origin of severe intracranial disease. It is mandatory to take a thorough clinical assessment with a holistic approach.

Primary Choroid Plexus Papilloma over Sellar Region Mimicking with Craniopharyngioma: A Case Report and Literature Review

Choroid plexus papillomas (CPPs) are slow-growing and benign tumors, representing less than 1% of all intracranial neoplasms. They are predominantly located in the lateral ventricles in children, and in the fourth ventricle in adults. Primary CPP over sellar regions is extremely rare. There was previously only one case reported in men.

We report the case of a 43-year-old male who initially presented with bilateral temporal hemiapnosia. A brain magnetic resonance imaging (MRI) revealed heterogenous enhanced mass lesion with cyst component compressing upward onto the optic chiasm. A craniopharyngioma was initially suspected. Further endoscopic trans-sphenoidal surgery (ETS) was performed for total tumor resection. After surgery, the patient had visual field improved without tumor recurrence on post-operative MRI in clinical follow-up. Histopathological examination of the lesion confirmed the diagnosis of CPP, with fibrovascular cores covered by a single layer of cuboidal to columnar epithelial cells.

CPP is a rare tumor without specific clinical patterns or imaging findings. Therefore, pre-operative differential diagnosis is difficult for this kind of tumor with complete separation from ventricular system. An ETS for total tumor resection provided effective treatment.

Glomeruloid Microvascular Proliferation, Desmoplasia, and High Proliferative Index as Potential Indicators of High Grade Canine Choroid Plexus Tumors

Choroid plexus tumors (CPT) are intraventricular neoplasms accounting for 10% of all primary central nervous system tumors in dogs. They are frequently classified according to the human WHO classification into choroid plexus papilloma (CPP, grade I), atypical CPP (aCPP, grade II), and choroid plexus carcinoma (CPC, grade III). Histological features observed in canine CPT such as increased vascular density (IVD) and glomeruloid microvascular proliferation (GMVP) are not part of the WHO classification. This multi-centric study aimed to investigate tumor-associated vascular hyperplasia in dogs by determining the prevalence of GMVP and IVD in 52 canine CPT and their association with tumor grade. In addition, the expression of angiogenic factors was assessed by immunohistochemistry in 25 tumors to investigate the pathogenesis of tumor-associated vascular hyperplasia. Based on the classical histological hallmarks, this study of 52 CPT identified 22 (42%) CPP (grade I) and 30 of (58%) CPC (grade III). GMVP was more prevalent in CPC (13/30; 43%) than CPP (1/22; 4%), whereas IVD occurred to a similar extent in CPP and CPC. Desmoplasia was more common in CPC (19/30; 63%) than CPP (2/22; 9%), and similarly, the proliferative index (PI) of neoplastic epithelium was significantly higher in CPC (5.14%) than CPP (0.94%). The majority of CPT expressed platelet-derived growth factor (PDGF), PDGFRα, PDGFRβ, and vascular endothelial growth factor (VEGF) irrespective of tumor grade or tumor-associated vascular hyperplasia. These results suggest that tumor-associated GMVP, desmoplasia, and PI may serve as histological indicators of malignancy in CPT.

Spinal drop metastasis from a benign fourth ventricular choroid plexus papilloma in a pediatric patient: case report

Choroid plexus papillomas (CPPs) are typically benign tumors that can occur in any age group but are more commonly found in pediatric patients. Although these tumors are benign, there are several reports in adult patients of distant metastases present either at the time of diagnosis or occurring months to years after initial resection. Here, the authors report the case of a 14-year-old boy who presented with symptoms of elevated intracranial pressure due to obstructive hydrocephalus that was caused by a large fourth ventricular mass. Preoperative imaging included a full MRI of the spine, which revealed an intradural lesion that encased the distal sacral nerve roots at the tip of the thecal sac and was concerning for a drop metastasis. The patient underwent gross-total resection of both the fourth ventricular and sacral tumors with histology of both lesions consistent with benign CPP (WHO Grade I). In addition, the authors review prior reports of both pediatric and adult patients in whom benign CPPs have metastasized with either benign or atypical pathology found at a distant site. Taking into account this unusual case and reports in the literature, patients with even benign CPPs may warrant initial and routine follow-up imaging of the total neural axis in search of the rare, but possible, occurrence of drop metastasis.

