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1/24. Intractable vomiting from glioblastoma metastatic to the fourth ventricle: three case studies.

    Dissemination of malignant glioma to the fourth ventricle with metastatic deposits and intractable vomiting is rare. Leptomeningeal extension of malignant glioma is an uncommon condition that has been reported in patients with end-stage disease and is usually unresponsive to any treatment modality. We describe 3 patients with progressing recurrent glioblastoma multiforme in whom leptomeningeal invasion manifested itself as intractable vomiting due to tumor metastases in the floor of the fourth ventricle. All patients received additional radiation therapy focused to the posterior fossa, with complete resolution of vomiting occurring within 10 days after irradiation. The remission of symptoms in these patients persisted until their death 3-4 months after the repeat radiation therapy. These reports indicate that additional focused radiation should be considered because of its significant therapeutic effect in alleviating intractable nausea and vomiting in patients with glioma metastasized to the posterior fossa.
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2/24. Diencephalic syndrome of emaciation in an adult associated with a third ventricle intrinsic craniopharyngioma: case report.

    OBJECTIVE AND IMPORTANCE: Diencephalic syndrome of emaciation (DS) is seen almost exclusively in infants and young children, and only two cases of DS in adults have been reported previously. We describe a case of DS associated with a third ventricle intrinsic craniopharyngioma in an adult patient. CLINICAL PRESENTATION: A 54-year-old man presented with profound emaciation, disorientation, memory loss, and psychological disorders. Computed tomographic scanning and magnetic resonance imaging of his brain disclosed a tumor within the third ventricle. The preoperative endocrinological examination indicated an elevated growth hormone level and a decreased somatomedin C level. INTERVENTION: The patient underwent partial resection of the tumor, which was adherent to the floor of the third ventricle but not to the ventricle wall, by an interhemispheric-transcallosal approach. The histological examination revealed a squamous papillary-type craniopharyngioma. The patient received 50 Gy of radiotherapy, which resulted in 90 to 95% reduction of the tumor size within 6 months, as indicated by the magnetic resonance images presented. The psychological disorders, memory disturbance, and severe emaciation improved gradually thereafter. CONCLUSION: Although extremely rare, DS can occur in an adult harboring a tumor in the anterior hypothalamus.
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3/24. Surgical approach to the fourth ventricle cavity through the cerebellomedullary fissure.

    Lesions of the fourth ventricle represent a challenge to neurosurgeons because of severe deficits that occur following injury to the delicate structures in the ventricle wall and floor. The conventional approach to the fourth ventricle is by splitting the vermis on the suboccipital surface of the cerebellum. In the last 9 years, a series of 21 patients in our clinic underwent microsurgical tumor resection by the unilateral transcerebellomedullary fissure approach. The patients had various pathologies including hemangioblastoma, epidermoid tumor, medulloblastoma, ependymoma, low grade astrocytoma, choroid plexus carcinoma, choroid plexus papilloma, adenocarcinoma in the pons, and cavernoma in the medulla. Total removal was achieved in all but three cases. One death occurred 2 months after surgery due to pulmonary complication. In the follow-up period of 2 months to 5 years, the preoperative symptoms disappeared in all cases except one with a brainstem lesion. By a unilateral transcerebellomedullary fissure approach, it is possible to provide sufficient operative space from aqueduct to obex without splitting the vermis. This approach needs meticulous dissection of the fissure and preservation of the posterior inferior cerebellar artery and its branches.
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4/24. ventriculostomy in a tumor involving the third ventricular floor.

    Recently, endoscopic management has gotten preference over open surgical treatment in selected cases of intraventricular tumors. Endoscopic third ventriculostomy (ETV) appears unfeasible when tumors extend to the third ventricular floor region due to the risk of perforators and injury to the basilar artery. We report the case of a 12-year-old male with symptoms of acute, chronic, raised intracranial pressure. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a posterior third ventricular tumor involving the aqueductal and floor regions. The ETV was done after clearing the floor by partial tumor resection, keeping the dorsum sellae as the major anatomical landmark. The patient improved satisfactorily and was given adjuvant radiotherapy, and the need for an external shunt was completely eliminated. We conclude that ETV appears worth trying, even in third ventricular tumors involving the floor region if they can be cleared from the tumor keeping the dorsum sellae as the major anatomical landmark.
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5/24. germinoma in the fourth ventricle.

