Tumors at the Trigone of the Lateral Ventricle — Clinical Analysis of Eight Cases—

Takashi ANDOH, Jun SHINODA, Yoshiaki MIWA, Toshifumi HIRATA, Noboru SAKAI, Hiromu YAMADA and Kuniyasu SHIMOKAWA*

Department of Neurosurgery and *Pathological Division of Central Laboratory, Gifu University School of Medicine, Gifu

Abstract

Tumors at the trigone of the lateral ventricles are relatively rare. The authors have operated on eight cases with trigonal tumors during a 10-year period. Four cases were true intraventricular tumors arising from the ventricular walls, consisting of two , one cavernous angioma, and one papilloma. On the other hand, the remaining four cases were paraventricular tumors originating in the adjacent brain and consisted of three and one multiforme. Although these trigonal tumors were readily detected with computed tomographic (CT) scanning, differential diagnosis was difficult because of their similar appearances on CT scans. The initial symptoms were headache in seven, and the neurological examination revealed personality changes, choked disc, visual field defects, , etc., in four, and no deficits in the remaining four cases. All cases were operated on viasuperior or middle temporal gyrus incision, and the sur gical results were good except for one case who died of postoperative brain edema. In the four cases with tumors located in the dominant hemisphere, two were left with sensory aphasia, dyslexia, dyscalculia, and hemianopsia which improved within 6 months. In these two cases, postoperative CT scans revealed cerebrospinal fluid retention with severe edema along the surgical route which disappeared spontaneously within 3 months. We consider that the temporal gyrus incision was the safest approach, even though the tumor was located in the dominant side.

Key words: intraventricular tumor, trigone, computed tomography, angiography, surgical approaches

Introduction between 1977 and 1987 (Table 1). Their ages ranged from 5 to 62 years, seven cases being adults aged over Tumors at the trigone of the lateral ventricle are rela 30 years, and one case with pilocytic tively rare and asymptomatic, and their incidental aged 5 years. The preoperative diagnosis of menin discovery has recently increased with the wide use of gioma was comparatively easy, but subependymal computed tomography (CT). Although almost all giant cell astrocytoma,') cavernous angioma, or trigonal tumors are meningiomas, it is difficult to were difficult to differentiate determine their precise nature before the operation from , and required histological con because of the various other tumors that may be firmation. Diagnoses were confirmed histologically suspected. We describe eight cases of trigonal tumors in addition to using CT scanning and cerebral with special reference to the neuroradiological diag angiography before operation. noses and surgical approaches. The cases were classified into the two groups according to Koos and Laubichler,'7) i.e., true intra Clinical Analysis ventricular tumors arising from the or choroid plexus and lying within the ventricular cavity Eight cases with trigonal tumor underwent surgery in four cases (2 meningiomas, 1 , and 1 cavernous angioma), and para Received March 27, 1989; Accepted August 15, ventricular tumors originating from the glial tissue 1989 adjacent to the ventricular walls in four cases (3 Table 1 Summary of eight cases with trigonal tumor

astrocytomas and 1 glioblastoma multiforme). As II. Surgical approach the initial symptoms, seven cases complained of The tumors were removed piecemeal via the mid headache, including two of vomiting, and one of dle or superior temporal gyrus incision in four unconsciousness attack were noted. During neuro cases each. Subtotal removal was performed in Case logical examination on admission, four cases were 4 as the tumor extended to the hippocampus, and found normal while the other four had choked disc, partial removal was accomplished in Case 8 as it visual field defect, hemiparesis, and sensory distur extended to the basal ganglia. Additionally, post bance. operative radiotherapy was given in Cases 4 and 8. Total removal was accomplished in the other six I. Neuroradiological findings cases. In three cases with choked disc, the tumor size was Case 2 with a bulky meningioma, the case before larger than 5 cm. Precontrast CT scans revealed a use of the microscope, died of marked brain edema low-density mass in Case 1, an isodensity