Incidental choroid plexus papilloma in a child: A difficult decision

Background:

Choroid plexus tumors (CPT) in the pediatric population are usually discovered in symptomatic patients often with symptoms of increased intracranial pressure, with hydrocephalus as the most common presentation, along with seizures, subarachnoid hemorrhage, or focal neurological deficit. Most CPTs are found to be benign choroid plexus papillomas (CPP), whereas a small number are intermediate and malignant choroid plexus carcinomas (CPC). Total surgical resection is the established definitive treatment for symptomatic CPP.

Case Description:

We describe a young female who was found to have an incidental CPT during workup for recent head trauma without neurological deficits or hydrocephalus. She underwent a surgical operation to remove the tumor successful, with 1-year follow-up showing no recurrence and normal developmental milestones.

Conclusion:

This rare presentation of an asymptomatic CPT brings attention to the fact that there is no clear evidence for how or when to treat such patients. Because discovery of a CPT in an asymptomatic patient is uncommon, the treatment plan appears to be developed on a case-by-case basis. We hope to generate discussion for establishing an agreed upon treatment approach for CPTs in asymptomatic patients.

Lesson of the month 2: A choroid plexus papilloma manifesting as anorexia nervosa in an adult

A Caucasian female previously diagnosed with anorexia nervosa was referred by psychiatric services to the general medical team. She presented with dehydration, vomiting, weakness, a body mass index of 13 kg/m2 and was treated with intravenous and enteral supplementation. During admission her vomiting worsened and she developed visual hallucinations and confabulation. Neurological examination demonstrated cerebellar signs and bilateral papilloedema on fundoscopy. Subsequent magnetic resonance imaging of the brain revealed a large fourth ventricular tumour causing obstructive hydrocephalus. The tumour was excised and histologically confirmed to be a choroid plexus papilloma. Postoperatively her neurological symptoms and negative feelings towards eating resolved.

Case series of choroid plexus papilloma in children at uncommon locations and review of the literature

Background:

Choroid plexus papillomas (CPPs) comprise around 1% of intracranial neoplasms. The most common location is atrium of the lateral ventricle in children and fourth ventricle in adults. Other rare locations include third ventricle, cerebellopontine (CP) angle and cerebral parenchyma, with only a few cases reported. Authors report three cases of CPP at uncommon locations in pediatric patients. The rarity of these locations, diagnostic dilemma and management aspects are discussed along with an extensive review of the literature.

Methods:

Retrospective institutional data analysis of histopathologically confirmed pediatric CPPs from 2010 to 2014.

Results:

Authors noted three cases of CPP in children in uncommon locations-one each in the posterior third ventricle, fourth ventricle, and CP angle. All were males in the first decade. Two cases presented with features of obstructive hydrocephalus while the latter presented with compressive effects. Complete excision was achieved in two cases while subtotal removal was performed in one case (fourth ventricular) because of excess blood loss. Mean follow-up duration was 24.6 months (range 20–30 months). One case (of subtotal removal) had fair recovery while other two had excellent outcomes.

Conclusions:

Posterior third ventricle, fourth ventricle, and CP angle are uncommon locations for these tumors in children. Complete surgical removal is the treatment of choice and approach needs to be tailored according to the site and size of the lesion. Blood loss is a major concern in young children as they are highly vascular tumors. Complete removal leads to excellent long-term survival rates. Adjuvant treatment is not required.