    A 33-year-old male presented with trigeminal, abducens, and facial nerve pareses associated with cerebellar signs. magnetic resonance imaging showed a homogeneously enhanced mass occupying the lower half of the fourth ventricle and attached to the floor of the fourth ventricle. The mass was subtotally removed. The histological diagnosis was pure germinoma. Neuro-imaging cannot distinguish germinoma in the fourth ventricle from ependymoma. germinoma in the fourth ventricle is extremely rare and requires histological differentiation from ependymoma to determine the indications for adjuvant irradiation and/or chemotherapy.
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6/24. Tanycytomas: a newly characterized hypothalamic-suprasellar and ventricular tumor.

    We report five cases of tumors occurring in three children and in two adults. The tumors had unusual histomorphology and a mixture of ependymal and piloid-like astrocytic features and a myxoid stroma similar to myxopapillary ependymomas. MR imaging in three of the cases showed aggressive, intensely enhancing partially cystic hypothalamic-suprasellar masses near midline and near the floor of the third ventricle. In the three pediatric cases, the tumor encased the circle of willis. This newly characterized tumor, the tanycytoma, has neoplastic cells with histomorphologic and ultrastructural characteristics similar to those of the tanycyte.
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7/24. Dysembryoplastic neuroepithelial tumor in the left lateral ventricle.

    Extracortical location of dysembryoplastic neuroepithelial tumor (DNT) is rare. We present a case of DNT localized in the left lateral ventricle of a 21-year-old female patient. magnetic resonance imaging of the brain showed a round mass lesion in the floor of the anterior horn of the left lateral ventricle. The lesion was hypointense on T (1)-weighted images and slightly hyperintense on T (2)-weighted images without contrast enhancement. Total removal of the yellowish-white colored soft tumor was performed through a transcallosal approach. Histologically, the tumor was of simple type of DNT that was composed of small oligodendrogliocytes clustered tightly about perivascular spaces with neurons floating in mucoid pools showing an eosinophilic fibrillary matrix in the background. The recognition of DNT with an unusual location in lateral ventricle has therapeutic and prognostic significance since DNT is curable by surgical excision and radiation therapy is of no obvious benefit.
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8/24. Intrinsic III ventricle craniopharyngioma.

    A case of intrinsic III ventricle craniopharyngioma in an 11-year-old girl is presented. Only five cases in children have previously been reported in detail. The intraventricular location of a craniopharyngioma originates from ectopic remnants and causes intracranial hypertension without hormonal or neurological disorders. The tumor was safely removed by the transcallosal approach, and we confirmed that the floor of the III ventricle was intact.
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9/24. Transcavum septum pellucidum interforniceal approach for the colloid cyst of the third ventricle Operative nuance.

    BACKGROUND: Despite their unfavorable locations, lesions of the third ventricle can be successfully removed via an interhemispheric, transcallosal approach. In cases with normal ventricular anatomy, this approach requires unilateral or bilateral identification of the foramen of Monro. TECHNIQUE: However, in the presence of abnormal ventricular configuration such as cavum septum pellucidum (CSP), this basic knowledge needs to be modified. After routine callosotomy, there may be a confusion while entering the CSP due to the invisualization of ventricular landmarks such as the foramen of Monro, thalamostriate vein, and choroid plexus. The floor of the CSP is formed by the fornices, and a direct approach to the interforniceal area is easier via the CSP. But the interforniceal approach is not a routine way to reach the third ventricle, which has higher risks than other modalities. CONCLUSION: This approach should be planned and used in selected cases of the CSP. Opening of the walls of CSP is recommended both to expose both the foramen of Monro and to gain safe access to the third ventricle before manipulating the interforniceal area.
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10/24. Cavernous angioma in the fourth ventricular floor--case report.

    A rare case of cavernous angioma located in the fourth ventricular floor occurred in a 44-year-old female complaining of occipital headache, vomiting, diplopia, and dysarthria. Computed tomographic scans demonstrated a high-density area in the fourth ventricle and slight hydrocephalus. Magnetic resonance (MR) imaging showed a mixed intensity mass on T2-weighted images and high- or isointensity regions on T1-weighted images. The tumor was totally removed and histologically diagnosed as cavernous angioma. Postoperatively, ataxic gait, nausea, and vomiting disappeared gradually. MR imaging was useful to accurately evaluate the anatomic relationship between the lesion and the brainstem.
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