mass in due to injury of the middle cerebral artery during the Case 7, a mixed density mass in Case 8, and high operation. The other seven cases showed favorable density masses in the five remaining cases. All cases outcome, where out of four cases with lesions on showed enhancement, only mildly in Cases 6 and 8, the dominant side three cases (Cases 1, 5, and 7) but marked in the other six cases (Fig. 1). The ap showed transient aphasia, dyslexia, and homony pearances of the tumors on postcontrast CT scans mous hemianopsia, etc., postoperatively. However, showed oval-shape lesion with a sharply defined they recovered almost completely 6 months later. margin in two cases (Cases 3 and 5), while the other Cases 5 and 7 pursued a very interesting course. six cases had various shapes with irregular margins. Postoperative CT scans revealed cerebrospinal fluid Calcification was noted in Cases 1 and 6. Hydro (CSF) retention associated with edema in the tem cephalus was not present in any cases, but the infe poral lobe adjacent to the trigone was noted along rior horn of the ipsilateral ventricle was apparently the corticotomy route (Fig. 3). This disappeared as dilated in three cases (Cases 5-7). the symptoms improved. Cerebral angiography revealed homogeneous over shadowing in three cases (Cases 1, 2, and 5), all of III. Representative case reports which were mainly supplied from the anterior Case 1: A 5-year-old girl suffered from headache choroidal artery (Fig. 2). In Case 2, the posterior on waking for about 1 year and was admitted to our choroidal artery was the feeder. hospital because of increased headache with vomit Fig. 1 Pre (left) and postcontrast (right) CT scans of eight cases. A: Case 1. CT scans showing a huge round hypodense mass with calcification at the anterior part, which is markedly enhanced. B: Case 2. CT scans showing a huge lobulated hyperdense mass with peritumoral edema, which is markedly enhanced. C: Case 3. CT scans showing a homogeneous hyperdense mass with marked uniform enhancement. D: Case 4. CT scans showing an ovoid hyperdense mass with marked enhancement. E: Case 5. CT scans showing a hyperdense mass with patchy hypodense areas and calcification associated with peritumoral edema, which is markedly enhanced. F: Case 6. CT scans showing an irregular hyperdense mass with moderate enhancement. G: Case 7. CT scans showing an oval isodensity with marked uniform enhancement. H: Case 8. CT scans showing a huge mixed density mass suggesting polycystic tumor with ring enhancement. markedly enhanced (Fig. IA). A left carotid angiog raphy showed a faint tumor blush supplied by an enlarged anterior choroidal artery in the arterial phase, and a uniform tumor stain in the capillary phase (Fig. 2A). The tumor, which was dark red and partially cystic with a well defined margin and attached to the lateral wall, was totally removed via the middle temporal gyrus incision. The histologic al diagnosis was (Fig. 4A). She was discharged with mild right hemiparesis and right homonymous hemianopsia. Case 5: A 37-year-old male was admitted to a local hospital for head trauma and abdominal injuries caused by a traffic accident. He was transferred to our hospital because of the incidental detection of a on CT scans. The CT scans showed a round hyperdense mass with an irregular margin which was intensely enhanced in the left trigone. Fig. 2 A: Case 1. Left carotid angiograms, arterial This lesion was partially calcified and contained (left) and capillary (right) phases, showing several foci of low-density spots accompanied by enlarged anterior choroidal artery supplying a edema of the surrounding white matter (Fig. iE). tumor with many faint blushes and uniform Left carotid angiography demonstrated a whorl tumor stain. B: Case 5. Left carotid angio formation of the anterior choroidal artery and a grams, arterial (left) and early venous (right) homogeneous tumor blush (Fig. 2B). The tumor, phases, showing whorl formation of the which was dark red, elastic and soft, and well en enlarged anterior choroidal artery and homo capsulated, was totally removed via the left superior geneous tumor blush. temporal gyrus incision. An yttrium-argon-garnet (YAG) laser was used because the tumor was ex tremely large and vascular. The histological diag nosis was choroid plexus papilloma (Fig. 4B). Post operatively, he had transient right homonymous hemianopsia, dysphasia, dyscalculia, and dysgra phia, all of