Superior parietal lobule approach for choroid plexus papillomas without preoperative embolization in very young children

OBJECT Choroid plexus papillomas (CPPs) are rare neoplasms, often found in the atrium of the lateral ventricle of infants, and cause overproduction hydrocephalus. The extensive vascularity and medially located blood supply of these tumors, coupled with the young age of the patients, can make prevention of blood loss challenging. Preoperative embolization has been advocated to reduce blood loss and prevent the need for transfusion, but this mandates radiation exposure and the additional risks of vessel injury and stroke. For these reasons, the authors present their experience using the superior parietal lobule approach to CPPs of the atrium without adjunct therapy. METHODS A retrospective review was conducted of all children who presented to Columbia University/Morgan Stanley Children's Hospital of New York with a CPP in the atrium of the lateral ventricle and who underwent surgery using a superior parietal lobule approach without preoperative embolization. RESULTS Nine children were included, with a median age of 7 months. There were no perioperative complications or new neurological deficits. All patients had intraoperative blood loss of less than 100 ml, with a mean minimum hematocrit of 26.9% (range 19.6%-36.2%). No patients required a blood transfusion. The median follow-up was 39 months, during which time no patient demonstrated residual or recurrent tumor on MRI, nor did any have an increase in ventricular size or require CSF diversion. CONCLUSIONS The superior parietal lobule approach is safe and effective for very young children with CPPs in the atrium of the lateral ventricle. The results suggest that preoperative embolization is not essential to avoid transfusion or achieve overall good outcomes in these patients. This management strategy avoids radiation exposure and the additional risks associated with embolization.

Endoscopic monoportal removal of a choroid plexus papilloma in the posterior third ventricle in a child

Currently, only a few reports describe the minimally invasive removal of choroid plexus papillomas (CPPs) and, to the best of the authors' knowledge, no reports detail the resection of such a papilloma through an endoscopic approach in infants. The authors here describe the endoscopic removal of a third ventricle CPP in a child. A 5-month-old male infant presented with progressive macrocephaly, vomiting, and convulsions. A lesion in the posterior third ventricle was detected on brain MRI. Because of the patient's very young age, neuroendoscopy was used as the least invasive technique. The tumor was completely resected through a monoportal neuroendoscopic approach. Histologically, the tumor was classified as a WHO Grade I CPP. After surgery, the patient's condition improved, with no complications during his recovery. Ten-month follow-up neuroimaging revealed no evidence of tumor recurrence or progressive hydrocephaly. In view of the successful neuroendoscopic excision of this posterior third ventricle CPP, the authors believe that this method seems promising in the treatment of young children with intraventricular lesions.

Purely endoscopic resection of a choroid plexus papilloma of the third ventricle: case report

The authors report an illustrative case of a purely endoscopic surgical approach to successfully remove a solid choroid plexus papilloma of the third ventricle in an infant. A 10-week-old male infant first presented with transient episodes of forced downward gaze, divergent macrocephaly, a tense anterior fontanel, diastasis of the cranial sutures, and papilledema. Brain MRI revealed a small, multilobulated contrast-enhancing mass situated within the posterior third ventricle, with resultant obstructive hydrocephalus. A purely endoscopic removal of the tumor was performed through a single right frontal bur hole. Intraoperatively, a unique vascular tributary was recognized coming from the tela choroidea and was controlled with coagulation and sharp dissection. Postoperative MRI confirmed complete tumor removal, and the tumor was classified as a choroid plexus papilloma. There has been no evidence of tumor recurrence over 42 months of follow-up. With this case report the authors intended to show that endoscopic surgery can be an additional tool to consider when planning a choroid plexus tumor approach. It seems to be of particular interest in selected cases in which there are concerns about the patient's total blood volume, as in infants with potential hemorrhagic tumors and when it is possible to preoperatively identify a single vascular pedicle that can be approached early in the surgery.

A case of difficult management of fluid-electrolyte imbalance in choroid plexus papilloma

A 22-month-old boy presented with nausea and gradual deterioration of gait disturbance. Computed tomography (CT) demonstrated an intraventricular mass lesion in the right lateral ventricle. He was referred to our department 3 weeks after onset. Acute hydrocephalus gradually proceeded 4 days after admission, and external ventricular drainage (EVD) was performed. EVD revealed cerebrospinal fluid (CSF) overproduction (800-1,500 mL/day) under constant pressure of 10 cm H2O above external auditory meatus. Magnetic resonance imaging showed a multi-lobular mass in the inferior horn of the right lateral ventricle. A choroid plexus tumor was suspected. The ratio of blood urea nitrogen:creatinine (BUN:Cre) remained between 30 and 40, and hemoglobin was between 14.0-17.0 mg/dL, suggesting marked dehydration. Serum sodium varied between 117 and 140 mmol/L, and serum potassium between 2.2 mmol/L and 6.9 mmol/L. The amount of EVD was unstable and fluid balance management was difficult. Hypotonic fluid with sodium chloride supplement was used to adjust the fluid and electrolyte imbalance. Surgical removal of the tumor was performed 6 days after EVD and tumor was grossly and totally removed. The high BUN:Cre ratio decreased to about 15 and hemoglobin recovered to 7.5-9.0 mg/dL after removal. Electrolytes returned to the normal range. Overproduction of CSF also markedly improved to < 300 mL/day. Histopathological examination diagnosed choroid plexus papilloma.We experienced a case of choroid plexus papilloma associated with fluid-electrolyte imbalance due to over-drainage after EVD, which could not be effectively controlled before tumor removal. Cautious fluid management and emergent surgical resection might be required to manage the overproduction of CSF and fluid-electrolyte imbalance.

Use of tranexamic acid in infants undergoing choroid plexus papilloma surgery: a report of two cases

Choroid plexus papilloma (CPP) is a highly vascular tumor of infancy. Reducing blood loss is the key to successful surgical removal of CPPs. Tranexamic acid (TXA) is efficacious in reducing bleeding in craniofacial surgery for infants. This report demonstrates the potential utility of TXA for decreasing blood loss in the removal of vascular tumors in infants. We administered tranexamic acid to two infants with CPP during surgical removal to potentially aid hemostasis and therefore lessen intra-operative bleeding. Gross total surgical resection was accomplished; the patients were hemodynamically stable perioperatively, and the total calculated blood loss was minimal at <20% of the patients' total circulating blood volume. This is the first report of tranexamic acid administration for CPP surgery in children. TXA is an easily administered hemostatic agent and may merit further study as an agent to help reduce intra-operative blood loss in this vulnerable population.

Encephalocraniocutaneous lipomatosis with neurocutaneous melanosis

Encephalocraniocutaneous lipomatosis is a rare neurocutaneous syndrome characterized by classical cutaneous and ocular lesions with central nervous system anomalies. We describe an infant with classical encephalocraniocutaneous lipomatosis characterized by probable naevus psiloliparus, frontal subcutaneous lipomas, ocular limbal dermoids and arachnoid cysts, and ventriculomegaly. He also had giant congenital nevus with leptomeningeal melanosis. This case represents a rare association between encephalocraniocutaneous lipomatosis and neurocutaneous melanosis.

Atypical choroid plexus papilloma treated with single agent bevacizumab

Choroid plexus papillomas (CPPs) are usually not malignant and occur in less than 1% of brain tumors in patients of all ages. They represent 3% of childhood intracranial neoplasms with a predilection in younger ages. Papillomas have an indolent course and carry a good long-term outcome if gross total surgical resection is achieved. However malignant evolution may occur, with a 10-30% incidence. Chemotherapy has been used with varied degrees of success. Most series are very small, some are only limited to case reports and cannot lead to guidelines or therapeutic recommendations. We are reporting the first case of recurrent CPP treated with 5 mg/kg of bevacizumab administered once every two weeks. Complete patient evaluations with follow-up contrast-enhanced magnetic resonance imaging (MRI) scans were obtained after the initial two treatments and every 8 weeks thereafter. Only after two treatments, the MRI scans showed radiological stabilization of the tumor, and the patient achieved an excellent clinical response with significant resolution of all skin lesions.