which improved within 3 months. A CT scan taken 3 days after the operation revealed CSF retention with edema along the operative route (Fig. 3A) which disappeared in proportion to the im provement in these neurological symptoms. Case 6: A 62-year-old female had a sudden attack of unconsciousness for 10 minutes about 2 weeks prior to admission. Seven days later, she noticed weakness of the right extremities. She also had occa sional headaches. Neurological examination showed Fig. 3 A: Case 5. CT scan 3 days after operation show slight right hemiparesis and hypesthesia in the right ing CSF retention with marked edema in the lower extremity. A CT scan revealed an irregular left temporal lobe. B: Case 7. CT scan 1 month after operation showing severe CSF hyperdense mass with moderate enhancement in the retention in the left temporal lobe. left trigone (Fig. IF). Gray and partially dark red colored, solid and well encapsulated tumor was totally removed. The histological diagnosis was ing. The neurological examination on admission cavernous angioma (Fig. 4C). She was discharged on disclosed a bilateral choked disc. Plain skull x-ray the postoperative day 20 with permanent lower showed split sutures and thinning of the calvarium right homonymous quadrantanopsia. attributed to increased intracranial pressure. CT Case 7: A 50-year-old female was admitted scans showed a large, round hypodense mass with because of severe headache on waking. CT scans show calcification in the left temporal region, which was ed an isodense mass with strong enhancement in the Fig. 4 A: Case 1. Photomicrograph showing bipolar and elongated tumor cells and some Rosenthal's fibers. B: Case 5. Photomicrograph showing nests of cuboidal epithelial tumor cells. Some tumor cells are arranged in a papillary structure. C: Case 6. Photomicrograph revealing irregular ly dilated large vascular spaces containing red blood cells. D: Case 7. Photomicrograph demonstrating tumor cells with fine delicate processes and some microcysts. HE stain, x 200 (A, D) and x 20 (B, C).

left trigone (Fig. 1G). Magnetic resonance (MR) imaging demonstrated a low signal intensity mass protruding into the lateral ventricle and widely attached to the inner wall of the trigone, suggestive of a paraventricular tumor (Fig. 5). The tumor, yellowish gray-colored, jelly-like in appearance, and having a well defined margin with partial calcifica tion, was totally removed via the middle temporal gyrus incision. The histological diagnosis was fibril lary astrocytoma (Fig. 4D). Postoperatively, she had transient sensory aphasia, alexia, dyscalculia, and finger agnosia, all of which improved gradual ly. A CT scan taken 1 month after the operation revealed CSF retention accompanied with edema in the left temporal lobe which disappeared 2 Fig. 5 Case 7. Coronal MR image (inversion recov months later (Fig. 3B). ery; TR 2000 msec, TI 500 msec) showing a tumor protruded from the inner wall of the Discussion left lateral ventricle as a heterogeneous low signal intensity lesion (arrow). Lateral ventricular tumors were divided into the two groups according to Koos and Laubichler,'7 i. e., loma, , metastasis, and might true intraventricular and paraventricular tumors. also show a hyperdense mass with marked enhance The former included meningioma, choroid plexus ment .3,9,'0,'3°19sGlioma in general demonstrates iso papilloma, ependymoma, colloid , dermoid, density or mixed-density areas 16) and, especially in epidermoid, or metastasis to the choroid plexus, etc., astrocytoma, a characteristic central low-density and the latter included astrocytoma, oligodendro area. 16) In our five glioma cases, various densities, glioma, or glioblastoma multiforme, etc. The occur i.e., low density in one, isodensity in one, mixed rence of tumors arising at the trigone of the density in one, and high density in two, were noted, lateral ventricle is comparatively low. Among the all of which showed marked enhancement. tumors found at the trigone, meningioma is com Kendall and Reider-Grosswasser16) reported that mon, followed by choroid plexus papilloma. On the tumor calcification was visible on CT scans in 47% of other hand, such as astrocytoma, epen meningiomas, 24% of choroid plexus papillomas, dymoma, and are rare. Also, and 20% of gliomas, while in our series it was visible arachnoid and ependymal , sarcoma, or in only two cases. One was a pilocytic astrocytoma melanoma, etc., have been rarely reported. and the other was a choroid plexus papilloma. The Though it is important to diagnose these tumors presence of hydrocephalus is characteristic of neuroradiologically before surgery to determine a choroid plexus papilloma on the basis of overproduc therapeutic plan, this is difficult practically. The tumor tion of CSF, but if the ventricle is obstructed by the location and shape can be identified to a cer tumor, hydrocephalus will appear .21) Our cases tain extent by CT scanning, the tumor shadow by (choroid plexus papilloma, fibrillary astrocytoma, cerebral angiography, and an overall diagnosis may and cavernous angioma) apparently revealed a local be made based on the age and sex of patients, etc.,2) ly dilated inferior horn of the lateral ventricle con although these are not sufficient. taining the tumor. In general, meningioma arises from the choroid Silver et al. 26)reported that paraventricular tumors plexus of the trigone, and is found more in female compress the ventricle and displace the choroid adults of ages ranging from 30 to 40 years and more plexus, while intraventricular tumors engulf the often on the left side. On the other hand, choroid choroid plexus which differentiates these tumors. plexus papilloma is found frequently in children of 5 However, it is very difficult to find the relationship be years or younger, in most cases associated with tween choroid plexus and other tumors on CT scans. hydrocephalus. Further, glioma is frequently found In our case of fibrillary astrocytoma the tumor in adults of 30 years or younger, with no sex differen seemed to engulf the choroid plexus, so an intraven tiation. 16) Since, clinically, trigonal tumors are rela tricular tumor was suspected. Only from this view tively asymptomatic, they may reach a large size point it is impossible to differentiate them. MR im before being found. As initial symptoms, headache aging of lateral ventricular tumors has been little is common, followed by visual disturbance, motor reported. The authors used MR imaging in two and sensory disturbances, personality change, epilep cases (Cases 7 and 8). The fibrillary astrocytoma tic attack, alexia, etc. Neurological findings of (Case 7) was widely attached to the lateral ventri hemiparesis, visual field defect, mental disturbance, cular walls, suggesting a paraventricular tumor. incoordination, ataxia, tremor, dysarthria, choked Thus MR imaging is useful for differentiating para disc, and sensory hypesthesia are known.") In our ventricular tumors from intraventricular tumors. series, seven cases started with headache, including Kendall and Reider-Grosswasser16) reported low two cases where the tumors were found incidently on density areas in the white matter adjacent to the CT scans performed due to head trauma. The neuro tumor in only one case of 13 meningiomas, but in logical findings noted in four cases were choked 1/3 of 21 cases with choroid plexus papilloma, which disc, visual field defect, hemiparesis, and sensory is caused by vasogenic edema through disruption of disturbance. In three cases with choked disc, the the ependyma by the tumor. In intracranial menin tumors had developed to 5 cm in size or larger. giomas, edema has been related to marked vascular The diagnosis of meningioma is comparatively ity and malignancy. 5,21)Mani et al.19) found that in easy as it appears as a hyperdense round mass with a four of seven cases with intraventricular meningi clear margin, enhanced more markedly and oma, edema occurred in the white matter around homogeneously than other tumors. However, other the tumor. In our series, peritumoral edema was tumors exhibiting the same CT findings as those of noted in cases of meningioma and choroid plexus meningioma might be observed, making differentia papilloma. The tumors were comparatively large tion difficult. For example, choroid plexus papil and vascular rich. Meningioma characteristically exhibits a homogeneous tumor shadow in cerebral angiography and in 16 of 17 cases with intraventri cular meningioma such tumor shadows were ob served. 161Further, in some choroid plexus papilloma and glioma an irregular and faint tumor shadows were seen. 161 It has been suggested that demonstra tion of a spiral formation of the artery is a useful angiographic sign of choroid plexus papilloma16,201 as shown in our case. The main blood supply to these tumors is reported to be not only from the anterior choroidal arteries, but also from the posterior choroidal arteries. 