Unique presentation of cerebellopontine angle choroid plexus papillomas: case report and review of the literature

Objectives We present the case of a choroid plexus papilloma (CPP) in the cerebellopontine angle (CPA), describe the different appearances of CPPs with a variety of imaging techniques, and discuss the differential diagnosis of CPA tumors.

Participant and Design We report the case of a 52-year-old woman with headache, tinnitus, and unilateral hearing impairment whose preoperative magnetic resonance imaging revealed a heterogeneously enhancing CPA mass that extended into the internal auditory canal.

Main Outcome Measures, Results, and Conclusion The preoperative imaging appearance of the lesion was most consistent with that of a schwannoma. Postoperative histopathologic examination found the tumor to be a CPP with cuboidal epithelial cells overlying fibrovascular stroma. CPPs are rare benign central nervous system neoplasms arising from choroid plexus epithelium. The most common site of presentation is in the fourth ventricle in adults and the lateral ventricles in children. CPPs rarely occur in the CPA, and when they do, clinical-radiologic diagnosis is difficult due to both the rarity of this presentation and to nonspecific radiological features.

Treatment of choroid plexus tumors: a 20-year single institutional experience

OBJECT

Choroid plexus tumors (CPTs) are rare intracranial neoplasms that constitute approximately 2%-5% of all pediatric brain tumors. Most of these tumors present with severe hydrocephalus. The optimal perioperative management and oncological care remain a matter of debate. The authors present the epidemiological and clinical features of CPTs from a 20-year single-institutional experience.

METHODS

A total of 39 consecutive patients with pathologically proven CPTs (31 choroid plexus papillomas [CPPs] and 8 choroid plexus carcinomas [CPCs]) were included in this series. Patient demographics, clinical presentation, comorbidities, indications for surgery, radiological studies, tumor location, and all operative variables were reviewed for each case. Multivariate regression analysis was performed to identify independent predictors of tumor recurrence and survival.

RESULTS

The overall mean age (± SD) was 13.13 ± 19.59 years (15.27 ± 21.10 years in the CPP group and 3.66 ± 3.59 years in the CPC group). Hydrocephalus was noted at presentation in 34% of patients. The most common presenting symptoms were headache (32%) and nausea/vomiting (26%). Gross-total resection (GTR) was achieved in 86% of CPPs and in 71% of CPCs (p = 0.57). There was 100% survival in patients with CPPs observed at the 5- and 10-year follow-up and 71% survival in patients with CPCs at the 5-year follow-up. In a multivariate regression analysis, a diagnosis of papilloma, preoperative vision changes, or hydrocephalus; right ventricle tumor location; and GTR were all independently associated with a decreased likelihood of tumor recurrence at last follow-up.

CONCLUSIONS

The authors' study suggests that patients with CPCs are more likely to experience local recurrence and metastasis; hence, GTR with chemotherapy and radiotherapy, particularly for CPCs, is pivotal in preventing recurrence and prolonging survival. While GTR was important for local control following resection of CPPs, it had a minimal effect on prolonging survival in this patient cohort.

Choroid plexus papilloma expansion over 7 years in Aicardi syndrome

Choroid plexus papillomas have been reported in Aicardi syndrome. Management of these tumors is controversial because their natural progression in Aicardi syndrome has only been rarely documented. This report describes the progression of such a tumor over 7 years in a girl with Aicardi syndrome. A magnetic resonance imaging study at 2 months of age demonstrated a right ventricular mass that was consistent with a unilateral choroid plexus papilloma. The mass enlarged over the next 7 years without causing any clinically apparent symptoms, ventricular enlargement, hydrocephalus, or mass effect. The tumor was removed without change in behavior or development. The known cases of Aicardi syndrome associated with choroid plexus papillomas are reviewed. The heterogeneous nature of this lesion is highlighted.