10,19,26) In our series, a tumor shadow was demonstrated in three cases, i.e., a pilocytic astrocytoma, a me ningioma and a choroid plexus papilloma, all of which demonstrated homogeneous overshadowing, caused by the anterior choroidal artery, but in one Fig. 6 Illustration of the various approaches sug case with meningioma, the homogeneous over gested for trigonal tumors. A: middle tem shadowing was caused by the posterior choroidal poral gyrus incision, B: lateral temporo artery too. In summary, from the CT and angio parietal incision, C: occipital lobe incision, D: superior parieto-occipital incision, E: trans graphic findings preoperative diagnoses can be ob corpus callosum approach, T: tumor. tained to a certain extent, but differential diagnosis is difficult. Final diagnosis must be made histo pathologically. We presented a case with cavernous angioma quadrantanopsia, so this approach can avoid which is extremely rare. In 1985, Chadduck et al.') damage to the optic radiation. The issue is speech summarized 19 cases of intracranial cavernous dysfunction such as aphasia in the dominant side. In angioma of which only four cases originated at the two cases, sensory aphasia, alexia, agraphia, homo trigone.4,6,14,22> CT scans of cavernous angioma nymous hemianopsia, etc., were noted postopera usually demonstrate a round, well demarcated, tively. However, they were transient, and the and slightly uneven high-density mass with minimal cause was not considered to be the surgical inva or no enhancement.') Our case was typical. sion posterior to the superior temporal gyrus but From the surgical viewpoint, as the tumor may rather CSF retention associated with edema along reach a large size, numerous surgical approaches the surgical route, since the symptoms improved have been devised to minimize the postoperative completely and in proportion to the disappearance neurological deficits (Fig. 6). The approach via the of excessive CSF retention. Fornari et al." reported middle temporal gyrus has many theoretical advan that with the temporal gyrus approach it is only tages"): 1) it is close to the tumor, 2) the anterior possible to reach the intraventricular segment of choroidal artery can be dealt with relatively early,''') the anterior choroidal artery, provided that the and 3) a sufficient decompression and a wide artery is not displaced medially by the tumor and operative field are obtainable, because the inferior therefore hidden deep behind the tumor. However, if horn of the lateral ventricle is generally dilated. The the tumor volume is reduced by piecemeal removal, disadvantages are 12): 1) homonymous hemianopsia the main blood supply of the tumor can be fairly may appear at least slightly, as the approach is made easily and quickly controlled with less bleeding. Fur parallel to optic radiation, 2) individual differences ther, retraction of the periventricular structures with are noted as to the site of Wernicke's area, so fluent important functions should be minimized by using aphasia might occur even when invasion does not an ultrasonic aspirator or a YAG laser. It should be take place at the posterior 1/3 of the superior tem remembered that the optic radiations run infero poral gyrus on the dominant side, and 3) tumors laterally to the ventricle. However, when the tumor which develop on the posterior body are hardly extends to the body from the trigone, a parieto removable. The authors proceeded with the ap occipital route or a transcallosal approach should proach via the superior or middle temporal gyrus in be considered. The paramedian parieto-occipital all cases, and a permanent visual field defect was route has been recommended by Fornari et al.10) noted in only one case with lower homonymous and Guidetti et al.,") since they neither damage the optic radiations nor injure the motor and speech 3) Bernasconi V, Cabrini GP: Radiological features of functions. However, these routes can result in such tumours of the lateral ventricles. Acta Neurochir dysfunctions occasionally. The transcallosal ap (Wien) 17: 290-310, 1967 proach of Kempe and Blaylock15) and Levin and 4) Chadduck WM, Binet EF, Farrell FW, Araoz CA, Rose") is suitable for tumors which are small and fed Reding DL: Intraventricular cavernous hemangioma: Report of three cases and review of the literature. by the posterior choroidal artery. 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